A Phase 2 Randomized, Open-Label, Multisite Trial to Inform Public Health Strategies Involving the Use of MVA-BN Vaccine for Mpox
Phase: PHASE2
Conditions: Monkeypox
Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)

 
DMID Protocol Number: 22-0020 
 
Sponsor: Division of Microbiology and Infectious Diseases 
 
 
NCT05512949 (22-0020A) 
Protocol Title: A Phase 2 Randomized, Open-Label, Multisite Trial to Evaluate the 
Immunogenicity of Dose Reduction Strategies of the MVA-BN Vaccine 
 
(DMID) Version Number: 1.0 
18 August 2022 
 
(DMID) Version Number: 2.0 
22 September 2022 
 
 
 
 
 
NCT05740982 (22-0020B) 
Protocol Title: A Phase 2 Randomized, Open-Label, Multisite Trial to Inform Public Health 
Strategies Involving the Use of MVA-BN Vaccine for Mpox 
(DMID) Version Number: 3.0 
 January 13, 2023  
 
(DMID) Version Number: 4.0 
 February 28, 2023 
 
(DMID) Version Number: 5.0 
April 13, 2023 
 
(DMID) Version Number: 6.0 
August 31, 2023 
 
(DMID) Version Number: 7.0 
May 23, 2024 
 
 

Protocol 22-0020 
Version 7.0 
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A Phase 2 Randomized, Open-Label, Multisite Trial to Inform Public 
Health Strategies Involving the Use of MVA-BN Vaccine for Mpox 
 
 
 
DMID Protocol Number: 22-0020 
 
Sponsor: Division of Microbiology and Infectious Diseases (DMID) 
 
Version Number: 7.0 
 
May 23, 2024 
 
 
 

Protocol 22-0020 
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STATEMENT OF COMPLIANCE 
Each institution engaged in this research will hold a current Federalwide Assurance (FWA) issued 
by the Office of Human Research Protection (OHRP) for federally funded research. The IRB/IEC 
must be registered with OHRP as applicable to the research.  
 
The study will be carried out in accordance with the following as applicable: 
• United States Code of Federal Regulations (CFR) 45 CFR Part 46: Protection of Human 
Subjects 
• Food and Drug Administration (FDA) Regulations: 21 CFR Part 50 (Protection of Human 
Subjects), 21 CFR Part 54 (Financial Disclosure by Clinical Investigators), 21 CFR Part 56 
(Institutional Review Boards), 21 CFR Part 11 (Electronic Records and Electronic 
Signatures), and 21 CFR Part 312 (Investigational New Drug Application), and/or 21 CFR 
812 (Investigational Device Exemptions) 
• The International Council for Harmonisation of Technical Requirements for Registration 
of Pharmaceuticals for Human Use (ICH) E6(R2) Good Clinical Practice (GCP), and the 
Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects 
of Research, Report of the National Commission for the Protection of Human Subjects of 
Biomedical and Behavioral Research 
• The policies and procedures of National Institutes of Health (NIH) Office of Extramural 
Research and DMID 
• The National Institute of Allergy and Infectious Diseases (NIAID) Terms of Award 
• Any additional Federal, State, and Local Regulations and Guidance 
 
 
The signature below provides the necessary assurance that this study will be conducted according 
to all stipulations of the protocol including statements regarding confidentiality, and according to 
local legal and regulatory requirements, US federal regulations, and ICH E6(R2) Good Clinical 
Practice (GCP) guidelines. 
 
Site Investigator Signature: 
 
 
Signed: 
 
Date: 
 
 
Print Name, Credentials 
Print Title 
 
 
 
 

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TABLE OF CONTENTS 
STATEMENT OF COMPLIANCE ....................................................................................................... 2 
TABLE OF CONTENTS ....................................................................................................................... 3 
LIST OF TABLES ............................................................................................................................... 11 
LIST OF FIGURES .............................................................................................................................. 11 
1. 
PROTOCOL SUMMARY ........................................................................................................... 12 
1.1 
Synopsis .........................................................................................................................12 
1.2 
Schedule of Activities (SOA) ........................................................................................15 
2. 
Introduction .................................................................................................................................. 15 
2.1 
Study Rationale ..............................................................................................................15 
2.2 
Background ....................................................................................................................15 
2.3 
Risk/Benefit Assessment ...............................................................................................18 
3. 
OBJECTIVES AND ENDPOINTS ............................................................................................. 18 
4. 
STUDY DESIGN ......................................................................................................................... 18 
4.1 
Overall Design ...............................................................................................................18 
4.2 
Scientific Rationale for Study Design............................................................................19 
4.3 
Justification for Dose .....................................................................................................19 
5. 
STUDY POPULATION .............................................................................................................. 19 
6. 
STUDY PRODUCT ..................................................................................................................... 19 
6.1 
Study Product(s) and Administration.............................................................................19 
6.1.1 
Study Product Description .....................................................................................19 
6.1.2 
Dosing and Administration ....................................................................................20 
6.1.3 
Dose Escalation ......................................................................................................20 
6.1.4 
Dose Modifications ................................................................................................20 
6.1.5 
Criteria for Redosing..............................................................................................20 
6.2 
Preparation/Handling/Storage/Accountability ...............................................................20 
6.2.1 
Acquisition and Accountability .............................................................................20 
6.2.2 
Formulation, Appearance, Packaging, and Labeling .............................................21 
6.2.3 
Product Storage and Stability.................................................................................21 
6.2.4 
Preparation .............................................................................................................22 
6.3 
Measures to Minimize Bias: Randomization and Blinding ...........................................22 
6.3.1 
Treatment Assignment Procedures ........................................................................22 
6.3.2 
Randomization .......................................................................................................22 
6.3.3 
Blinding and Masking Procedures .........................................................................23 
6.4 
Study Intervention Compliance .....................................................................................23 
6.5 
Concomitant Therapy.....................................................................................................23 
7. 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL ............................................................................................ 23 
8. 
STUDY ASSESSMENTS AND PROCEDURES ....................................................................... 23 

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8.6 
Adverse Events and Serious Adverse Events ................................................................23 
8.6.1 
Definition of Adverse Events (AE)........................................................................23 
8.6.1.1 
Solicited Adverse Events ................................................................................... 24 
8.6.1.2 
Unsolicited Events ............................................................................................. 24 
8.6.2 
Definition of Serious Adverse Events....................................................................24 
8.6.3 
Classification of an Adverse Event ........................................................................25 
8.6.3.1 
Severity of Event................................................................................................ 25 
8.6.3.2 
Relationship to Study Intervention .................................................................... 25 
8.6.5 
Adverse Event Reporting .......................................................................................26 
8.6.5.1 
Investigators Reporting of AEs .......................................................................... 26 
8.6.5.2 
Special Reporting of Adverse Events ................................................................ 26 
8.6.6 
Serious Adverse Event Reporting ..........................................................................26 
8.6.6.1 
Investigators Reporting of SAEs ....................................................................... 26 
8.6.6.2 
Regulatory Reporting of SAEs .......................................................................... 27 
8.6.7 
Reporting Events to Participants ............................................................................28 
8.6.8 
Reporting of Pregnancy .........................................................................................28 
8.7 
Unanticipated Problems .................................................................................................28 
8.7.1 
Definition of Unanticipated Problems (UP) ..........................................................28 
8.7.2 
Unanticipated Problem Reporting..........................................................................28 
8.7.3 
Reporting Unanticipated Problems to Participants ................................................29 
9. 
STATISTICAL CONSIDERATIONS ......................................................................................... 29 
10. SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS ................ 29 
10.1 
Regulatory, Ethical, and Study Oversight Considerations.............................................29 
10.1.1 
Informed Consent Process .....................................................................................30 
10.1.2 
Study Termination and Closure .............................................................................30 
10.1.3 
Confidentiality and Privacy ...................................................................................30 
10.1.4 
Secondary Use of Stored Specimens and Data ......................................................32 
10.1.4.1 
Samples for Secondary Research ................................................................... 32 
10.1.4.2 
Data Sharing for Secondary Research ........................................................... 32 
10.1.5 
Key Roles and Study Governance .........................................................................32 
10.1.6 
Safety Oversight.....................................................................................................32 
10.1.7 
Clinical Monitoring ................................................................................................33 
10.1.8 
Quality Assurance and Quality Control .................................................................33 
10.1.9 
Data Handling and Record Keeping ......................................................................33 
10.1.9.1 
Data Collection and Management Responsibilities ....................................... 33 
10.1.9.2 
Data Coordinating Center / Biostatistician Responsibilities .......................... 34 
10.1.9.3 
Data Capture Methods ................................................................................... 34 
10.1.9.4 
Study Record Retention ................................................................................. 34 
10.1.9.5 
Source Records .............................................................................................. 34 
10.1.10 Protocol Deviations ................................................................................................35 
10.1.11 Publication and Data Sharing Policy .....................................................................35 
10.1.11.1 
Human Data Sharing Plan .............................................................................. 35 
10.1.11.2 
Genomic Data Sharing Plan ........................................................................... 35 
10.1.11.3 
Publication ..................................................................................................... 35 
10.1.12 Conflict of Interest Policy ......................................................................................35 

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10.2 
Additional Considerations .............................................................................................36 
10.2.1 
Research Related Injuries ......................................................................................36 
10.2.2 
PREP Act ...............................................................................................................36 
10.3 
Abbreviations .................................................................................................................38 
10.4 
Protocol Amendment History ........................................................................................40 
11. References .................................................................................................................................... 42 
APPENDIX A – Stage 1: Dose Sparing Study in Adults ..................................................................... 46 
TABLE OF CONTENTS ..................................................................................................................... 46 
LIST OF TABLES ............................................................................................................................... 48 
LIST OF FIGURES .............................................................................................................................. 49 
1. 
PROTOCOL SUMMARY .......................................................................................................... 50 
1.1 
Synopsis .........................................................................................................................50 
1.2 
Schedule of Activities (SOA) .........................................................................................52 
1.3 
Study Schema .................................................................................................................53 
2. 
INTRODUCTION ....................................................................................................................... 53 
2.1 
Study Rationale ..............................................................................................................53 
2.2 
Background ....................................................................................................................53 
2.3 
Risk/Benefit Assessment ................................................................................................55 
2.3.1 
Known Potential Risks ...........................................................................................55 
2.3.2 
Known Potential Benefits .......................................................................................59 
2.3.3 
Assessment of Potential Risks and Benefits...........................................................59 
3. 
OBJECTIVES AND ENDPOINTS............................................................................................. 60 
4. 
STUDY DESIGN ........................................................................................................................ 61 
4.1 
Overall Design ...............................................................................................................61 
4.2 
Scientific Rationale for Study Design ............................................................................61 
4.3 
Justification for Dose ......................................................................................................61 
5. 
STUDY POPULATION .............................................................................................................. 61 
5.1 
Inclusion Criteria ............................................................................................................62 
5.2 
Exclusion Criteria ...........................................................................................................62 
5.2.1 
Exclusion of Specific Populations ..........................................................................63 
5.3 
Inclusion of Vulnerable Participants ..............................................................................63 
5.4 
Lifestyle Considerations ................................................................................................64 
5.5 
Screen Failures ...............................................................................................................64 
5.6 
Strategies for Recruitment and Retention .......................................................................64 
5.6.1 
Recruitment ............................................................................................................64 
5.6.2 
Retention ................................................................................................................65 
5.6.3 
Compensation Plan for Participants .......................................................................65 
5.6.4 
Costs .......................................................................................................................65 
6. 
STUDY PRODUCT .................................................................................................................... 65 
6.1 
Study Product(s) and Administration .............................................................................65 

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6.1.1 
Study Product Description ......................................................................................65 
6.1.2 
Dosing and Administration ....................................................................................65 
6.1.3 
Dose Escalation ......................................................................................................66 
6.1.4 
Dose Modifications ................................................................................................66 
6.1.5 
Criteria for Redosing ..............................................................................................66 
6.2 
Preparation/Handling/Storage/Accountability ...............................................................66 
6.2.1 
Acquisition and Accountability ..............................................................................66 
6.2.2 
Formulation, Appearance, Packaging, and Labeling Product: JYNNEOS (MVA-
BN vaccine) ...........................................................................................................................67 
6.2.3 
Product Storage and Stability Product: JYNNEOS (MVA-BN vaccine) ...............67 
6.2.4 
Preparation .............................................................................................................67 
6.3 
Measures to Minimize Bias: Randomization and Blinding ............................................68 
6.3.1 
Treatment Assignment Procedures .........................................................................68 
6.3.2 
Randomization .......................................................................................................68 
6.3.3 
Blinding and Masking Procedures .........................................................................68 
6.4 
Study Intervention Compliance ......................................................................................68 
6.5 
Concomitant Therapy .....................................................................................................68 
6.5.1 
Rescue Medicine ....................................................................................................69 
7. 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL ............................................................................................... 69 
7.1 
Halting Criteria and Discontinuation of Study Intervention ...........................................69 
7.1.1 
Study Halting Criteria ............................................................................................69 
7.1.1.1 
Sentinel Participant Halting Rules ..................................................................... 69 
7.1.1.2 
Cohort Halting Rules .......................................................................................... 69 
7.1.2 
Individual Halting Criteria .....................................................................................70 
7.1.3 
Follow up for participants that discontinued study intervention ............................70 
7.2 
Lost to Follow-Up ..........................................................................................................71 
8. 
STUDY ASSESSMENTS AND PROCEDURES ...................................................................... 71 
8.1 
Screening Procedures .....................................................................................................71 
8.1.1 
Procedures to be Followed in the Event of Abnormal Clinical Laboratory Test 
Values or Abnormal Clinical Findings During Screening .....................................................72 
8.1.2 
Sick Visit ................................................................................................................72 
8.2 
Immunogenicity Assessments ........................................................................................73 
8.2.1 
Immunogenicity/Efficacy Evaluations ...................................................................73 
8.2.2 
Exploratory Assessments .......................................................................................73 
8.3 
Safety and Other Assessments .......................................................................................73 
8.3.1 
Procedures to be Followed in the Event of Abnormal Clinical Laboratory Test 
Values or Abnormal Clinical Findings During Conduct of the Trial ....................................74 
8.4 
Adverse Events and Serious Adverse Events .................................................................74 
8.4.1 
Definition of Adverse Events (AE) ........................................................................74 
8.4.1.1 
Solicited Adverse Events ................................................................................... 75 
8.4.1.2 
Unsolicited Events ............................................................................................. 75 
8.4.2 
Definition of Serious Adverse Events ....................................................................75 
8.4.2.1 
Definition of Medically Attended Adverse Events (MAAE) ............................. 76 
8.4.2.2 
Definition of Suspected Unexpected Serious Adverse Reactions (SUSAR) ..... 76 

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8.4.3 
Classification of an Adverse Event ........................................................................76 
8.4.3.1 
Severity of Event ................................................................................................ 76 
8.4.3.2 
Relationship to Study Intervention ..................................................................... 77 
8.4.4 
Time Period and Frequency for Event Assessment and Follow-Up ......................77 
8.4.5 
Adverse Event Reporting .......................................................................................78 
8.4.5.1 
Investigators Reporting of AEs .......................................................................... 78 
8.4.5.2 
Special Reporting of Adverse Events ................................................................. 78 
8.4.6 
Serious Adverse Event Reporting ..........................................................................78 
8.4.6.1 
Investigators Reporting of SAEs ........................................................................ 78 
8.4.6.2 
Regulatory Reporting of SAEs ........................................................................... 79 
8.4.7 
Reporting Events to Participants ............................................................................79 
8.4.8 
Adverse Events of Special Interest (AESI) ............................................................80 
8.4.9 
Reporting of Pregnancy ..........................................................................................80 
8.5 
Unanticipated Problems .................................................................................................80 
8.5.1 
Definition of Unanticipated Problems (UP) ...........................................................80 
8.5.2 
Unanticipated Problem Reporting ..........................................................................80 
8.5.3 
Reporting Unanticipated Problems to Participants .................................................81 
9. 
STATISTICAL CONSIDERATIONS ......................................................................................... 81 
9.1 
Statistical Hypotheses.....................................................................................................81 
9.2 
Sample Size Determination ............................................................................................82 
9.3 
Statistical Analyses ........................................................................................................83 
9.3.1 
General Methodology ............................................................................................83 
9.3.2 
Timing of Analyses ................................................................................................83 
9.3.2.1 
Interim Safety Analyses ..................................................................................... 83 
9.3.2.2 
Interim Immunogenicity Analyses ..................................................................... 84 
9.3.2.3 
Final Analyses .................................................................................................... 84 
9.3.3 
Populations for Analyses ........................................................................................84 
9.3.4 
Baseline Characteristics and Participant Disposition .............................................84 
9.3.5 
Immunogenicity Analyses ......................................................................................84 
9.3.6 
Safety Analyses ......................................................................................................85 
9.3.6.1 
Reactogenicity.................................................................................................... 85 
9.3.6.2 
Other Adverse Events......................................................................................... 85 
10. SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS ................. 86 
10.1 
Regulatory, Ethical, and Study Oversight Considerations ..............................................86 
10.1.1 
Informed Consent Process ......................................................................................86 
10.1.1.1 
Requirements for Permission by Parents/Guardians and Assent by Children 
(in case of a minor) ............................................................................................................ 87 
10.1.1.2 
Other Informed Consent Procedures .............................................................. 87 
10.1.2 
Study Termination and Closure ..............................................................................88 
10.1.3 
Confidentiality and Privacy ....................................................................................89 
10.1.4 
Secondary Use of Stored Specimens and Data ......................................................90 
10.1.4.1 
Samples for Secondary Research ................................................................... 90 
10.1.4.2 
Data Sharing for Secondary Research ............................................................ 90 
10.1.5 
Key Roles and Study Governance ..........................................................................91 
10.1.6 
Safety Oversight .....................................................................................................91 

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10.1.7 
Clinical Monitoring ................................................................................................92 
10.1.8 
Quality Assurance and Quality Control .................................................................92 
10.1.9 
Data Handling and Record Keeping .......................................................................93 
10.1.9.1 
Data Collection and Management Responsibilities ........................................ 93 
10.1.9.2 
Data Coordinating Center / Biostatistician Responsibilities .......................... 93 
10.1.9.3 
Data Capture Methods .................................................................................... 93 
10.1.9.4 
Study Record Retention ................................................................................. 93 
10.1.9.5 
Source Records ............................................................................................... 94 
10.1.10 Protocol Deviations ................................................................................................94 
10.1.11 Publication and Data Sharing Policy ......................................................................94 
10.1.11.1 
Human Data Sharing Plan .............................................................................. 94 
10.1.11.2 
Genomic Data Sharing Plan ........................................................................... 95 
10.1.11.3 
Publication ..................................................................................................... 95 
10.1.12 Conflict of Interest Policy ......................................................................................95 
10.2 
Additional Considerations..............................................................................................95 
10.2.1 
Research Related Injuries .......................................................................................95 
10.2.2 
PREP Act ...............................................................................................................95 
11. REFERENCES ............................................................................................................................ 97 
APPENDIX B – Stage 2: Adolescent and Adult Noninferiority Study ................................................ 99 
TABLE OF CONTENTS ................................................................................................................... 100 
1. 
Introduction ................................................................................................................................ 103 
1.1 
Study Rationale ............................................................................................................103 
1.2 
Background ..................................................................................................................103 
1.3 
Risk/Benefit Assessment .............................................................................................104 
1.3.1 
Known Potential Risks .........................................................................................104 
1.3.2 
Known Potential Benefits ....................................................................................107 
1.3.3 
Assessment of Potential Risks and Benefits ........................................................108 
2. 
OBJECTIVES AND ENDPOINTS ........................................................................................... 108 
3. 
STUDY DESIGN ....................................................................................................................... 109 
3.1 
Overall Design .............................................................................................................109 
3.2 
Scientific Rationale for Study Design..........................................................................111 
3.3 
Justification for Dose ...................................................................................................111 
4. 
STUDY POPULATION ............................................................................................................ 111 
4.1 
Inclusion Criteria .........................................................................................................112 
4.2 
Exclusion Criteria ........................................................................................................112 
4.2.1 
Exclusion of Specific Populations .......................................................................114 
4.3 
Inclusion of Vulnerable Participants ............................................................................114 
4.4 
Lifestyle Considerations ..............................................................................................114 
4.5 
Screen Failures .............................................................................................................115 
4.6 
Strategies for Recruitment and Retention ....................................................................115 
4.6.1 
Recruitment ..........................................................................................................115 
4.6.2 
Retention ..............................................................................................................115 

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4.6.3 
Compensation Plan for Participants .....................................................................115 
4.6.4 
Costs .....................................................................................................................116 
5. 
STUDY PRODUCT ................................................................................................................... 116 
5.1 
Study Product(s) and Administration...........................................................................116 
5.1.1 
Study Product Description ...................................................................................116 
5.1.2 
Dosing and Administration ..................................................................................116 
5.1.3 
Dose Escalation ....................................................................................................117 
5.1.4 
Dose Modifications ..............................................................................................117 
5.1.5 
Criteria for Redosing............................................................................................117 
5.2 
Preparation/Handling/Storage/Accountability .............................................................117 
5.2.1 
Acquisition and Accountability ...........................................................................117 
5.2.2 
Formulation, Appearance, Packaging, and Labeling ...........................................117 
5.2.3 
Product Storage and Stability...............................................................................117 
5.2.4 
Preparation ...........................................................................................................117 
5.3 
Measures to Minimize Bias: Randomization and Blinding .........................................118 
5.3.1 
Treatment Assignment Procedures ......................................................................118 
5.3.2 
Randomization .....................................................................................................118 
5.3.3 
Blinding and Masking Procedures .......................................................................118 
5.4 
Study Intervention Compliance ...................................................................................118 
5.5 
Concomitant Therapy...................................................................................................118 
6. 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL .......................................................................................... 119 
6.1 
Halting Criteria and Discontinuation of Study Intervention ........................................119 
6.1.1 
Study Halting Criteria ..........................................................................................119 
6.1.1.1 
Sentinel Participant Halting Rules ................................................................... 119 
6.1.1.2 
Cohort Halting Rules ....................................................................................... 119 
6.1.2 
Individual Halting Criteria ...................................................................................119 
6.1.3 
Follow up for participants that discontinued study intervention .........................120 
6.2 
Participant Withdrawal from the Study and Replacement ...........................................121 
6.3 
Lost to Follow-Up ........................................................................................................121 
7. 
STUDY ASSESSMENTS AND PROCEDURES ..................................................................... 121 
7.1 
Screening Procedures ...................................................................................................121 
7.1.1 
Procedures to be Followed in the Event of Abnormal Clinical Laboratory Test 
Values or Abnormal Clinical Findings During Screening ...................................................122 
7.2 
Sick Visit ......................................................................................................................123 
7.3 
Additional Study Procedures in Stage 2 ......................................................................123 
7.3.1 
Phone Visits .........................................................................................................123 
7.3.2 
Photography .........................................................................................................123 
7.4 
Immunogenicity Assessments ......................................................................................123 
7.4.1 
Immunogenicity/Efficacy Evaluations .................................................................123 
7.4.2 
Exploratory Assessments .....................................................................................124 
7.5 
Safety and Other Assessments .....................................................................................124 
7.5.1 
Alternative Schedules ..........................................................................................125 

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7.5.2 
Procedures to be Followed in the Event of Abnormal Clinical Laboratory Test 
Values or Abnormal Clinical Findings During the Trial .....................................................126 
7.6 
Adverse Events and Serious Adverse Events ..............................................................126 
7.6.1.1 
Definition of Medically Attended Adverse Events (MAAE) .......................... 126 
7.6.1.2 
Definition of Suspected Unexpected Serious Adverse Reactions (SUSAR) ... 126 
7.6.1.3 
Definition of Adverse Event of Special Interest (AESI) ................................. 126 
7.6.2 
Classification of an Adverse Event ......................................................................127 
See main section of the protocol for a description of the classification of an AE in terms of 
severity and causality. ..........................................................................................................127 
7.6.3 
Time Period and Frequency for Event Assessment and Follow-Up ....................127 
7.6.4 
Adverse Event Reporting .....................................................................................127 
7.7 
Unanticipated Problems ...............................................................................................127 
8. 
STATISTICAL CONSIDERATIONS ....................................................................................... 127 
8.1 
Statistical Hypotheses ..................................................................................................127 
8.2 
Sample Size Determination..........................................................................................128 
8.3 
Statistical Analyses ......................................................................................................130 
8.3.1 
General Methodology ..........................................................................................130 
8.3.2 
Timing of Analyses ..............................................................................................130 
8.3.2.1 
Interim Safety Analyses ................................................................................... 130 
8.3.2.2 
Interim Immunogenicity Analyses ................................................................... 130 
8.3.2.3 
Final Analyses .................................................................................................. 130 
8.3.3 
Populations for Analyses .....................................................................................131 
8.3.4 
Baseline Characteristics and Participant Disposition ..........................................131 
8.3.5 
Immunogenicity Analyses ...................................................................................131 
8.3.6 
Safety Analyses ....................................................................................................132 
8.3.6.1 
Reactogenicity.................................................................................................. 132 
8.3.6.2 
Other Adverse Events ...................................................................................... 132 
9. 
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS .............. 133 
9.1 
Regulatory, Ethical, and Study Oversight Considerations...........................................133 
9.1.1 
Informed Consent Process ...................................................................................133 
9.1.1.1 
Requirements for Permission by Parents/LARs and Assent by Children (in case 
of a minor)........................................................................................................................ 135 
9.1.1.2 
Other Informed Consent Procedures ................................................................ 135 
9.1.2 
Study Termination and Closure ...........................................................................136 
9.1.3 
Confidentiality and Privacy .................................................................................136 
9.1.4 
Secondary Use of Stored Specimens and Data ....................................................137 
9.1.4.1 
Samples for Secondary Research ..................................................................... 137 
9.1.4.2 
Data Sharing for Secondary Research ............................................................. 138 
9.1.5 
Key Roles and Study Governance .......................................................................138 
9.1.6 
Safety Oversight...................................................................................................138 
9.1.7 
Clinical Monitoring ..............................................................................................139 
9.1.8 
Quality Assurance and Quality Control ...............................................................140 
9.1.9 
Data Handling and Record Keeping ....................................................................140 
9.1.9.1 
Data Collection and Management Responsibilities ......................................... 140 
9.1.9.2 
Data Coordinating Center / Biostatistician Responsibilities ............................ 140 

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9.1.9.3 
Data Capture Methods ..................................................................................... 140 
9.1.9.4 
Study Record Retention ................................................................................... 141 
9.1.9.5 
Source Records ................................................................................................ 141 
9.1.10 
Protocol Deviations ..............................................................................................141 
9.1.11 
Publication and Data Sharing Policy ...................................................................142 
9.1.11.1 
Human Data Sharing Plan ............................................................................ 142 
9.1.11.2 
Genomic Data Sharing Plan ......................................................................... 142 
9.1.11.3 
Publication ................................................................................................... 142 
9.1.12 
Conflict of Interest Policy ....................................................................................142 
9.2 
Additional Considerations ...........................................................................................142 
9.2.1 
Research Related Injuries ....................................................................................142 
9.2.2 
PREP Act .............................................................................................................143 
10. References .................................................................................................................................. 145 
 
LIST OF TABLES 
Table 1 Study Schema ................................................................................................................... 13 
Table 2 Prior Subcutaneous Dosing Trials .................................................................................... 16 
Table 3 MVA-BN Compared to ACAM2000 ............................................................................... 17 
Table 4. Prior Intradermal Dosing Compared to Subcutaneous .................................................... 17 
Table 5 Study Arms ....................................................................................................................... 20 
 
 
 
LIST OF FIGURES 
No table of figures entries found. 
 
 
 

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1. 
PROTOCOL SUMMARY 
1.1 
Synopsis 
Rationale 
Since the first case was identified in May of 2022 in the United Kingdom, mpox (previously known 
as monkeypox) has rapidly spread to more than 100 non-endemic countries, marking the first time 
mpox has spread widely outside Central and West Africa. In the U.S., there have been 29,630 
confirmed mpox cases and 20 deaths as of December 6, 2022. To prevent further spread of mpox 
and to mitigate this outbreak, MVA-BN vaccine is being offered to individuals at high risk of 
acquiring the disease which in this outbreak include gay, bisexual, and other men who have sex 
with men, transgender or nonbinary people and people at occupational risk of exposure to 
orthopoxviruses. Post-exposure prophylaxis with JYNNEOS (Modified Vaccinia Ankara-Bavarian 
Nordic [MVA-BN] vaccine) is also recommended for other moderate or high-risk exposures, 
including in young infants, even though safety and immunogenicity data are sparse in pediatric 
populations. While the incidence of mpox is declining in the U.S., there is still uncertainty about 
when this outbreak will end and whether it will establish endemicity in high-risk groups. In 
addition, there is a global vaccine shortage and increasing vaccine supply will take time.  
 
This Phase 2, open-label multi-site platform trial will evaluate strategies to inform public health 
decisions regarding the use of JYNNEOS for mpox prevention and mitigation of outbreaks. As 
JYNNEOS is also used for smallpox prophylaxis, this trial will also inform public health decisions 
on the use of the vaccine for smallpox. The trial is divided into stages according to public health 
needs and scientific priorities. Public health strategies will be evaluated in separate stages of the 
trial and include intradermal dose sparing strategies in adults (Stage 1) and extension of the target 
population for JYNNEOS to include adolescents (Stage 2). This protocol may add additional arms 
as needed based on public health needs and priorities. The study arms will be conducted in different 
stages that could overlap. 
 
Each stage of the study will have a separate protocol in an appendix (e.g., Stage 1 is described in 
Appendix A, Stage 2 in Appendix B, etc.).  Commonalities between the stages will be included 
and highlighted in this main section of this protocol. 
 
Stage 1 
Approximately 230 healthy, vaccinia-naïve adults ages 18 to 50 years, inclusive, will be enrolled 
to retain 210 participants assuming a 10% drop-out rate. Participants will be randomized 1:1:1 to 
one of three study arms (Table 1). Participants in Arms 1 and 2 will receive a 2-dose intradermal 
regimen of 2x107 and 1x107 MVA-BN, respectively and Arm 3 will receive the licensed 2-dose SC 
regimen of 1x108 MVA-BN.  All vaccines will be administered on Day 1 and 29. There will be 
eight study visits (plus an optional screening visit) with the last visit at approximately one year 
after the first study vaccination. Participants reporting mpox-like illness and who have a positive 
MPXV diagnostic test (laboratory-confirmed mpox case) will be seen at a sick visit. Enrollment of 
this Stage ended on October 13, 2022. 
 
Stage 2 
Approximately 315 healthy, vaccinia-naïve adolescents ages 12 to 17 years, inclusive, will be 
enrolled in Arm 5 to retain 300 participants assuming a 5% drop-out rate (Table 1). Approximately 

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135 healthy, vaccinia-naïve adults ages 18 to 50 years, inclusive, will be enrolled in Arm 4.  These 
adults (Arm 4) will be combined with participants from Arm 3 (adults given subcutaneous standard 
dose in Stage 1) and together will be the comparator group for the primary endpoint, non-inferiority 
testing. Participants in Arms 4 and 5 will receive the 2-dose SC regimen of 1x108 MVA-BN. All 
vaccines will be administered on Day 1 and 29. There will be nine study visits (plus an optional 
screening visit) with the last visit at approximately one year after the second study vaccination. 
Participants reporting a laboratory-confirmed case of mpox will be seen at a sick visit. 
 
Table 1 Study Schema 
  
Arm 
N 
Age in 
years 
Dose of JYNNEOS  
(MVA-BN) 
Route of 
Administration* 
Stage 1 
Adult 
1 
76 
18-50 
2 x 107 TCID50, (0.1 mL) 
Intradermal 
2 
77 
1 x 107 TCID50, (0.05 mL) 
Intradermal 
3 
76 
1 x 108 TCID50, (0.5 mL) 
Subcutaneous 
Stage 2 
Adult and 
Adolescent 
4 
135 
18-50 
1 x 108 TCID50, (0.5 mL) 
Subcutaneous 
5 
315 
12-17 
1 x 108 TCID50, (0.5 mL) 
Subcutaneous 
*Subcutaneous is administered in the upper arm on Day 1 and 29. Intradermal is administered in the volar aspect 
(inner side) of the forearm on Day 1 and Day 29. 
 
Primary Objectives: 
Stage 1 (Adult) 
• To determine if peak (Day 43) humoral immune responses in adults ages 18-50 years 
following an ID regimen of 2 x 107 TCID50 MVA-BN are non-inferior to the licensed 
regimen of 1 x 108 TCID50 MVA-BN administered SC. 
• To determine if peak (Day 43) humoral immune responses in adults ages 18-50 years 
following an ID regimen of 1 x 107 TCID50 MVA-BN are non-inferior to the licensed 
regimen of 1 x 108 TCID50 MVA-BN administered SC 
 
Stage 2 (Adult and Adolescent) 
• To determine if peak (Day 43) humoral immune responses in adolescents ages 12 to 17 
years following administration of a 2-dose 1 x 108 TCID50 MVA-BN regimen 
administered SC are non-inferior to the response in adults ages 18 to 50 years who 
received the licensed 2-dose SC regimen of 1 x 108 TCID50 MVA-BN. 
• To describe safety of a 2-dose 1 x 108 TCID50 MVA-BN regimen administered SC in 
adolescents ages 12 to 17 years. 
 
For a full list of Objectives/Endpoints, see corresponding section of the protocol.   
 
Inclusion Criteria 
Inclusion criteria will remain relatively consistent between stages with differences only in the 
ability to give informed consent in pediatric populations. See inclusion criteria for each stage in 
corresponding section of the protocol.  
 
 

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Exclusion Criteria 
Exclusion criteria will remain relatively consistent between stages with differences due to limited 
data on the safety profile in pediatric population. See exclusion criteria for each stage in 
corresponding section of the protocol. 
 
Study Phase 
Phase 2  
 
Study Population 
This platform trial will enroll a study population that is healthy, vaccinia-naïve, non-pregnant, and 
non-breastfeeding. Participants with stable chronic medical conditions including those with 
controlled HIV can participate.  In Stage 1 and Stage 2, adults ages 18 to 50 years, inclusive, will 
be enrolled, and in Stage 2, adolescents ages 12 to 17 years, inclusive will also be enrolled.  The 
study will attempt to enroll a representative study population that is demographically diverse, and 
for the adult study (Stage 1), that is proportional to those affected by the disease during the current 
mpox outbreak in the United States. In Stage 2, the study will aim to enroll a population that is 
representative of the U.S. population to ensure broad applicability of the study findings given that 
the findings will be used to inform a label change in the U.S. for use of JYNNEOS in adolescents. 
While adolescents are not the main population impacted by the current global outbreak, there is a 
risk that sexually active adolescents could be impacted if mpox were introduced into this 
population. 
 
Sites 
Up to 21 U.S. clinical research sites will be involved in the study. Not all sites will participate in 
all stages or in all arms.   
 
Study intervention 
JYNNEOS is live vaccine produced from the strain MVA-BN, an attenuated orthopoxvirus, that 
does not replicate in human cells. A 2-dose SC regimen of 1 x 108 TCID50 MVA-BN given 4 weeks 
apart is FDA-approved and licensed as a smallpox and mpox vaccine for adults, and FDA-
authorized under an emergency use authorization (EUA) for children and adolescents in the United 
States.  In addition, the FDA authorized an EUA for use of a 2-dose ID regimen of 2 x 107 TCID50 
MVA-BN given 4 weeks apart in adults on August 9, 2022.  In Stage 1 of this study, a 2-dose ID 
regimen of 1 x 107 TCID50 MVA-BN, given 4 weeks apart, was evaluated as an investigational 
dose sparing regimen. 
 
Stage 1 (Adult)  
There will be three study arms in which JYNNEOS will be administered by either ID or SC 
injection at Day 1 and 29. 
 
Stage 2 (Adult and Adolescent) 
There will be two study arms in which JYNNEOS will be administered by SC injection at Day 1 
and 29.  
 
Study Duration 

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This study will take approximately 24-36 months to conduct from study activation to the last study 
visit of the final participant enrolled. 
 
Participant Duration 
It will take approximately one year for a participant to complete their participation in the study in 
Stage 1 and approximately 13 months in Stage 2. 
 
Safety 
The trial will use study and individual pausing rules. See corresponding section for details. This 
trial will use a Data Safety Monitoring Board (DSMB) for objective study oversight and review of 
any study pause. 
 
1.2 
Schedule of Activities (SOA) 
For the Schedule of Activities (SOA) for each study stage refer to the corresponding appendix. 
Refer to Manual of Procedures (MOP) for detailed description of study activities.  
 
2. 
INTRODUCTION 
 
2.1 
Study Rationale 
On July 23, 2022, WHO declared the 2022 mpox outbreak a public health emergency of 
international concern (PHEIC).1 Since the first case of mpox was detected in the UK in a returning 
traveler from Nigeria on May 6, 2022, as of December 2022 the outbreak has rapidly spread to 110 
countries or locations worldwide, including 103 that are non-endemic, marking the first time mpox 
has spread widely outside Central and West Africa. In August, the number of confirmed mpox 
cases in the U.S. surpassed that of any other country2,3. To mitigate the consequences of this 
outbreak, JYNNEOS vaccine is being offered to individuals considered to be at high risk. However, 
there is a global vaccine shortage and increasing the supply will take time. This study will evaluate 
vaccine dose sparing strategies to extend the limited supply during this global public health crisis 
in Stage 1, and in Stage 2, the study will evaluate vaccine safety and immunogenicity among 
adolescents ages 12 to 17 years to extend eligibility to adolescent population. 
 
2.2 
Background 
Mpox is a reemerging infectious disease caused by Monkeypox virus (MPXV), a large double-
stranded DNA virus belonging to the genus Orthopoxvirus.4 MPXV is a zoonotic orthopoxvirus, 
primarily transmitted to humans via contact with infected animals, and causing disease similar to 
smallpox, although with substantially lower mortality.4-6 MPXV is endemic to West and Central 
Africa, where the incidence of human mpox cases has increased as much as 20-fold since the end 
of the smallpox vaccination campaign in 1980.7,8 Outbreaks in non-endemic countries have been 
related to the exotic pet trade9 and international travel.10-12 Prior to the current global mpox 
outbreak, secondary human-to-human transmission in non-endemic countries was rare, and 
documented only twice since 2018, both cases involving travelers returning from Nigeria. The first 
case involved transmission between the index patient and a healthcare provider13 and second case 

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involved transmission to another adult and an infant within the household of the index case.14,15 
Mpox reemerged in Nigeria in 2017 after more than 40 years with no reported cases.16,17  
 
On May 18, 2022, the first U.S. case of mpox was detected as part of the larger global 2022 mpox 
outbreak.18 The U.S. was the fourth non-endemic country to detect a case in a returning traveler. 
On August 4, the U.S. Department of Health and Human Services declared the U.S. mpox outbreak 
to be a public health emergency with 7,510 confirmed cases of mpox detected in all U.S. states, 
D.C, and Puerto Rico.19 As of December 22, 2022, there have been 83,424 confirmed mpox cases 
in 110 locations and countries; most cases have been from 103 non-endemic areas including 29,740 
confirmed cases and 20 deaths in the United States.2  
 
Vaccination is being used as a mitigation strategy in the current mpox outbreak for those exposed 
to and those deemed to be at higher risk of being exposed to mpox. There is one FDA-approved 
vaccine for mpox: JYNNEOS Modified Vaccinia Ankara-Bavarian Nordic (MVA-BN). A second 
vaccine, ACAM2000, is likely effective but is not FDA-approved for mpox and associated with 
moderate risk of myocarditis and pericarditis (5.7 cases per 1,000 vaccinated) as well as 
encephalomyelitis, progressive vaccinia, generalized vaccinia, and ocular complications. 
ACAM2000 should not be given to people with a weakened immune system, eczema, cardiac 
disease, infants <12 months, or pregnant women. Given these attributes, JYNNEOS is the preferred 
vaccine during the current outbreak and there is a limited supply of the vaccine globally with 
production unlikely to keep up with the growing demand as the outbreak continues to spread. Given 
the limited supply of MVA-BN, on August 9, 2022, the FDA issued an Emergency Use 
Authorization (EUA) for the emergency use of a lower (2 x 107) ID dose of JYNNEOS for 
individuals 18 years of age and older determined to be at high risk for mpox infection. In addition, 
the EUA allowed for the emergency use of the licensed SC dose for individuals less than 18 years 
of age determined to be at high risk for mpox infection as JYNNEOS is licensed for use in only 
adults. 
 
In the first stage of this platform trial, several potential dose sparing strategies were considered. 
Use of a reduced dose administered SC is unlikely to be of comparable immunogenicity to the 
licensed SC regimen. There were several Phase 1 and 2 trials that evaluated 2-dose regimens of 
MVA-BN administered SC four weeks apart (Table 2). Although the 2-dose 5x107 TCID50 SC 
regimen may elicit GMT similar to that of ACAM2000, the GMT will likely be below that of the 
licensed 2-dose 1 x 108 TCID50 MVA-BN regimen.  
 
Table 2 Prior Subcutaneous Dosing Trials 
Reference 
 
1 X107 
TCID50 
2 X107 
TCID50 
5 X107 
TCID50 
1 X108 
TCID50 
Assay 
Vollmar et al,  
Vaccine, 2006 20 
Liquid 
formulation 
6.4 
(CI not reported) 
-- 
-- 
29.3 
(CI not reported) 
IHD-J 
PRNT GMT 
Frey at al.  
Vaccine, 2007 
Lyophilized 
formulation 
-- 
347.2 
(161.9, 744.7) 
551.5 
(321.5, 946.0) 
914.5 
(528.0, 1584) 
MVA 
PRNT GMT 
von Krempelhuber  
Vaccine, 2010 
Lyophilized 
formulation 
-- 
5.5 
(3.2, 9.6) 
10.3 
(5.8, 18.4) 
19.4 
(11.1, 34.2) 
IHD-J 
PRNT GMT 
 
A single 1 x 108 TCID50 MVA-BN dose has also been suggested for dose sparing, but in our 
assessment of the published literature, it is unlikely to be immunogenically equivalent to the 

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standard licensed 2-dose regimen. The pivotal Phase 3 trial demonstrated that a single dose is likely 
to provide a significantly lower GMT than the licensed 2-dose MVA-BN regimen, 16.9 [13.7, 20.8] 
as compared to 153.5 [134.3, 175.6], respectively (Table 3).  
 
Table 3 MVA-BN Compared to ACAM2000 
MVA-BN 
(N=185) 
ACAM2000 
(N=186) 
GMTs ratio 
MVA/ ACAM 
Visit Week 
n 
GMT 
95% CI 
n 
GMT 
95% CI 
Ratio 
95% CI 
Plaque Reduction Neutralization Test 
Week 0 
185 
1.0 
[1.0, 1.1] 
186 
1.0 
[1.0, 1.0] 
1.008 
[0.97, 1.05] 
Week 2 
184 
16.2 
[13.0, 20.1] 
184 
16.2 
[13.1, 20.0] 
0.997 
[0.74, 1.35] 
Week 4 
185 
16.9 
[13.7, 20.8] 
186 
79.3 
[67.1, 93.8] 
0.213 
[0.16, 0.28] 
Week 6 
185 153.5 
[134.3, 175.6] 
181 
64.7 
[54.9, 76.2] 
2.372 
[1.92, 2.93] 
 
NIAID conducted a Phase 2 trial comparing the standard (now licensed) 2-dose 1 x 108 TCID50 
MVA-BN SC regimen (liquid formulation) and a 2-dose 2 x 107 TCID50 MVA-BN ID regimen 
(liquid formulation) and found peak vaccinia virus, Western reserve strain (VV-WR) GMT of 49.5 
(40.0, 61.3) and 59.6 (48.1, 74.0), respectively (Table 4).21 The 2-dose 2 x 107 TCID50 ID regimen 
was non-inferior to the 2-dose 1 x 108 TCID50 SC regimen and utilized only one-fifth of the dose. 
These results are supported by a trial evaluating another MVA vaccine (ACAM3000) which 
showed ID vaccination at 1x107 TCID50 had similar VV-WR GMT to 1x108 TCID50 administered 
SC or IM.22  
 
Table 4. Prior Intradermal Dosing Compared to Subcutaneous 
Study Visit Day 
Group 
Lyophilized SC 1x108 
(N=145) GMT [95% CI] 
Liquid SC 1x108 
(N=149) GMT [95% CI] 
Liquid ID 2x107 
(N=146) GMT [95% CI] 
Day 0 
7.5 [,] 
7.7 [7.4, 8.0] 
7.7 [7.4, 7.9] 
Day 14 
10.9 [9.9, 12.0] 
10.0 [9.0, 11.1] 
10.3 [9.3, 11.3] 
Day 28 
10.8 [9.9, 11.9] 
9.6 [8.7, 10.6] 
10.8 [9.9, 11.9] 
Day 42 
77.6 [62.3, 96.7] 
45.2 [36.4, 56.2] 
54.4 [43.7, 67.8] 
Peak post vaccination 2 
87.8 [71.2, 108.3] 
49.5 [40.0, 61.3] 
59.6 [48.1, 74.0] 
 
Even with the EUA for intradermal MVA-BN being available, Stage 1 of this trial is designed to 
evaluate several unique issues: 
• As vaccine supply is not anticipated to meet the demand in the next year, this trial will 
evaluate dose reduction strategies focused on the ID route, that is, confirming the 
previously studied ID dose and evaluating one tenth dose of MVA-BN (1x107). 
• This trial will also assess differences in safety and tolerability of the ID versus the licensed 
SC regimen as issues of tolerability have been raised by the manufacturer and some in the 
medical community.  
 
While JYNNEOS is available under EUA for individuals younger than 18 years of age, this EUA 
will expire in January 31, 2023.  An FDA approved mpox vaccine for adolescents is lacking and 
remains a public health need. Most reported cases in the global 2022 mpox outbreak have involved 

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men who have sex with men, with a median age of 34 years.  Among global cases with age data 
available, 1.2% are aged 0-17 years;23 in the United States, from May 17 through September 24, 
2022, MPXV infections in persons under 18 years of age accounted for 0.3% of reported cases.24  
Among 55 adolescents aged 13-17 years, 89% were male, and the most common route of exposure 
was male to male sexual contact (66%). Prior to the global 2022 outbreak, mpox occurred primarily 
in children and adolescents in endemic countries.25,26 Increased mpox transmission within 
adolescent populations could occur if the outbreak continues, or in future outbreaks, given the 
mode of transmission through skin and mucosal contact during sexual activity or other activities 
with close contact.  
2.3 
Risk/Benefit Assessment 
 
For information regarding risk/benefit assessment for each study stage, see the corresponding 
appendix.  
 
3. 
OBJECTIVES AND ENDPOINTS 
 
For objectives and endpoints for each study stage, see the corresponding appendix. 
4. 
STUDY DESIGN 
4.1 
Overall Design 
This study is a Phase 2 randomized, open-label, non-placebo controlled, multi-site clinical trial that 
will evaluate two ID regimens for MVA-BN vaccine compared to the standard SC regimen in 
healthy, vaccinia-naïve adults 18 to 50 years of age, inclusive, (Stage 1). In Stage 2 of the study, 
the standard SC regimen will be evaluated in adolescents ages 12 through 17 years, inclusive, and 
compared to the standard SC regimen in adults ages 18 to 50, inclusive.   
 
In Stage 1, approximately 230 adult participants will be enrolled and randomized to one of three 
study arms. The two dose sparing strategies include one-fifth (2 x107) and one-tenth (1 x107) of 
the standard dose of MVA-BN administered ID on Day 1 and 29 (Arm 1 and 2, respectively). The 
comparator arm (Arm 3) will be the 2-dose standard (1x108) MVA-BN SC regimen. Stage 1 will 
enroll a 1:1:1 randomization allocation.  
 
In Stage 2, approximately 135 healthy, vaccinia-naïve adults will be enrolled (Arm 4) and will be 
given the standard, licensed regimen of 1x108 MVA-BN administered SC on Day 1 and 29 and 
will be combined with adults from Arm 3 (Stage 1) to be the comparator for the primary endpoint, 
non-inferiority testing. Approximately 315 healthy, vaccinia-naïve adolescents will be enrolled and 
given 1x108 MVA-BN administered SC on Days 1 and 29 (Arm 5). The study will have a set target 
enrollment of at least 25% adolescents ages 12 to 14 years to ensure that adequate numbers of 
younger adolescents are enrolled.  
 
 

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4.2 
Scientific Rationale for Study Design 
The rationale for each of the arms in this study is as follows: 
1. MVA-BN 2 x 107 ID (1/5th dose) on Days 1, 29 (Study Arm 1) – This regimen matches 
the prior ID dosing and matches the dose authorized in the EUA. This regimen would allow 
for 5-fold increase in vaccine supply.  
2. MVA-BN 1 x 107 ID (1/10th dose) on Days 1, 29 (Study Arm 2) – This regimen would 
test a larger dose conservation. This regimen would allow for 10-fold increase in vaccine 
supply. 
3. MVA-BN 1 x 108 SC on Days 1, 29 (Study Arms 3, 4, and 5) – This regimen is the 
licensed dose and route. Arm 3 will be used as a comparator to ID doses of MVA BN (Arms 
1 and 2, Stage 1). Arms 4 (adult) and 5 (adolescent) will be used to evaluate noninferiority 
of this licensed regimen among adolescents compared to adults (Stage 2). 
4.3 
Justification for Dose 
This study will use the FDA-approved, licensed dose 1 x 108 TCID50 MVA-BN administered SC 
on Day 1 and 29 in Stage 2 of the study and as the comparator for the ID doses of MVA-BN in 
Stage 1. It is anticipated that the licensed, 2-dose SC regimen will be safe and immunogenic in 
adolescents. The ID regimens being evaluated in this study use lower doses of the licensed vaccine, 
and either match or are one dilution lower than the dose used in the prior ID dosing study (PMID 
26143613). Therefore, it is anticipated that these doses administered ID will be safe and 
immunogenic.  
 
5. 
STUDY POPULATION 
 
For a description of the study population, eligibility criteria, lifestyle considerations, procedures 
for screen failures, recruitment and retention strategies for each stage see the corresponding 
appendix. 
 
 
6. 
STUDY PRODUCT 
6.1 
Study Product(s) and Administration 
6.1.1 
Study Product Description 
JYNNEOS is FDA-approved and licensed as a smallpox and mpox vaccine in the United States. 
The vaccine, when thawed, is a milky, light yellow to pale white colored suspension that is licensed 
for subcutaneous injection. JYNNEOS is a live vaccine produced from the strain Modified 
Vaccinia Ankara-Bavarian Nordic (MVA-BN), an attenuated, non-replicating orthopoxvirus. 
MVA-BN is grown in primary Chicken Embryo Fibroblast (CEF) cells suspended in a serum-free 
medium containing no material of direct animal origin, harvested from the CEF cells, purified, and 
concentrated by several Tangential Flow Filtration (TFF) steps including benzonase digestion. 
Each 0.5 mL dose is formulated to contain 0.5 x 108 to 3.95 x 108 infectious units of MVA-BN 
live virus in 10 mM Tris (tromethamine), 140 mM sodium chloride at pH 7.7. Each 0.5 mL dose 

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may contain residual amounts of host-cell DNA (≤ 20 mcg), protein (≤ 500 mcg), benzonase 
(≤0.0025 mcg), gentamicin (≤0.163 mcg), and ciprofloxacin (≤0.005 mcg).  
 
6.1.2 
Dosing and Administration 
In this trial, a licensed vaccine is being evaluated (i.e., JYNNEOS) and there is no placebo group 
(Table 5). In Stage 1, use of the contralateral arm was an option if there is any residual local reaction 
at Day 29 or if participant requests that this be done.  In Stage 2, the second vaccination will be 
given in the contralateral arm unless the site deems that using the same arm is in the best interest 
of the participant in terms of safety or using the same arm (for the second injection) will enable the 
site to better evaluate reactogenicity (e.g., tattoo on opposite upper arm). If the second vaccination 
is given in the same arm as the first vaccination, the second injection should be given 
approximately 5 cm away from the first injection site if physically possible. 
 
Table 5 Study Arms 
Stage 1 (Adult) 
Arm 
Dose of JYNNEOS (MVA-BN) 
Route of Administration* 
Vaccination Day 
Day 1 
Day 29 
1 
2 x 107 TCID50, (0.1 mL) 
Intradermal 
X 
X 
2 
1 x 107 TCID50, (0.05 mL) 
Intradermal 
X 
X 
3 
1 x 108 TCID50, (0.5 mL) 
Subcutaneous 
X 
X 
 
Stage 2 (Adults and Adolescent) 
Arm 
Dose of JYNNEOS 
(MVA-BN) 
Route of Administration* 
Vaccination Day 
Day 1 
Day 29 
4 (Adult) 
 1 x 108 TCID50, (0.5 mL) 
Subcutaneous 
X 
X 
5 (Adolescent) 
1 x 108 TCID50, (0.5 mL) 
Subcutaneous 
X 
X 
*Subcutaneous is administered in the upper arm, intradermal is administered in the volar aspect (inner side) of 
the forearm. 
 
6.1.3 
Dose Escalation 
Not Applicable. 
 
6.1.4 
Dose Modifications 
Not Applicable. 
 
6.1.5 
Criteria for Redosing 
If study product administration is unsuccessful, another administration will not be attempted.  
 
6.2 
Preparation/Handling/Storage/Accountability 
6.2.1 
Acquisition and Accountability 
 

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Product: JYNNEOS (MVA-BN vaccine) 
The JYNNEOS (MVA-BN vaccine) will be stored and provided by DMID Repository. Study 
product will be shipped to the clinical research site upon request and approval from DMID. 
 
Accountability 
The participating site PI is responsible for study product distribution and disposition and has 
ultimate responsibility for study product accountability. The participating site PI may delegate to 
the participating site’s research pharmacist responsibility for study product accountability. The 
participating site’s research pharmacist will be responsible for maintaining complete records and 
documentation of study product receipt, accountability, dispensation, storage conditions, and final 
disposition of the study products.  
 
Time of vaccine administration to the participant will be recorded on the appropriate data collection 
form (DCF). All study product(s), including the amount of JYNNEOS (MVA-BN vaccine), and 
whether administered or not, must be documented on the appropriate study product accountability 
record or dispensing log. The sponsor’s monitoring staff will verify the participating site’s study 
product accountability records and dispensing logs per the DMID-approved clinical monitoring 
plan (CMP). 
 
Once all participant dosing is complete, the pharmacy staff should retain or dispose of used study 
products and complete study product accountability procedures in accordance with site-specific 
standard operating procedures (SOPs). This applies to: 
• used JYNNEOS (MVA-BN vaccine) vials 
• JYNNEOS (MVA-BN vaccine) cartons 
 
All used vials and cartons may either be sequestered from the unused supplies and retained until 
study conclusion or until study product accountability has occurred by the monitor and written 
notification stating retention is no longer required is received. Used syringes should be discarded 
per usual procedure.  
 
Disposition  
After the study treatment period has ended or as appropriate over the course of the study after study 
product accountability has been performed, guidance for disposition of unused JYNNEOS (MVA-
BN vaccine) vials will be provided by DMID.  
 
6.2.2 
Formulation, Appearance, Packaging, and Labeling 
 
Product: JYNNEOS (MVA-BN vaccine) 
JYNNEOS is supplied in a single-dose vial with turquoise and white label for SC injection. Each 
0.5 mL dose is formulated to contain 0.5 x 108 to 3.95 x 108 infectious units of MVA-BN live virus 
in 10 mM Tris (tromethamine), 140 mM sodium chloride at pH 7.7. Each 0.5 mL dose may contain 
residual amounts of host-cell DNA (≤ 20 mcg), protein (≤ 500 mcg), benzonase (≤0.0025 mcg), 
gentamicin (≤0.163 mcg), and ciprofloxacin (≤0.005 mcg). JYNNEOS is a sterile vaccine 
formulated without preservatives. The vial stoppers are not made with natural rubber latex.  
 
6.2.3 
Product Storage and Stability 

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Product: JYNNEOS (MVA-BN vaccine) 
JYNNEOS should be kept frozen at -25°C to -15°C (-13°F to +5°F) and stored in the original 
package to protect from light. JYNNEOS should not be re-frozen once a vial has been thawed. 
Once thawed, the vaccine may be kept at +2°C to +8°C (+36°F to +46°F) for 4 weeks. The package 
insert provides additional instructions for the handling and storage of JYNNEOS. 
 
6.2.4 
Preparation 
Each dose (0.5 mL) is supplied in a single-dose vial. Sites should allow the vaccine to thaw and 
reach room temperature before use (about 15 to 30 minutes). After thawing, the total time stored 
at +2°C to +8°C (+36°F to +46°F) should not exceed 4 weeks. Once the vial is punctured and a 
dose is withdrawn, if it is not used in its entirety, it should be stored at +2°C to +8°C (+36°F to 
+46°F) and discarded within 8 hours of the first puncture. If the unpunctured vial is initially 
shipped/stored at 2-8C then it is stable for up to 8 weeks. Sites should not refreeze the vaccine. 
JYNNEOS may be kept frozen until the expiration date.  
 
JYNNEOS is a light yellow to pale white colored, milky suspension when thawed. Sites will 
visually inspect the product for particulate matter and discoloration prior to administration. If either 
condition is present, the vaccine will not be administered. Study product administrators will gently 
swirl the vial for at least 30 seconds.  
 
For the ID injection (Arm 1), 0.1 mL of vaccine will be withdrawn from the vial into a sterile 
syringe and injected intradermally into the volar aspect (inner side) of the forearm. 
 
For the ID injection (Arm 2), 0.05 mL of vaccine will be withdrawn from the vial into a sterile 
syringe and injected intradermally into the volar aspect of the forearm. 
 
For the SC injection (Arms 3, 4 and 5), 0.5 mL of vaccine will be withdrawn from the vial into a 
sterile syringe and injected into the fatty subcutaneous tissue of the upper arm. 
 
See the protocol-specific MOP for detailed information on the preparation, labeling, storage, and 
administration for each arm. 
 
6.3 
Measures to Minimize Bias: Randomization and Blinding 
6.3.1 
Treatment Assignment Procedures 
The randomization procedure will be described in the MOP.  
 
 
 
6.3.2 
Randomization  
For Stage 1, there will be a 1:1:1 randomization allocation. Randomization will not be stratified. 
Randomized treatment assignments will be generated by a statistician at The Emmes Company, 
LLC, the Data and Statistical Coordinating Center (SDCC) for this study. Participants will be 
registered using a web-based application developed by The Emmes Company, LLC. Upon entry 

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of demographic data and confirmation of eligibility for the trial, the participant will be enrolled 
and randomized. The randomization procedure will be described in more detail in the MOP.  
 
Stage 2 is not randomized.  All Stage 2 participants will receive the licensed SC regimen. For Stage 
2, the aim is to enroll at least 25% adolescents ages 12 to 14 years. 
 
6.3.3 
Blinding and Masking Procedures 
This study will not utilize blinding or masking procedures as it is an open-label, non-placebo-
controlled trial. Research laboratories will be blinded to participant study arm for the purposes of 
immunogenicity/efficacy evaluations.  
6.4 
Study Intervention Compliance 
Each dose of JYNNEOS will be administered by a member of the clinical research team that is 
qualified per state and institution policies to administer the study product. Administration and date, 
time, and location of injection will be recorded on the appropriate eCRF. 
6.5 
Concomitant Therapy 
For this platform trial that evaluates use of JYNNEOS vaccine, participants in all stages will be 
asked to avoid use of medications that might interfere with the evaluation of the immune response 
to the vaccine unless clinically indicated for a medical condition diagnosed after enrollment. 
Specific information regarding concomitant therapy for each study stage, see the corresponding 
appendix. 
 
7. 
STUDY INTERVENTION DISCONTINUATION AND 
PARTICIPANT DISCONTINUATION/WITHDRAWAL 
 
For this platform trial, additional individual and study halting criteria were added for stages 
involving more vulnerable populations for which safety profile is largely unknown (e.g., 
adolescents).  For each stage, see the corresponding appendix for specific information.  Refer to 
the corresponding appendix for information regarding participants who discontinue study 
intervention, study withdrawal, and participants lost to follow-up. 
 
8. 
STUDY ASSESSMENTS AND PROCEDURES 
 
Please see Appendix A and B for Sections 8.1 through 8.5. 
 
For information regarding study assessments and procedures for each study stage, see the 
corresponding appendix. 
 
8.6 
Adverse Events and Serious Adverse Events 
8.6.1 
Definition of Adverse Events (AE) 

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Adverse event means any untoward medical occurrence associated with the use of an intervention 
in humans, whether or not considered intervention-related (21 CFR 312.32 (a)). An AE can 
therefore be any unfavorable and unintended sign (including an abnormal laboratory finding), 
symptom, or disease temporally associated with the use of medicinal (investigational) product.  
 
Any medical condition that is present at the time the participant is screened will be considered as 
baseline and not reported as an AE. However, if the severity (i.e., grade) of any pre-existing 
medical condition increases, it should be recorded as an AE. 
 
Adverse events can be further divided into solicited adverse events and unsolicited adverse events. 
Solicited adverse events are those for which the study team will specifically query the participant 
whether they occurred. Unsolicited adverse events are those events that the participant report 
occurring without being queried about the specific event.  
 
8.6.1.1 
Solicited Adverse Events 
Reactogenicity will be especially important to document because of prior studies demonstrating 
more local (measurement) reactogenicity among participants who received the ID MVA-BN 
vaccine injection. This study will collect the following solicited adverse events based on prior 
studies. This includes local (pain at the site of the injection, erythema/redness, induration/swelling, 
pruritis) and systemic (fever, chills, nausea, headache, fatigue, change in appetite, myalgia 
[exclusive of the injection site], and arthralgia) reactogenicity. In addition, there is an expectation 
that some participants will develop skin discoloration and nodules which will be reported as AEs 
and not collected on the memory aid and followed through to resolution. For this study, the 
following toxicity grading scale is used: 
“FDA Guidance for Industry, Toxicity Grading Scale for Healthy Adults and Adolescent 
Volunteers Enrolled in Preventive Vaccine Clinical Trials” as a reference.  
 
Of note, pruritis/itching, arthralgia, chills, and change in appetite are not included in the FDA 
toxicity table. However, the FDA Guidance allows for addition of other signs and symptoms as 
follows: 
 
Mild: 
 
 
 
 
No interference with activity 
Moderate: 
 
 
 
Some interference with activity 
Severe:   
 
 
 
Prevents daily activity 
Potentially Life Threatening:   
ER visit or hospitalization 
 
8.6.1.2 
Unsolicited Events 
Unsolicited events are all AEs spontaneously reported by the participant and/or in response to an 
open question from study personnel or revealed by observation, physical examination, or other 
diagnostic procedures.  
 
 
8.6.2 
Definition of Serious Adverse Events  
An adverse event or suspected adverse reaction is considered "serious" if, in the view of either the 
investigator or sponsor, it results in any of the following outcomes (21 CFR 312.32 (a)):  

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• death 
• a life-threatening adverse event* 
• inpatient hospitalization or prolongation of existing hospitalization 
• a persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions, or  
• a congenital anomaly/birth defect.  
 
Important medical events that may not result in death, be life-threatening, or require hospitalization 
may be considered serious when, based upon appropriate medical judgment, they may jeopardize 
the patient or participant and may require medical or surgical intervention to prevent one of the 
outcomes listed in this definition. Examples of such medical events include allergic bronchospasm 
requiring intensive treatment in an emergency room or at home, convulsions that do not result in 
inpatient hospitalization, etc. 
 
* An adverse event is considered “life-threatening” if, in the view of either the investigator or 
sponsor, its occurrence places the patient or participant at immediate risk of death. It does not 
include grade 4 severity unless the adverse event might have caused death.  
 
8.6.3 
Classification of an Adverse Event 
The determination of seriousness, severity and causality will be made by an on-site investigator 
or other staff as listed on the delegation log. Any potential grade 3 or 4 AE should be evaluated 
by someone qualified to provide a medical evaluation of AEs. This includes but is not limited to 
physicians, physician assistants, and nurse practitioners.  
 
8.6.3.1 
Severity of Event 
All AEs or SAEs will be assessed for severity, according to the toxicity grading scale, FDA 
Guidance for Industry, Toxicity Grading Scale for Healthy Adults and Adolescent Volunteers 
Enrolled in Preventive Vaccine Clinical Trials. For adverse events (AEs) not included in the 
protocol-defined grading scale, the following guidelines will be used to describe severity.  
 
Mild (Grade 1): Events that are usually transient and may require only minimal or no 
treatment or therapeutic intervention and generally do not interfere with the participant’s 
usual activities of daily living. 
Moderate (Grade 2): Events that are usually alleviated with additional specific therapeutic 
intervention. The event interferes with usual activities of daily living, causing discomfort 
but poses no significant or permanent risk of harm to the research participant. 
Severe (Grade 3): Events interrupt usual activities of daily living, or significantly affects 
clinical status, or may require intensive therapeutic intervention. Severe events are usually 
incapacitating. 
Life-threatening (Grade 4): Extreme limitation in activity, significant assistance required; 
significant medical intervention/therapy required, hospitalization or care provided.  
 
8.6.3.2 
Relationship to Study Intervention 
For each reported adverse event or reaction, the Principal Investigator or designee must assess the 
relationship of the event to the study product using the following guideline: 

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Related – The AE is known to occur with the study intervention, there is a reasonable 
possibility that the study intervention caused the AE, or there is a temporal relationship 
between the study intervention and event. Reasonable possibility means that there is 
evidence to suggest a causal relationship between the study intervention and the AE. 
Not Related – There is not a reasonable possibility that the administration of the study 
intervention caused the event, there is no temporal relationship between the study 
intervention and event onset, or an alternate etiology has been established. 
 
8.6.5 
Adverse Event Reporting 
8.6.5.1 
Investigators Reporting of AEs 
All clearly related signs, symptoms, and results of diagnostic procedures performed because of an 
AE should be grouped together and recorded as a single diagnosis or AE term, if available. If the 
AE is a laboratory abnormality that is part of a clinical condition or syndrome, it should be recorded 
as the syndrome or diagnosis rather than the individual laboratory abnormality. Each AE will also 
be described in terms of duration (start and stop date), severity, association with the study product, 
action(s) taken, and outcome. 
 
AEs characterized as intermittent require documentation of onset and duration of each episode.  
All AEs will be assessed for severity, relatedness to study vaccine (see Section 8.6.3.1 and Section 
8.6.3.2) and seriousness (see Section 8.3.2) by the study PI or sub-investigator. 
 
All AEs will be captured on the appropriate data collection form. Information to be collected for 
AEs includes event term or description, date of onset, assessment of severity, relationship to study 
product, and alternate etiology (assessed only by those with the training and authority to make a 
diagnosis and listed on the Form FDA 1572 as an investigator), date of resolution, seriousness, and 
outcome. AEs occurring during the trial collection and reporting period will be documented 
appropriately regardless of relationship.  
 
8.6.5.2 
Special Reporting of Adverse Events 
Protocol specified Adverse Events of Special Interest (AESIs) will be reported within 24 hours of 
the site awareness of the AESI to the DMID Pharmacovigilance Group via the mechanism 
described below for SAE reporting (see Section 8.6.6.1). 
  
8.6.6 
Serious Adverse Event Reporting 
8.6.6.1 
Investigators Reporting of SAEs 
Any AE that meets a protocol-defined serious criterion must be submitted immediately (within 24 
hours of site awareness) on an SAE form to the DMID Pharmacovigilance Group, at the following 
address: 
  
DMID Pharmacovigilance Group 
Clinical Research Operations and Management Support (CROMS) 
6500 Rock Spring Dr. Suite 650 
Bethesda, MD 20817, USA 

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SAE Hot Line: 1-800-537-9979 (US) or 1-301-897-1709 (outside US) 
SAE FAX Number: 1-800-275-7619 (US) or 1-301-897-1710 (outside US) 
SAE Email Address: PVG@dmidcroms.com 
 
In addition to the SAE form, select SAE data fields must also be entered into the SDCC system. 
See the protocol-specific MOP for details regarding this procedure.  
 
Other supporting documentation of the event may be requested by the DMID Pharmacovigilance 
Group and should be provided as soon as possible. The DMID Medical Monitor will review and 
assess the SAE for regulatory reporting and potential impact on study participant safety and 
protocol conduct. 
 
At any time after completion of the study, if the site principal investigator or appropriate sub-
investigator becomes aware of an SAE that is suspected to be related to study product, the site 
principal investigator or appropriate sub-investigator will report the event to the DMID 
Pharmacovigilance Group. 
 
8.6.6.2 
Regulatory Reporting of SAEs 
Following notification from the site Principal Investigator or appropriate sub-investigator, DMID, 
as the IND sponsor, will report any Suspected Unexpected Serious Adverse Reaction (SUSAR) to 
the FDA as an IND safety report. DMID will report an AE as a suspected unexpected adverse event 
only if there is evidence to suggest a causal relationship between the study intervention and the 
AE.  
 
The Sponsor must ensure the event meets all three of the definitions: 
• Suspected adverse reaction. 
• Serious. 
• Unexpected.  
 
Both serious and unexpectedness are important, but the event will be reported only if there is 
evidence to suggest a causal relationship between the drug and the adverse event, such as:  
• A single occurrence of an event that is uncommon and known to be strongly associated 
with drug exposure.  
• One or more occurrences of an event that is not commonly associated with drug exposure 
but is otherwise uncommon in the population exposed to the drug.  
• On review as an aggregate analysis when the occurrence is higher than the historical 
control.  
 
DMID will report to the FDA any unexpected fatal or life-threatening suspected adverse reaction 
as soon as possible, but in no case later than 7 calendar days after the sponsor’s initial receipt of 
the information. If the event is not fatal or life-threatening the IND safety report will be submitted 
within 15 calendar days after the sponsor determines that the information qualifies for reporting as 
specified in 21 CFR Part 312.32. Relevant follow up information to an IND safety report will be 
submitted as soon as the information is available. Upon request from FDA, DMID will submit to 
the FDA any additional data or information that the agency deems necessary, as soon as possible, 
but in no case later than 15 calendar days after receiving the request.  

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DMID will submit an IND safety report to the FDA and will notify all participating site Principal 
Investigators (i.e., all Principal Investigators to whom the sponsor is providing drug under its 
IND(s) or under any Principal Investigator’s IND(s) of potential serious risks from clinical studies 
or any other source, as soon as possible. SAEs that are not SUSARs will be reported to the FDA 
at least annually in a summary format which includes all SAEs.  
 
8.6.7 
Reporting Events to Participants 
Participants have the right to be informed of any new findings of AEs or SAEs that may affect their 
safety or influence their choice to participate or continue participating in the study. 
 
8.6.8 
Reporting of Pregnancy 
Pregnancy is not an AE. However, any pregnancy that occurs during study participation (through 
Day 365 Stage 1, and Day 394 for Stage 2) should be reported to the sponsor on the appropriate 
DCF. Pregnancy should be followed for safety and outcome. This follow-up will include pregnancy 
outcome (termination, pre-term birth, term birth) and newborn outcome (live birth, fetal demise, 
stillbirth; presence of any congenital anomalies). No in-person visits will be required for pregnancy 
outcome determination. 
 
8.7 
Unanticipated Problems  
8.7.1 
Definition of Unanticipated Problems (UP) 
The Department of Health and Human Services Office for Human Research Protections (OHRP) 
considers unanticipated problems (UPs) involving risks to participants or others to include, in 
general, any incident, experience, or outcome that meets all of the following criteria: 
• Unexpected in terms of nature, severity, or frequency given (a) the research procedures that 
are described in the protocol-related documents, such as the Institutional Review Board 
(IRB)-approved research protocol and informed consent, parental permission and assent 
documents; and (b) the characteristics of the participant population being studied; and 
• Related or possibly related to participation in the research (“possibly related” means there 
is a reasonable possibility that the incident, experience, or outcome may have been caused 
by the procedures involved in the research); and 
• Suggests that the research places participants or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or 
recognized. 
 
Incidents arising from noncompliance with study procedures should be reported as protocol 
deviations (see Section 8.1.1). An incident that qualifies as both a UP and a protocol deviation 
should be reported as both. 
 
 
8.7.2 
Unanticipated Problem Reporting 
The investigator will report UPs to the study sponsor, the reviewing Institutional Review Board 
(IRB) and to the SDCC.  

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The UP report will include the following information: 
• Protocol identifying information: protocol title and number, PI’s name, and the IRB project 
number; 
• A detailed description of the event, incident, experience, or outcome;  
• An explanation of the basis for determining that the event, incident, experience, or outcome 
represents an UP;  
• A description of any changes to the protocol or other corrective actions that have been taken 
or are proposed in response to the UP. 
 
To satisfy the requirement for prompt reporting, UPs will be reported using the following timeline:  
 
• UPs that are SAEs will be reported to the IRB and to the SDCC/study sponsor within 24 
hours of the investigator becoming aware of the event.  
• Any other UP will be reported to the IRB and to the SDCC/study sponsor within a timeline 
defined according to the relevant policies.  
• UPs will be collected through the end of the study. 
 
8.7.3 
Reporting Unanticipated Problems to Participants 
Participants will be informed of any UPs that will potentially influence their participation in this 
trial. 
 
9. 
STATISTICAL CONSIDERATIONS 
 
For statistical considerations for each study stage, see the corresponding appendix. 
 
10. 
SUPPORTING DOCUMENTATION AND OPERATIONAL 
CONSIDERATIONS 
10.1 
Regulatory, Ethical, and Study Oversight Considerations 
This study will be conducted in conformity with the principles set forth in The Belmont Report: 
Ethical Principles and Guidelines for the Protection of Human Participants of Research (US 
National Commission for the Protection of Human Participants of Biomedical and Behavioral 
Research; April 18, 1979), and the federal policy for the Protection of Human Participants codified 
in 45 CFR Part 46, 21 CFR Part 50 (Protection of Human Participants), and the ICH E6(R2). 
 
An OHRP-registered IRB will review and approve this protocol, associated informed consent, 
parental permission and assent documents, recruitment materials, and handouts or surveys intended 
for the participants, prior to the recruitment, screening and enrollment of participants. The IRB 
review shall be in accordance with 45 CFR 46 and 21 CFR 50, 21 CFR 56 (IRBs), and other federal, 
state, and local regulations and policies, as applicable. 
 

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Each institution engaged in this research will hold a current Federalwide Assurance (FWA) issued 
by the Office for Human Research Protections (OHRP) for federally funded research. and provide 
the FWA number to DMID. Each site principal investigator will obtain IRB approval for this 
protocol and any amendments to be conducted at his/her research site(s).  
 
Any amendments to the protocol or informed consent, parental permission and assent documents 
will be approved by the IRB before they are implemented. IRB review and approval will occur at 
least annually throughout enrollment and follow-up of participants, in accordance with applicable 
regulations and the requirements of the IRB/IEC. The participating site PI will notify the IRB of 
deviations from the protocol and reportable SAEs, as applicable to the IRB policy. 
 
DMID must receive the documentation that verifies IRB/IEC approval for this protocol, informed 
consent, parental permission and assent documents and associated documents, prior to the 
recruitment, screening and enrollment of participants, and any IRB approvals for continuing review 
or amendments as required by DMID. 
  
10.1.1 
Informed Consent Process 
 
For information regarding the informed consent and assent, where applicable, process for each 
study stage, see the corresponding appendix. 
 
10.1.2 
Study Termination and Closure 
Section 7, Study Intervention Discontinuation and Participant Discontinuation/Withdrawal, 
describes the temporary halting of the study. This study may be prematurely terminated if there is 
sufficient reasonable cause, including but not limited to: 
• Determination of unexpected, significant, or unacceptable risk to participants 
• Results of interim efficacy or futility analysis  
• Insufficient compliance to protocol requirements 
• Data that are not sufficiently complete and/or evaluable 
• Regulatory authorities’ determination 
• Sponsor’s determination 
 
If the study is prematurely terminated, the Principal Investigator (PI) will promptly inform study 
participants and the Institutional Review Board (IRB) and regulatory authorities as applicable. 
Study participants will be contacted, as applicable, and be informed of changes to study visit 
schedule. The PI will assure appropriate follow-up for the participants, as necessary. The sponsor 
will notify regulatory authorities as applicable.  
  
10.1.3 
Confidentiality and Privacy 
Participant confidentiality is strictly held in trust by the participating investigators, their staff, and 
the sponsor(s) and their agents. This confidentiality is extended to cover clinical information 
relating to participants, test results of biological samples and genetic tests, and all other information 
generated during participation in the study. No identifiable information concerning participants in 

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the study will be released to any unauthorized third party. Participant confidentiality will be 
maintained when study results are published or discussed in conferences.  
  
The study monitor, other authorized representatives of the sponsor, representatives of the 
Institutional Review Board (IRB), and/or regulatory agencies may inspect all documents and 
records required to be maintained by the investigator, including but not limited to, medical records 
(office, clinic, or hospital) and pharmacy records for the participants in this study. The clinical 
study site will permit access to such records. 
 
All source records including electronic data will be stored in secured systems in accordance with 
institutional policies and federal regulations. All study data and research specimens that leave the 
site (including any electronic transmission of data) will be identified only by a coded number that 
cannot be linked to a participant. 
 
As this research is funded by the NIH, it is covered by NIH policy which effectively issues the 
research a Certificate of Confidentiality. By this policy, researchers cannot be forced to disclose or 
provide, in any Federal, State, or local civil, criminal, administrative, legislative, or other 
proceeding, the name of such individual or any such information, document, or biospecimen that 
contains identifiable, sensitive information about the individual and that was created or compiled 
for purposes of the research, unless such disclosure or use is made with the consent of the individual 
to whom the information, document, or biospecimen pertains. 
 
The Certificate cannot be used to resist a demand for information from personnel of the United 
States Government that is used for auditing or evaluation of federally funded projects, like this 
study, or for information that must be released in order to meet the requirements of the FDA. 
 
A Certificate of Confidentiality does not prevent the participant from voluntarily releasing 
information about themselves or their involvement in this research. If any person or agency obtains 
a written consent to receive research information, then the researchers may not use the Certificate 
to withhold that information.  
 
The Certificate of Confidentiality does not prevent the researchers from reporting without the 
participant’s consent, information that would identify the participant as a participant in the research 
project regarding matters that must be legally reported including child and elder abuse, sexual 
abuse, or wanting to harm themselves or others. 
  
The release of individual private information or specimens for other research will only occur if 
consent was obtained from the individual or the parent(s) or LAR of the adolescent participants to 
whom the information, document, or biospecimen pertains, or for the purposes of other research 
that the release is in compliance with applicable Federal regulations governing the protection of 
human participants in research.  
 
 
 
 
 

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10.1.4 
Secondary Use of Stored Specimens and Data  
 
10.1.4.1 
Samples for Secondary Research 
Repository Research Sample 
To participate in this study, adult participants and the parent or LAR of adolescent participants will 
be asked for consent for storage of samples for secondary use. Samples will be stored indefinitely 
at a DMID-designated storage facility. Each sample will be encoded (labeled) only with a barcode 
and a unique tracking number to protect participant confidentiality. Secondary research with coded 
samples and data may occur, however, participant confidentiality will be maintained as described 
for this protocol. An IRB review of the secondary research using coded specimens is required. 
 
Repository Research Samples, upon written request and approval from DMID and any approvals 
required by the site, may be shared for secondary research with investigators at the participating 
site, with researchers at other sites or other institutions, or company-designated research 
laboratories. The samples will not be sold or used directly for production of any commercial 
product. DMID will authorize shipment from the repository. 
 
Reports from secondary research will not be kept in the participants’ health records or shared with 
participants, unless required by law. Reports will not be sent to the specimen repository. The 
participant’s decision for secondary research can be changed at any time by notifying the study 
doctors or nurses in writing. If the participant changes his/her decision, the samples will be 
destroyed if the samples have not been used for research or released for a specific research project. 
 
10.1.4.2 
Data Sharing for Secondary Research 
Data from this study may be used for secondary research. Individual participant data collected 
during the trial that are sufficient to reanalyzed primary and secondary endpoints will be made 
available after deidentification. The SAP and Analytic Code will also be made available. This data 
will be available following publication, with no end date. The data will be made available to 
researchers who provide a methodologically sound proposal. The data will be available for any 
purpose outlined in the approved proposal. Proposals should be directed to DMID. To gain access, 
data requestors will need to sign a data access agreement. The investigator may request removal of 
data on individual study participants from NIH data repositories in the event that a research 
participant withdraws or changes his or her consent. However, data that have been distributed for 
approved research use cannot be retrieved. 
 
10.1.5 
Key Roles and Study Governance 
This is a multi-site clinical trial and as such, all study team members and roles are listed in the 
Manual of Procedures (MOP). 
 
10.1.6 
Safety Oversight 
For information regarding safety oversite for each study stage, see the corresponding appendix. 
 
 
 

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10.1.7 
Clinical Monitoring 
Clinical site monitoring is conducted to ensure that the rights and well-being of trial participants 
are protected, that the reported trial data are accurate, complete, and verifiable. Clinical Monitoring 
ensures that the conduct of the trial is in compliance with the currently approved 
protocol/amendment(s), International Council for Harmonisation (ICH), Good Clinical Practice, 
and with applicable regulatory requirement(s) and sponsor requirements.  
 
Monitoring for this study will be overseen by NIAID/DMID and conducted by NIAID/DMID 
contractors. Details of clinical site monitoring are documented in a Clinical Monitoring Plan 
(CMP). The CMP describes in detail who will conduct the monitoring, at what frequency 
monitoring will be done, at what level of detail monitoring will be performed, and the distribution 
of monitoring reports. Monitoring visits will include, but are not limited to, review of regulatory 
files, investigational product administration and accountability records, eCRFs, informed consent, 
parental permission and assent forms, medical and laboratory reports, site study storage records, 
training records, and protocol and GCP compliance. Site monitors will have access to each 
participating site, study personnel, and all study documentation according to the NIAID or DMID-
approved site monitoring plan.  Study monitors will meet with site principal investigators (or 
designee) to discuss any problems and outstanding issues and will document site visit findings and 
discussions.  
 
10.1.8 
Quality Assurance and Quality Control 
Quality control (QC) and quality assurance (QA) activities are essential to the safety of 
participants, and the reliability of study data. Each site participating in the study is responsible for 
integrating quality control checks throughout the study and implementing a QA Checklist or 
Clinical Quality Management Plan (CQMP). The site will conduct the following:  
 
1. Routine internal QC and QA activities for the purposes of measuring, documenting and 
reporting study conduct, protocol adherence, human participants’ protections, and 
reliability of the protocol-driven data collected.  
2. Processes for addressing data quality issues (i.e., collecting, recording), and reporting 
findings in a timely manner.  
3. Identify systemic issues (e.g., protocol or human participant protections non-compliance), 
and implementation and evaluation of Corrective and Preventative Action Plan (CAPA) 
procedures, if applicable. 
 
10.1.9 
Data Handling and Record Keeping 
10.1.9.1 
Data Collection and Management Responsibilities 
Data collection is the responsibility of the clinical trial staff at the site under the supervision of the 
site investigator. The investigator is responsible for ensuring the accuracy, completeness, legibility, 
and timeliness of the data reported. All source documents should be completed in a neat, legible 
manner to ensure accurate interpretation of data.  
 

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10.1.9.2 
Data Coordinating Center / Biostatistician Responsibilities 
The data coordinating center for this study will be responsible for data management, quality review, 
analysis, and reporting of the study data. Adverse events and medical history will be coded 
according to the MedDRA dictionary. Concomitant medications will be coded according to the 
WHO Drug dictionary. At the end of the study, a copy of all datasets including annotated case 
report forms and data dictionary will be provided to DMID.  
 
A separate Study Data Standardization Plan (SDSP) will be developed which describes the 
technical recommendations for the submission of human study data and related information in a 
standardized electronic format throughout product development. 
 
10.1.9.3 
Data Capture Methods 
Clinical research data, including, but not limited to, AE/SAEs, concomitant medications, medical 
history, physical assessments will be abstracted from the source documentation and/or collected 
on source document worksheet by study personnel then entered into an eCRFs via a 21 CFR Part 
11-compliant internet data entry system provided by the study data coordinating center. The data 
system includes password protection and internal quality checks, such as automatic range checks, 
to identify data that appear inconsistent, incomplete, or inaccurate.  
 
The IND Sponsor is responsible for review of data collection tools and processes, and review of 
data and reports. 
 
Study data will be collected on paper CRFs and then entered into the eCRF or data will be entered 
directly into the eCRF.  
  
10.1.9.4 
Study Record Retention 
For information regarding study record retention for each study stage, see the corresponding 
appendix. 
 
10.1.9.5 
Source Records 
Source data are all information, original records of clinical findings, observations, or other 
activities documented in a clinical trial necessary for the reconstruction and evaluation of the trial. 
Each participating site will maintain appropriate medical and research records for this trial, in 
compliance with ICH GCP, regulatory, and institutional requirements. Data recorded in the 
electronic case report form (eCRF) derived from source documents should be consistent with the 
data recorded on the source documents. Data entered directly into the eCRFs will be considered 
the source document. All source documents should be completed in a neat, legible manner to ensure 
accurate interpretation of data.  
 
Interview of participants is sufficient for obtaining medical history. Solicitation of medical records 
from the participant’s primary care provider is not required. 
 
 
 

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10.1.10 
Protocol Deviations 
A protocol deviation is any noncompliance with the clinical trial protocol, any process that is noted 
in the protocol and refers to details in the MOP, or GCP requirements.  
 
The noncompliance may be either on the part of the participant, the investigator, or the study site 
staff. Following a deviation(s), corrective actions should be developed by the site and implemented 
promptly. All individual protocol deviations will be addressed in participant study records.  
 
It is the responsibility of the site principal investigator and personnel to use continuous vigilance 
to identify and report deviations within five working days of identification of the protocol 
deviation, or within five working days of the scheduled protocol-required activity. All deviations 
must be promptly reported to DMID per the protocol deviation reporting procedures. Protocol 
deviations must be sent to the local IRB/IEC per their guidelines. The site principal investigator 
and personnel are responsible for knowing and adhering to their IRB requirements.  
 
10.1.11 
Publication and Data Sharing Policy 
10.1.11.1 Human Data Sharing Plan 
All NIH protocols are required to have a Data Sharing Plan describe provisions for protecting the 
participants’ privacy and the confidentiality of the data. This study will be conducted in accordance 
with the following publication and data sharing policies and regulations: 
National Institutes of Health (NIH) Public Access Policy, which ensures that the public has access 
to the published results of NIH funded research. It requires scientists to submit final peer-reviewed 
journal manuscripts that arise from NIH funds to the digital archive PubMed Central upon 
acceptance for publication. 
 
As of January 2018, all clinical trials supported by the NIH must be registered on 
ClinicalTrials.gov, no later than 21 days after the enrollment of the first participant. Results of all 
clinical trials supported by the NIH, generally, need to be submitted no later than 12 months 
following the primary completion date. As part of the result posting, a copy of this protocol and a 
copy of the Statistical Analysis Plan will be posted on ClinicalTrials.gov.  
 
10.1.11.2 Genomic Data Sharing Plan 
Not Applicable. 
 
10.1.11.3 Publication 
This study will comply with the NIH Public Access Policy, which ensures that the public has access 
to the published results of NIH funded research. As such, the final peer-reviewed journal 
manuscripts will be accessible to the public on PubMed Central no later than 12 months after 
publication. 
 
10.1.12 
Conflict of Interest Policy 
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical. Therefore, any actual conflict of interest of persons who have 
a role in the design, conduct, analysis, publication, or any aspect of this trial will be disclosed and 

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managed. Furthermore, persons who have a perceived conflict of interest will be required to have 
such conflicts managed in a way that is appropriate to their participation in the design and conduct 
of this trial. DMID has established policies and procedures for all study group members to disclose 
all conflicts of interest and will establish a mechanism for the management of all reported dualities 
of interest. 
 
10.2 
Additional Considerations 
10.2.1 
Research Related Injuries 
For any potential research related injury, the site principal investigator or designee will assess the 
participant. The site principal investigator should then determine if an injury occurred as a direct 
result of the tests or treatments that are done for this trial. As needed, referrals to appropriate health 
care facilities will be provided to the participant. No financial compensation will be provided by 
the NIAID, NIH, or the federal government to the participant, for any injury suffered due to 
participation in this trial. 
 
10.2.2 
PREP Act 
The study vaccine and the efforts for this clinical trial are covered under the Public Readiness and 
Emergency Preparedness Act (PREP Act). The PREP Act applies under the terms of the PREP Act 
declaration in place for smallpox/orthopoxvirus countermeasures for activities conducted pursuant 
to 
federal 
agreements 
or 
federal 
programs 
(ref: 
www.federalregister.gov/documents/2015/12/09/2015-31092/smallpox-medical-
countermeasures-amendment). JYNNEOS is used under an IND for mpox pursuant to a federal 
agreement/program and is therefore covered under the PREP Act. The PREP Act covers persons 
(such as manufacturers, distributers, program planners, and other qualified persons who prescribe, 
administer or dispense study product) are immune from liability from the administration, or use of 
a covered countermeasure, such as JYNNEOS. The PREP Act provides immunity for covered 
persons from liability, unless the injury was caused by willful misconduct.  
 
The PREP Act also established the Countermeasures Injury Compensation Program (CICP) to 
provide compensation for serious injuries or death that occur as the direct result of the 
administration or use of certain countermeasures. Any requests for compensation must be filed 
within one year of the administration or use of the covered countermeasure. Requests for Benefits 
must be made to the Health Resources and Services Administration’s (HRSA) Countermeasures 
Injury Compensation Program (http://www.hrsa.gov/cicp/) by filing a Request for Benefits Form 
and all required medical records and supporting documentation. Additional information on filing 
a Request for Benefits is available on the CICP’s website at http://www.hrsa.gov/cicp/. 
Compensation may then be available for reasonable and necessary medical benefits, lost wages 
and/or death benefits to eligible individuals for certain injuries in accordance with regulations 
published by the Secretary of HHS (found at 42 CFR part 110). 
 
If an individual suffers a serious physical injury or death from the administration or use of a covered 
countermeasure in this study, the individual, the individual’s legal or personal representative, the 
administrator/executor of a deceased individual’s estate, or certain survivors may request benefits 
from the CICP. A serious physical injury means an injury that warranted hospitalization (whether 

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or not the person was actually hospitalized) or that led to a significant loss of function or disability. 
The CICP is the payer of last resort. This means that it only covers expenses or provides benefits 
that other third-party payers (such as health insurance, the Department of Veterans Affairs, or 
Workers’ Compensation programs) do not have an obligation to pay. 
 
If the Secretary of HHS does not make a final determination on the individual’s request within 240 
days, or if the individual decides not to accept the compensation, the injured individual or his 
representative may pursue a tort claim in the US District Court for the District of Columbia, but 
only if the claim involves willful misconduct and meets the other requirements for suit under the 
PREP Act. Any award is reduced by any public or private insurance or worker’s compensation 
available to the injured individual. Awards for non-economic damages, such as pain, suffering, 
physical impairment, mental anguish, and loss of consortium are also limited. If the individual 
accepts compensation, or if there is no willful misconduct, then the individual does not have a tort 
claim that can be filed in a US Federal or a State court.

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10.3 
Abbreviations 
AE 
Adverse Event 
AESI 
Adverse Event of Special Interest 
BLA 
Biologics License Application 
BP 
Blood Pressure 
CAPA 
Corrective and Preventative Action Plan 
CEF 
Chicken Embryo Fibroblast 
CFR 
Code of Federal Regulations 
CI 
Confidence Interval 
CICP 
Countermeasures Injury Compensation Program 
CMP 
Clinical Monitoring Plan 
CMS 
Clinical Material Services 
CQMP 
Clinical Quality Management Plan 
CRF 
Case Report Form 
CRO 
Contract Research Organization 
CSR  
Clinical Study Report 
 
 
DHHS 
Department of Health and Human Services 
DMID 
Division of Microbiology and Infectious Diseases 
DSMB 
Data and Safety Monitoring Board 
 
 
eCRF 
Electronic Case Report Form 
EUA 
Emergency Use Authorization 
FDA 
Food and Drug Administration 
FDAAA 
Food and Drug Administration Amendments Act of 2007 
FWA 
Federalwide Assurance 
GCP 
Good Clinical Practice 
GMFR 
Geometric Mean Fold Rise 
HHS 
Health and Human Services 
HIPAA 
Health Insurance Portability and Accountability Act 
HR 
Heart Rate 
HRSA 
Health Resources and Services Administration 
IB 
Investigator’s Brochure 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
ICMJE 
International Committee of Medical Journal Editors 
ID 
Intradermal 
IEC 
Independent or Institutional Ethics Committee 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
ISO 
International Organization for Standardization 
ITT 
Intention-To-Treat 
LAR 
Legal Authorized Representative 
MAAE 
Medically Attended Adverse Event 

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MedDRA 
Medical Dictionary for Regulatory Activities 
MITT 
Modified Intent to Treat 
MOP 
Manual of Procedures 
MPXV 
Monkeypox Virus 
N 
Number (typically refers to participants) 
NDA 
New Drug Application 
NI 
Non - Inferior 
NIAID 
National Institute of Allergy and Infectious Diseases 
NIH 
National Institutes of Health 
OHRP 
Office for Human Research Protections 
PHI 
Protected Health Information 
PI 
Principal Investigator 
PP 
Per Protocol 
PREP 
Public Readiness and Emergency Preparedness Act 
QA 
Quality Assurance 
QC 
Quality Control 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SC 
Subcutaneous 
SDCC 
Statistical and Data Coordinating Center 
SDSP 
Study Data Standardization Plan 
SOA 
Schedule of Activities 
SOC 
System Organ Class 
SOP 
Standard Operating Procedure 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TCID 
Mean Tissue Culture Infectious Dose 
TFF 
Tangential Flow Filtration 
UP 
Unanticipated Problem 
US 
United States 
WHO 
World Health Organization 
 
 

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10.4 
Protocol Amendment History 
 
Versio
n 
Date 
Description of 
Change  
Brief Rationale 
7.0 
5/23/2
4 
-Updated analysis 
plan for Stage 2 
-Will allow for Stage 2 interim Clinial Study Report 
to be produced to inform public health needs. 
6.0 
8/31/2
3 
-Updated interim 
immunogenicity 
analysis plan for 
Stage 1  
-Corrected an error in 
the Stage 2 
Objectives and 
Endpoints table 
-Updated interim 
immunogenicity 
analysis plan for 
Stage 2 
-Revised language in 
main section of 
protocol regarding 
study product 
disposition 
-Clarified Protocol 
Amendment History 
table for Version 5.0 
-Fixed typo in Stage 
2 SOA footnotes 
 
- Stage 1 interim data review of immunogenicity 
may be performed after all participants have 
completed Day 181, rather than Day 43 
-Stage 2 Objectives and Endpoints table did not list 
Day 1 as a timepoint for Vaccinia Virus specific 
PRNT assay for first Secondary Objective 
-Will allow for Stage 2 interim immunogenicity 
analysis 
-Guidance for disposition of unused and used study 
product in Stage 2 will be provided by DMID. 
5.0 
4/13/2
023 
Allow Day 57 visit in 
Stage 2 to be done by 
phone/virtual visit in 
certain scenarios. 
-Added that a Day 43 
targeted physical 
exam (at least 
assessment of 
vaccination site) is 
required 
 
-JYNNEOS MVA-
BN vaccine thaw 
time increased from 
12 hours to 4 weeks. 
-Will allow for phone/virtual visit at Day 57 if no 
ongoing vaccine site skin changes at Day 43 visit 
-Per FDA approval of labeling change dated 
4/14/2023 
https://www.fda.gov/media/166224/download?utm
_medium=email&utm_source=govdelivery 

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4.0 
2/28/2
3 
Adjustment of 
sample size and 
revision to exclusion 
criteria for Stage 2.  
Revisions made in response to FDA and DSMB 
feedback. Exclusion criteria revised to reduce 
potential for confounding of safety data.  
3.0 
1/13/2
3 
Addition of new 
stage to the protocol, 
see Appendix B of 
this document. 
 
New stage of the platform trial to evaluate safety 
and immunogenicity of the standard dose regimen 
of JYNNEOS in adolescents ages 12 to 17 years, 
inclusive compared to adults. 
2.0 
9/22/2
2 
For description of 
changes to Version 
1.0, see document on 
study website 
Clarification of study procedures and correction of 
internal inconsistencies within the protocol 
 
 
 

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von Sonnenburg F, Perona P, Darsow U, et al. Safety and immunogenicity of modified 
vaccinia Ankara as a smallpox vaccine in people with atopic dermatitis. Vaccine 
2014;32(43):5696-702. DOI: 10.1016/j.vaccine.2014.08.022. 
40. 
Greenberg RN, Hurley MY, Dinh DV, et al. A Multicenter, Open-Label, Controlled 
Phase II Study to Evaluate Safety and Immunogenicity of MVA Smallpox Vaccine 
(IMVAMUNE) in 18-40 Year Old Subjects with Diagnosed Atopic Dermatitis. PLoS One 
2015;10(10):e0138348. DOI: 10.1371/journal.pone.0138348. 
41. 
Cassimatis DC, Atwood JE, Engler RM, Linz PE, Grabenstein JD, Vernalis MN. 
Smallpox vaccination and myopericarditis: a clinical review. J Am Coll Cardiol 
2004;43(9):1503-10. DOI: 10.1016/j.jacc.2003.11.053. 
42. 
Department of Health and Human Services. 46.110 Expedited review procedures for 
certain kinds of research involving no more than minimal risk, and for minor changes in 
approved research. 

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(https://www.hhs.gov/ohrp/sites/default/files/ohrp/sachrp/mtgings/2013%20March%20Mt
g/approvedexpeditedreviewcategories.pdf). 
43. 
von Krempelhuber A, Vollmar J, Pokorny R, et al. A randomized, double-blind, dose-
finding Phase II study to evaluate immunogenicity and safety of the third generation 
smallpox vaccine candidate IMVAMUNE. Vaccine 2010;28(5):1209-16. DOI: 
10.1016/j.vaccine.2009.11.030. 
44. 
Pittman PR, Hahn M, Lee HS, et al. Phase 3 Efficacy Trial of Modified Vaccinia Ankara 
as a Vaccine against Smallpox. N Engl J Med 2019;381(20):1897-1908. DOI: 
10.1056/NEJMoa1817307. 

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APPENDIX A – STAGE 1: DOSE SPARING STUDY IN ADULTS 
 
Stage 1 began enrollment on September 7, 2022 and completed enrollment on October 12, 2022.  
This appendix contains Version 2.0 dated September 22, 2022 which is also found on the study 
website.
TABLE OF CONTENTS 
TABLE OF CONTENTS ..................................................................................................................... 46 
1.1 
Synopsis .........................................................................................................................50 
1.2 
Schedule of Activities (SOA) .........................................................................................52 
1.3 
Study Schema .................................................................................................................53 
2. 
INTRODUCTION ....................................................................................................................... 53 
2.1 
Study Rationale ..............................................................................................................53 
2.2 
Background ....................................................................................................................53 
2.3 
Risk/Benefit Assessment ................................................................................................55 
2.3.1 
Known Potential Risks ...........................................................................................55 
2.3.2 
Known Potential Benefits .......................................................................................59 
2.3.3 
Assessment of Potential Risks and Benefits...........................................................59 
3. 
OBJECTIVES AND ENDPOINTS............................................................................................. 60 
4. 
STUDY DESIGN ........................................................................................................................ 61 
4.1 
Overall Design ...............................................................................................................61 
4.2 
Scientific Rationale for Study Design ............................................................................61 
4.3 
Justification for Dose ......................................................................................................61 
5. 
STUDY POPULATION .............................................................................................................. 61 
5.1 
Inclusion Criteria ............................................................................................................62 
5.2 
Exclusion Criteria ...........................................................................................................62 
5.2.1 
Exclusion of Specific Populations ..........................................................................63 
5.3 
Inclusion of Vulnerable Participants ..............................................................................63 
5.4 
Lifestyle Considerations ................................................................................................64 
5.5 
Screen Failures ...............................................................................................................64 
5.6 
Strategies for Recruitment and Retention .......................................................................64 
5.6.1 
Recruitment ............................................................................................................64 
5.6.2 
Retention ................................................................................................................65 
5.6.3 
Compensation Plan for Participants .......................................................................65 
5.6.4 
Costs .......................................................................................................................65 
6. 
STUDY PRODUCT .................................................................................................................... 65 
6.1 
Study Product(s) and Administration .............................................................................65 
6.1.1 
Study Product Description ......................................................................................65 
6.1.2 
Dosing and Administration ....................................................................................65 
6.1.3 
Dose Escalation ......................................................................................................66 

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6.1.4 
Dose Modifications ................................................................................................66 
6.1.5 
Criteria for Redosing ..............................................................................................66 
6.2 
Preparation/Handling/Storage/Accountability ...............................................................66 
6.2.1 
Acquisition and Accountability ..............................................................................66 
6.2.2 
Formulation, Appearance, Packaging, and Labeling Product: JYNNEOS (MVA-BN 
vaccine) 67 
6.2.3 
Product Storage and Stability Product: JYNNEOS (MVA-BN vaccine) ...............67 
6.2.4 
Preparation .............................................................................................................67 
6.3 
Measures to Minimize Bias: Randomization and Blinding ............................................68 
6.3.1 
Treatment Assignment Procedures .........................................................................68 
6.3.2 
Randomization .......................................................................................................68 
6.3.3 
Blinding and Masking Procedures .........................................................................68 
6.4 
Study Intervention Compliance ......................................................................................68 
6.5 
Concomitant Therapy .....................................................................................................68 
6.5.1 
Rescue Medicine ....................................................................................................69 
7. 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL ............................................................................................... 69 
7.1 
Halting Criteria and Discontinuation of Study Intervention ...........................................69 
7.1.1 
Study Halting Criteria ............................................................................................69 
7.1.2 
Individual Halting Criteria .....................................................................................70 
7.1.3 
Follow up for participants that discontinued study intervention ............................70 
7.2 
Lost to Follow-Up ..........................................................................................................71 
8. 
STUDY ASSESSMENTS AND PROCEDURES ...................................................................... 71 
8.1 
Screening Procedures .....................................................................................................71 
8.1.1 
Procedures to be Followed in the Event of Abnormal Clinical Laboratory Test Values or 
Abnormal Clinical Findings During Screening .....................................................................72 
8.1.2 
Sick Visit ................................................................................................................72 
8.2 
Immunogenicity Assessments ........................................................................................73 
8.2.1 
Immunogenicity/Efficacy Evaluations ...................................................................73 
8.2.2 
Exploratory Assessments .......................................................................................73 
8.3 
Safety and Other Assessments .......................................................................................73 
8.3.1 
Procedures to be Followed in the Event of Abnormal Clinical Laboratory Test Values or 
Abnormal Clinical Findings During Conduct of the Trial .....................................................74 
8.4 
Adverse Events and Serious Adverse Events .................................................................74 
8.4.1 
Definition of Adverse Events (AE) ........................................................................74 
8.4.2 
Definition of Serious Adverse Events ....................................................................75 
8.4.3 
Classification of an Adverse Event ........................................................................76 
8.4.4 
Time Period and Frequency for Event Assessment and Follow-Up ......................77 
8.4.5 
Adverse Event Reporting .......................................................................................78 
8.4.6 
Serious Adverse Event Reporting ..........................................................................78 
8.4.7 
Reporting Events to Participants ............................................................................79 
8.4.8 
Adverse Events of Special Interest (AESI) ............................................................80 
8.4.9 
Reporting of Pregnancy ..........................................................................................80 
8.5 
Unanticipated Problems .................................................................................................80 
8.5.1 
Definition of Unanticipated Problems (UP) ...........................................................80 

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8.5.2 
Unanticipated Problem Reporting ..........................................................................80 
8.5.3 
Reporting Unanticipated Problems to Participants .................................................81 
9. 
STATISTICAL CONSIDERATIONS ......................................................................................... 81 
9.1 
Statistical Hypotheses.....................................................................................................81 
9.2 
Sample Size Determination ............................................................................................82 
9.3 
Statistical Analyses ........................................................................................................83 
9.3.1 
General Methodology ............................................................................................83 
9.3.2 
Timing of Analyses ................................................................................................83 
9.3.3 
Populations for Analyses ........................................................................................84 
9.3.4 
Baseline Characteristics and Participant Disposition .............................................84 
9.3.5 
Immunogenicity Analyses ......................................................................................84 
9.3.6 
Safety Analyses ......................................................................................................85 
10. SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS ................. 86 
10.1 
Regulatory, Ethical, and Study Oversight Considerations ..............................................86 
10.1.1 
Informed Consent Process ......................................................................................86 
10.1.2 
Study Termination and Closure ..............................................................................88 
10.1.3 
Confidentiality and Privacy ....................................................................................89 
10.1.4 
Secondary Use of Stored Specimens and Data ......................................................90 
10.1.5 
Key Roles and Study Governance ..........................................................................91 
10.1.6 
Safety Oversight .....................................................................................................91 
10.1.7 
Clinical Monitoring ................................................................................................92 
10.1.8 
Quality Assurance and Quality Control .................................................................92 
10.1.9 
Data Handling and Record Keeping .......................................................................93 
10.1.10 Protocol Deviations ................................................................................................94 
10.1.11 Publication and Data Sharing Policy ......................................................................94 
10.1.12 Conflict of Interest Policy ......................................................................................95 
10.2 
Additional Considerations..............................................................................................95 
10.2.1 
Research Related Injuries .......................................................................................95 
10.2.2 
PREP Act ...............................................................................................................95 
11. REFERENCES ............................................................................................................................ 97 
 
LIST OF TABLES 
Table 1 Schedule of Activities (SOA) .......................................................................................................... 52 
Table 2 Study Schema .................................................................................................................................. 53 
Table 3 Prior Subcutaneous Dosing Trials ................................................................................................... 54 
Table 4 MVA-BN Compared to ACAM2000 .............................................................................................. 55 
Table 5 Prior Intradermal Dosing Compared to Subcutaneous .................................................................... 55 
Table 6 Study Arms ..................................................................................................................................... 66 
Table 7: Power calculations ......................................................................................................................... 82 
Table 8: Standard deviation estimates .......................................................................................................... 82 
Table 9: Standard deviation estimates .......................................................................................................... 83 
 

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LIST OF FIGURES 
No table of figures entries found. 

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1. 
PROTOCOL SUMMARY 
1.1 
Synopsis 
Rationale 
Since the first case was identified four months ago, monkeypox has rapidly spread to 85 non- 
endemic countries, marking the first time monkeypox has spread widely outside Central and West 
Africa. To prevent further spread of this outbreak, MVA-BN vaccine is being offered to individuals 
at high risk. However, there is a global vaccine shortage and increasing vaccine supply will take 
time. This study will evaluate dose sparing strategies to extend the vaccine supply during this global 
public health crisis. 
 
Study Design 
This study is a Phase 2 randomized, open-label, non-placebo controlled, multi-site clinical trial that 
will evaluate the immunogenicity and safety of two, dose sparing strategies including one- fifth 
(2x107) and one-tenth (1x107) of the standard dose of MVA-BN (JYNNEOS) administered 
intradermally (ID) on Day 1 and 29 (Arm 1 and 2, respectively), compared with the standard, 
licensed regimen of 1x108 MVA-BN administered subcutaneously (SC) on Day 1 and 29 (Arm 3). 
At least 210 healthy, vaccinia-naïve adults 18 to 50 years of age will be enrolled and randomized 
1:1:1 to one of three study arms. There will be eight study visits (plus an optional screening visit) 
with the last visit at approximately one year after the first study vaccination. 
 
Participants reporting monkeypox-like illness and who have a laboratory-confirmed monkeypox 
(i.e., a positive diagnostic test for monkeypox) will be seen at a sick visit. 
 
Primary Objectives 
• To determine if peak (Day 43) humoral immune responses following an ID regimen 
of 2 x 107 TCID50 MVA-BN are non-inferior to the licensed regimen of 1 x 108 
MVA-BN administered SC. 
• To determine if peak (Day 43) humoral immune responses following an ID regimen 
of 1 x 107 TCID50 MVA-BN are non-inferior to the licensed regimen of 1 x 108 
MVA-BN administered SC 
 
For a full list of Objectives/Endpoints, see corresponding section of the protocol. 
 
Inclusion Criteria 
See inclusion criteria in corresponding section of the protocol. 
 
Exclusion Criteria 
See exclusion criteria in corresponding section of the protocol. 
 
Study Phase 
Phase 2 
 
Study Population 

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The study population will be healthy, vaccinia-naïve, non-pregnant, non-breastfeeding adults 18 to 
50 years of age. Participants with stable chronic medical conditions including those with controlled 
HIV infection can participate. The study will attempt to enroll a representative study population that 
is proportional to those affected by the disease and demographically diverse. 
 
Sites 
Up to 10 US clinical research sites. 
 
Study intervention 
There will be three study arms in which JYNNEOS will be administered by either ID or SC injection 
at Day 1 and 29. JYNNEOS is live vaccine produced from the strain Modified Vaccinia Ankara-
Bavarian Nordic (MVA-BN), an attenuated orthopoxvirus, that is non-replicating in human cells. 
It is FDA-approved and licensed as a smallpox and monkeypox vaccine in the United States. 
 
Study Duration 
This study will take approximately 15 months to conduct from study activation to the final 
participant’s last study visit. 
 
Participant Duration 
It will take approximately one year for a participant to complete their participation in the study. 
 
Safety 
The trial will use study and individual pausing rules. See corresponding section for details. This 
trial will use a Data Safety Monitoring Board (DSMB) for objective oversight of the study and 
review for any study pause.   

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1.2 
Schedule of Activities (SOA) 
The trial will include the following activities and procedures at each study visit. Only procedures 
that contribute to participant eligibility and study objectives and endpoints are included. Refer to 
Manual of Procedures (MOP) for detailed description of study activities. 
Table 1 Schedule of Activities (SOA) 
 
Procedures 
Optional 
Screening Visit 
Day -7 to -1 
Enrollment / Baseline 
Visit 1 Day 1 
Visit 2 
Day 15 +/- 3 day 
Visit 3 
Day 29 +/- 3 days 
Visit 4 
Day 43 +/- 3 days 
Visit 5 
Day 57 +/- 3 days 
Visit 6 Day 90 +/- 5 
days 
Visit 7 
Day 181 +/- 7 days 
Visit 8 
Day 365 +/- 14 days 
Sick/Unscheduled 
Visit 6 
Informed consent 
X 
X1 
Demographics 
X 
X1 
Medical history 
X 
X1 
X 
X 
X 
X 
X 
X 
X 
X 
Randomization 
X 
Vaccine administration 
X 
X 
Targeted physical 
exam 
X 
X1 
X2 
X2 
X2 
X2 
X2 
X2 
X2 
X2 
Vital signs 
X 
X1 
X2 
X2 
X2 
X2 
X2 
X2 
X2 
X2 
Concomitant 
medication review 
X 
X1 
X 
X 
X 
X 
X3 
X3 
X 
SAE/ MAAEs 4 
All SAE/MAAEs, Days 1 through 57 
Only related 
SAE/MAAEs 
Days 58 -181 
X4 
Unsolicited AEs4 
Day 1 through Day 29 and Day 29 through 
Day 57 
X4 
Solicited (Local and 
Systemic) AEs 
Day 1 through 
Day 15 
Day 29 through 
Day 43 
X4 
Tolerability 
Assessment 
X 
X 
Pregnancy test 5 
X 
X1 
X 
Blood volume per visit (ml) 
32 
20 
20 
32 
20 
20 
20 
20 
20 
Blood volume total (ml) 
32 
52 
72 
104 
124 
144 
164 
184 
204 
1 If there is no screening visit, these activities should be conducted at the Day 1 visit prior to randomization. Temperature 
should be collected on Day 1 and 29 pre-vaccination for all participants. 
2 A targeted (symptom-driven) physical exam will be done at screening (i.e., screening visit or Day 1), on Days 15, 29, 
and 43 (at least assessment of vaccination site and presence of skin discoloration and nodules will be done), and as 
needed in all other visits if interim change in medical status reported by participant. Vital signs will be done at screening 
and on Day 1 and 29 prior to vaccination and on an as needed basis during all other visits. 
3 After Day 57, only concomitant medications that are associated with a related SAE or MAAE (detected through Day 
181) and clinically relevant to report, will be recorded in the CRF. An exception to this rule for recording concomitant 
medications is for sick visits. During sick visits, concomitant medications will be collected. 
4 If SAE/MAAE or unsolicited AE are reported during a sick visit and within the reporting window, it will be reported 
as AE. See more information about collection of AEs in the safety section of the protocol. 

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5 A pregnancy test will be done at the screening visit (if conducted) and on Day 1 prior to randomization. If there is no 
screening visit, then pregnancy test done will be done on Day 1 only. Participants of childbearing potential must have 
negative serum or urine pregnancy test in the 24 hours prior to Day 1 and 29 study vaccinations and results confirmed 
prior to randomization. 
6 Participants reporting monkeypox-like illness and who have a laboratory-confirmed monkeypox will be seen at a sick 
visit. An unscheduled visit may also occur for reasons including, but not limited to, AE follow up, blood draw, or early 
termination final visit. 
 
1.3 
Study Schema 
Table 2 Study Schema 
 
Arm 
Dose of JYNNEOS (MVA-BN) 
Route of Administration* 
Vaccination Day 
Day 1 
Day 29 
1 
2 x 107 TCID50, (0.1 mL) 
Intradermal 
X 
X 
2 
1 x 107 TCID50, (0.05 mL) 
Intradermal 
X 
X 
3 
1 x 108 TCID50, (0.5 mL) 
Subcutaneous 
X 
X 
*Subcutaneous is administered in the upper arm, intradermal is administered in the volar aspect (inner side) of the 
forearm. 
 
 
2. 
INTRODUCTION 
2.1 
Study Rationale 
On July 23, 2022, WHO declared the 2022 monkeypox outbreak a public health emergency of 
international concern (PHEIC). Since the first case of monkeypox was detected in the UK in a 
returning traveler from Nigeria on May 6, 2022, as of September 2022 the outbreak has rapidly 
spread to >100 countries or locations worldwide, including 96 that are non-endemic, marking the 
first time monkeypox has spread widely outside Central and West Africa. In August, the number of 
confirmed monkeypox cases in the U.S. surpassed that of any other country. To mitigate the 
consequences of this outbreak, monkeypox vaccine is being offered to individuals considered to be 
at high risk. However, there is a global vaccine shortage and increasing the supply will take time. 
This study will evaluate vaccine dose sparing strategies to extend the limited supply during this 
global public health crisis. 
 
2.2 
Background 
Monkeypox is a reemerging infectious disease caused by Monkeypox virus (MPXV), a large 
double-stranded DNA virus belonging to the genus, Orthopoxvirus.1 MPXV is a zoonotic 
orthopoxvirus, primarily transmitted to humans via contact with infected animals, and causing 
disease similar to smallpox, although with substantially lower mortality.1-3 MPXV is endemic to 
West and Central Africa, where the incidence of human monkeypox cases has increased as much 
as 20-fold since the end of the smallpox vaccination campaign in 1980.4,5 Outbreaks in non- 
endemic countries have been related to the exotic pet trade6 and international travel.7-9 Prior to the 
current global monkeypox outbreak, secondary human-to-human transmission in non- endemic 
countries was rare, and documented only twice since 2018, both cases involving travelers returning 
from Nigeria. The first case involved transmission between the index patient and a healthcare 

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provider10 and second case involved transmission to another adult and an infant within the 
household of the index case.11,12 Monkeypox reemerged in Nigeria in 2017 after more than 40 years 
with no reported cases.13,14 
 
On May 18, 2022, the first U.S. case of monkeypox was detected as part of the larger global 2022 
monkeypox outbreak. The U.S. was the fourth non-endemic country to detect a case in a returning 
traveler. On August 4, the U.S. Department of Health and Human Services declared the 
U.S. monkeypox outbreak to be a public health emergency with 7,510 confirmed cases of 
monkeypox detected in all U.S. states, D.C, and Puerto Rico. As of August 15, 2022, there have 
been 36,589 confirmed monkeypox cases in 92 countries; most cases have been from 85 non- 
endemic countries including 11,890 confirmed cases in the United States. 
 
Vaccination is being used as a mitigation strategy in the current monkeypox outbreak for those 
exposed to and those deemed to be at higher risk of being exposed to monkeypox. There is one 
FDA-approved vaccine for monkeypox: JYNNEOS Modified Vaccinia Ankara-Bavarian Nordic 
(MVA-BN). A second vaccine, ACAM2000 is likely effective but is not FDA-approved for 
monkeypox and associated with moderate risk of myocarditis and pericarditis (5.7 cases per 1,000 
vaccinated) as well as encephalomyelitis, progressive vaccinia, generalized vaccinia, and ocular 
complications. ACAM2000 should not be given to people with weakened immune system, eczema, 
cardiac disease, infants <12 months, or pregnant women. Given these attributes, JYNNEOS is the 
preferred vaccine during the current outbreak and there is a limited supply of the vaccine globally 
with production unlikely to keep up with the growing demand as the outbreak continues to spread. 
Given the limited supply of MVA-BN, dose sparing strategies have been suggested. On August 9, 
2022, the U.S. Food and Drug Administration (FDA) issued an Emergency Use Authorization 
(EUA) for the emergency use of a lower (2 x 107) ID dose of JYNNEOS for individuals 18 years of 
age and older determined to be at high risk for monkeypox infection. 
 
There are several potential dose sparing strategies we considered. Use of a reduced dose 
administered SC is unlikely to be of comparable immunogenicity to the licensed SC regimen. There 
were several Phase 1 and 2 trials that evaluated 2-dose regimens of MVA-BN administered SC four 
weeks apart (Table 3). Although the 2-dose 5x107 TCID50 SC regimen may elicit GMT similar to 
ACAM2000, the GMT will likely be below that of the licensed 2-dose 1 x 108 MVA-BN regimen.  
Table 3 Prior Subcutaneous Dosing Trials 
 
Reference 
1 X107 
TCID50 
2 X107 
TCID50 
5 X107 
TCID50 
1 X108 
TCID50 
Assay 
Vollmar et al, 
Vaccine, 2006 15 
Liquid 
formulation 
6.4 
(CI not reported) 
-- 
-- 
29.3 
(CI not reported) 
IHD-J PRNT 
GMT 
Frey at al. 
Vaccine, 2007 
Lyophilized 
formulation 
-- 
347.2 
(161.9, 744.7) 
551.5 
(321.5, 946.0) 
914.5 
(528.0, 1584) 
MVA PRNT 
GMT 
von Krempelhuber 
Vaccine, 2010 
Lyophilized 
formulation 
-- 
5.5 
(3.2, 9.6) 
10.3 
(5.8, 18.4) 
19.4 
(11.1, 34.2) 
IHD-J PRNT 
GMT 
 
A single 1 x 108 TCID50 MVA-BN dose has also been suggested for dose sparing, but in our 
assessment of the published literature, it is unlikely to be immunogenically equivalent to the 
standard licensed 2-dose regimen. The pivotal Phase 3 trial demonstrated that a single dose is likely 
to provide a significantly lower GMT than the licensed 2-dose MVA-BN regimen, 16.9 [13.7, 20.8] 
as compared to 153.5 [134.3, 175.6], respectively (Table 4). 

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Table 4 MVA-BN Compared to ACAM2000 
 
MVA-BN 
(N=185) 
ACAM2000 
(N=186) 
GMTs ratio 
MVA/ ACAM 
Visit Week 
n 
GMT 
95% CI 
n 
GMT 
95% CI 
Ratio 
95% CI 
Plaque Reduction Neutralization Test 
Week 0 
185 1.0 
[1.0, 1.1] 
186 
1.0 
[1.0, 1.0] 
1.008 
[0.97, 1.05] 
Week 2 
184 16.2 
[13.0, 20.1] 
184 
16.2 
[13.1, 20.0] 
0.997 
[0.74, 1.35] 
Week 4 
185 16.9 
[13.7, 20.8] 
186 
79.3 
[67.1, 93.8] 
0.213 
[0.16, 0.28] 
Week 6 
185 153.5 
[134.3, 175.6] 
181 
64.7 
[54.9, 76.2] 
2.372 
[1.92, 2.93] 
 
NIAID conducted a Phase 2 trial comparing the standard (now licensed) 2-dose 1 x 108 TCID50 
MVA-BN SC regimen (liquid formulation) and a 2-dose 2 x 107 TCID50 MVA-BN ID regimen 
(liquid formulation) and found peak vaccinia virus, Western reserve strain (VV-WR) GMT of 49.5 
(40.0, 61.3) and 59.6 (48.1, 74.0), respectively (Table 5).16 The 2-dose 2 x 107 TCID50 ID regimen 
was non-inferior to the 2-dose 1 x 108 TCID50 SC regimen and utilized only one-fifth of the dose. 
These results are supported by a trial evaluating another MVA vaccine (ACAM3000) which 
showed ID vaccination at 1x107 TCID50 had similar VV-WR GMT to 1x108 TCID50 administered 
SC or IM.17 
 
Table 5 Prior Intradermal Dosing Compared to Subcutaneous 
 
Study Visit Day 
Group 
Lyophilized SC 1x108 
(N=145) GMT [95% CI] 
Liquid SC 1x108 (N=149) 
GMT [95% CI] 
Liquid ID 2x107 (N=146) 
GMT [95% CI] 
Day 0 
7.5 [,] 
7.7 [7.4, 8.0] 
7.7 [7.4, 7.9] 
Day 14 
10.9 [9.9, 12.0] 
10.0 [9.0, 11.1] 
10.3 [9.3, 11.3] 
Day 28 
10.8 [9.9, 11.9] 
9.6 [8.7, 10.6] 
10.8 [9.9, 11.9] 
Day 42 
77.6 [62.3, 96.7] 
45.2 [36.4, 56.2] 
54.4 [43.7, 67.8] 
Peak post vaccination 2 
87.8 [71.2, 108.3] 
49.5 [40.0, 61.3] 
59.6 [48.1, 74.0] 
 
Even with the EUA for intradermal MVA-BN being available, this trial is designed to evaluate 
several unique issues: 
• As vaccine supply is not anticipated to meet the demand in the next year, this trial will 
evaluate dose reduction strategies focused on the ID route, that is, confirming the 
previously studied ID dose and evaluating one tenth dose of MVA-BN (1x107). 
• This trial will also assess differences in safety and tolerability of the ID versus the 
licensed SC regimen as issues of tolerability have been raised by the manufacturer and 
some in the medical community. 
 
2.3 
Risk/Benefit Assessment 
2.3.1 
Known Potential Risks 

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The potential risks to the participants in the study are those related to venipuncture and 
reactogenicity as well as possible reactions to the vaccine. 
 
Venipuncture 
Venipuncture may cause transient mild discomfort and/or fainting. Bruising at the site of the 
venipuncture may occur but can be prevented or lessened by applying pressure for several minutes 
after the injection. Infection at the site is possible but highly unlikely with the use of aseptic 
technique. 
 
Adverse Reactions 
MVA-BN administered SC was approved by the FDA as the vaccine JYNNEOS for smallpox and 
monkeypox on September 24, 2019.18 At the time of licensure, the clinical development program for 
JYNNEOS included 22 studies involving 7,093 smallpox vaccine-naïve and 766 smallpox vaccine-
experienced participants who received at least 1 dose of JYNNEOS and were monitored for safety 
for at least 6 months following the first vaccination. There were mostly local and systemic 
reactogenicity and rare cases of allergy/hypersensitivity observed. Within 8 days of administration 
of a first or second dose of JYNNEOS, the most common solicited local (injection site) reactions 
among 2,943 smallpox vaccine-naïve healthy adult participants included pain (84.9%), redness 
(60.8%), swelling (51.6%), induration (45.4%), and itching (43.1%). The most common solicited 
systemic adverse reactions were muscle pain (42.8%), headache (34.8%), fatigue (30.4%), nausea 
(17.3%), and chills (10.4%). In a large clinical trial involving 3,003 participants who received at 
least one dose of MVA, the majority of solicited local and systemic adverse reactions had a median 
duration of 1 to 6 days, and there was a similar frequency of reported adverse reactions after the first 
and second dose of JYNNEOS except for site pain which was more common after the first dose 
(79.3% versus 69.9%).19 
 
An analysis of serious adverse events (SAEs) among the 7,093 smallpox vaccine-naïve and 766 
smallpox vaccine-experienced participants who received at least 1 dose of JYNNEOS identified 
only four SAEs (0.05%) in which a causal relationship could not be ruled out. All were non-fatal 
SAEs and included Crohn’s disease, sarcoidosis, extraocular muscle paresis, and throat tightness 
(angioedema). The trial that had the related angioedema had three other post-vaccination 
hypersensitivity reactions which were non-serious and judged to related to the vaccination. 
 
As with all injectable vaccines, there is a risk of an allergic reaction or an anaphylactic event. To 
mitigate the risk, individuals with known allergy or history of anaphylaxis or other serious adverse 
reaction to a vaccine or vaccine products will not be eligible to participate in the study. In addition, 
sites must observe participants for 30 minutes after each vaccination and will have appropriate 
medical treatment available to manage possible anaphylactic reactions. Participants who have an 
allergic reaction that is temporally associated with vaccination and that the PI believes to be related, 
will not receive any more study product. However, the participant will be encouraged not to 
withdraw from the study so that they may be followed for safety and immunogenicity until the end 
of the study. 
 
Intradermal Route of Administration 
In a Phase 2 clinical trial that compared the ID and SC administration of the liquid formation of 
MVA-BN, no participants in the Liquid SC dose group experienced a severe systemic reaction and 
20.4% experienced a moderate systemic reaction following the first vaccination, and 1.9% of 

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participants experienced severe systemic reactions and 16.6% experienced moderate systemic 
reactions following the second vaccination.16 In the Liquid ID dose group, 3.1% of participants 
experienced a severe systemic reaction and 24.1% experienced moderate systemic reactions 
following the first vaccination, and 0.7% experienced a severe systemic reaction and 15.0% 
experienced moderate systemic reactions following the second vaccination. Fatigue was the most 
common systemic reaction reported in both groups after both vaccinations, reported by 35.9% in 
the Liquid SC dose group and 41.4% in the Liquid ID dose group after the first vaccination, and 
33.1%, and 29.4% of participants in the Liquid SC, and Liquid ID dose groups, respectively after 
the second vaccination. 
 
Pain at the injection site occurred in 65.4% and 91.0% of participants in the Liquid ID group and 
the SC group, respectively. Itchiness was the most prevalent local reaction in the Liquid ID group, 
reported by 89.0% of participants after either vaccination compared to 48.5% in the Liquid SC 
group. Vaccine site discoloration (hyperpigmentation) was seen in 122 (63.9%) participants in the 
Liquid ID group and all but three of these events were graded as mild (Grade 1). In contrast, only 
seven (4.2%) participants in the Liquid SC group had discoloration at the vaccine site and all but 
one event was Grade 1. Nodule formation at the vaccine site occurred at a similar frequency of 
participants in the Liquid ID and Liquid SC group; 35 (18.3%) and 34 (20.4%) participants 
developed a nodule, respectively. 
 
The original protocol (and report) used a more conservative grading scale for erythema and 
induration than the FDA's current guidance document, “Toxicity Grading Scale for Healthy Adult 
and Adolescent Volunteers Enrolled in Preventive Vaccine Clinical Trials”. When NIAID re-
analyzed the data using the FDA’s current toxicity grading scale, 12% of participants in the ID group 
and 7.2% in the SC group experienced moderate/severe erythema following the first vaccination, 
and 59.5% in the ID group and 31.2% in the SC group following the second vaccination. Systemic 
reactogenicity was similar across the two arms. 
 
Risk During Pregnancy 
There were four developmental toxicity studies that evaluated the effect of JYNNEOS on fetal and 
postnatal development and found no vaccine-related fetal malformations or adverse effects on 
postnatal development. JYNNEOS has not been evaluated in preclinical studies for carcinogenicity 
or mutagenicity. 
 
No safety signals were observed in 29 pregnancies that occurred during the clinical development 
program of MVA-BN and the rate of spontaneous abortions observed was similar to the published 
background incidence. However, there is insufficient data to assess the vaccine risk to the pregnant 
woman and her fetus and because of this, woman who are pregnant will not be eligible to participate 
in this study and females of reproductive potential will be asked to use effective birth control 
through Day 57. 
 
Risk to Breast Feeding Infant 
It is not known whether JYNNEOS is excreted in human milk. Data are not available to assess the 
effects of JYNNEOS in the breastfed infant or on milk production/excretion. For this reason, woman 
who are breastfeeding will not be eligible to participate in this study. 
 
Risk to Children and Adolescents 

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Safety and immunogenicity of JYNNEOS have not been established in individuals less than 18 
years of age. For this reason, this study will enroll only adults 18 to 50 years of age. 
 
Risk to Individuals with Chronic Diseases 
JYNNEOS does not replicate in human cell lines and therefore the vaccine can be safely 
administered to immunocompromised individuals. Safety has been demonstrated in clinical trials 
and studies involving severely immunocompromised animals20,21 and humans with HIV 
infection.22-24 The safety of JYNNEOS in HIV-infected individuals was evaluated in an open label 
trial that included 351 HIV-infected smallpox vaccine-naïve participants, 131 HIV-infected 
participants who previously received smallpox vaccine, 88 non-HIV-infected smallpox vaccine- 
naïve participants, and 9 non-HIV-infected participants who had previously received a smallpox 
vaccine.22 HIV-infected participants had CD4 counts ≥ 200 and ≤ 750 cells/μL at study entry. 
 
Among smallpox vaccine-naïve participants, solicited local and systemic adverse reactions were 
reported at similar or lower frequencies in HIV-infected participants than in non-HIV-infected 
participants. Frequencies of other solicited local and systemic adverse reactions were similar to 
those reported in other trials.23,24 In this study, individuals infected with HIV can participate in the 
study unless they had an AIDS defining illness within the last year or their viral load is not well-
controlled with antiretroviral therapy (ART). 
 
Individuals with atopic dermatitis (AD) are not able to receive replicating smallpox vaccines 
including ACAM2000. However, two clinical trials have shown that they can safely be given 
JYNNEOS.25,26 The larger of the two studies was a multicenter, open-label clinical trial that 
evaluated the safety of JYNNEOS in 350 smallpox vaccine-naïve participants either with active or 
a history of AD and in 282 participants without AD.26 The proportion of participants reporting 
solicited local and systemic adverse reactions was similar between the arms, except for redness 
(61.2% with AD vs. 49.3% without AD), swelling (52.2% with AD vs. 40.8% without AD), chills 
(15.9% with AD vs. 7.8% without AD) and headache (47.2% with AD vs. 34.8% without AD). 
However, most adverse events were mild to moderate in severity. In this study, individuals with 
AD are eligible to participate. 
 
Cardiac Adverse Events of Special Interest (AESI) 
During the 2002-2004 smallpox vaccination campaign initiated by the US Department of Defense 
(DoD) and Department of Health and Human Services (DHHS) to protect military personnel and 
civilian first-responders, there were high rates of pericarditis and myocarditis reported among those 
vaccinated with Dryvax. Similarly, high rates were detected after receipt of ACAM2000.27 
Because of this, during the clinical development of MVA-BN, participants were monitored for 
cardiac-related signs or symptoms through at least 6 months after the last vaccination. In 22 
studies, cardiac AESIs were reported to occur in 1.3% (95/7,093) of JYNNEOS recipients and in 
0.2% (3/1,206) of placebo recipients who were smallpox vaccine naïve. The higher proportion of 
JYNNEOS recipients who experienced cardiac AESIs was driven by cases of asymptomatic post-
vaccination elevation of troponin I, the clinical significance of which is unknown. 
 
Among the cardiac AESIs reported, there were six, non-serious cases (0.08%) deemed causally 
related to JYNNEOS vaccination including tachycardia, electrocardiogram (ECG) T wave 
inversion, unspecified ECG abnormality, ECG ST segment elevation, ECG T wave abnormality, 
and palpitations. These data are consistent with findings from a randomized, double-blind, placebo-

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controlled Phase 3 trial that evaluated the immunogenicity and safety of three consecutive 
production lots of MVA-BN. In that trial, eight out of 3,003 (0.3%) participants who received at 
least one dose of MVA-BN had a cardiac AESI. Of these events, two of the eight were considered 
possibly related to MVA-BN vaccination; one participant had a right bundle branch block on ECG, 
and the other participant had clinical symptoms consistent with acute pericarditis but had a negative 
cardiac work-up. This same participant had positive serology to Coxsackie B virus suggesting that 
an acute viral infection may have been the cause of their symptoms. Given these data, we will not 
be monitoring for cardiac AESI during this study. 
 
However, we will be monitoring AE, MAAE, and SAE that will allow us to detect symptomatic 
cardiac conditions. 
 
2.3.2 
Known Potential Benefits 
JYNNEOS was licensed in 2019 based on pre-clinical studies and clinical trial data showing that 
the vaccinia virus-specific (VV-WR) geometric mean titer (GMT) elicited by two doses of 
JYNNEOS was non-inferior to that elicited by ACAM2000; ACAM2000 was licensed based on 
non-inferiority to Dryvax. Participation in this study may result in protection against monkeypox 
during this current outbreak. However, participation may also provide no direct benefit to the 
participant if they develop antibodies to vaccinia virus and/or monkeypox virus that are not fully 
protective. Society may benefit from the identification of dose sparing regimens that could be used 
during the current global vaccine shortage. Additional supportive data on ID dosing may be used to 
inform the public health response to the current outbreak. 
 
2.3.3 
Assessment of Potential Risks and Benefits 
JYNNEOS is a licensed product with a good safety profile. This study compares the standard 2- 
dose licensed SC dosing regimen with two, 2-dose ID regimens that use lower doses of the vaccine. 
We do not anticipate that the risks of participating in the trial and receiving this licensed vaccine 
will outweigh the benefits of participation and the value of the information gained from conducting 
this study. Risk to participants will be minimized by excluding groups of individuals identified to 
be at greatest risk for adverse reactions following vaccination with JYNNEOS. 

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3. 
OBJECTIVES AND ENDPOINTS 
 
OBJECTIVES 
ENDPOINTS 
(OUTCOME MEASURES) 
Primary 
To determine if peak (Day 43) humoral immune 
responses following an ID regimen of 2 x 107 
TCID50 MVA- BN are non-inferior to the licensed 
regimen of 1 x 108 TCID50 MVA-BN administered 
SC 
Vaccinia virus specific PRNT GMT at Day 43 
To determine if peak (Day 43) humoral immune 
responses following an ID regimen of 1 x 107 
TCID50 MVA- BN are non-inferior to the licensed 
regimen of 1 x 108 TCID50 MVA-BN administered 
SC 
Vaccinia virus specific PRNT GMT at Day 43 
Secondary 
To determine if individual peak humoral immune 
responses following each ID regimen are non- 
inferior to the licensed regimen administered SC 
Individual peak GMT through Day 365 
To evaluate humoral immune responses of each 
ID regimen (separately) compared to licensed SC 
regimen each study day. 
Vaccinia virus specific PRNT GMT at Study Day 1, 
15, 29, 43, 57, 90, 181, and 365 
To evaluate the kinetics of the humoral immune 
responses of each ID regimen (separately) 
compared to licensed SC regimen through Day 
365 
Vaccinia virus specific PRNT half-life (t ½) 
To compare relative safety among study arms as 
assessed by systemic and local reactogenicity for 
14 days after each vaccination, unsolicited adverse 
events for 28 days after each vaccination, and 
serious adverse events (SAE) and medically 
attended events (MAAE) from Day 1 through Day 
57, and related SAE/MAAEs through Day 181 
Frequency, severity, and relatedness of solicited 
systemic and local AE for 14 days after each 
vaccination. 
Frequency severity, and relatedness of unsolicited 
AEs in each study arm for 28 days after each 
vaccination. 
Frequency and relatedness of MAAE and SAEs in 
each study arm. 
Frequency of withdrawals or discontinuation of 
vaccination in each study arm 
Exploratory 
To evaluate other measures of the humoral 
immune responses for each regimen 
Results from additional immunologic assays for 
vaccinia and other related viruses. 
To evaluate humoral immune responses of each ID 
regimen (separately) compared to licensed dose 
administered SC to monkeypox virus. 
Monkeypox virus specific PRNT GMT at Day 1 
and 43. 

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4. 
STUDY DESIGN 
4.1 
Overall Design 
This study is a Phase 2 randomized, open-label, non-placebo controlled, multi-site clinical trial that 
will evaluate two ID regimens for MVA-BN vaccine compared to the standard SC regimen in 
healthy, vaccinia-naïve adults 18 to 50 years of age, inclusive. At least 210 participants will be 
enrolled and randomized to one of three study arms. The two dose sparing strategies include one- 
fifth (2 x107) and one-tenth (1 x107) of the standard dose of MVA-BN administered ID on Day 1 
and 29 (Arm 1 and 2, respectively). The comparator arm (Arm 3) will be the 2-dose standard (1x108) 
MVA-BN SC regimen. 
 
The study will enroll a 1:1:1 randomization allocation. Participants will not be stratified by clinical 
trial site, demographic characteristics or HIV infection status; however, these data will be collected 
during screening and enrollment. Each participant may be screened either in a separate visit in the 
7 days prior to Day 1 or on Day 1. Participants will be followed as outlined in the Schedule of 
Activities. The last follow-up visit will be at about 1 year after the first vaccination. 
 
4.2 
Scientific Rationale for Study Design 
The rationale for each of the arms in this study is as follows: 
1. MVA-BN 2 x 107 TCID50 ID (1/5th dose) on Days 1, 29 (Study Arm 1) – This regimen 
matches the prior ID dosing and matches the dose authorized in the EUA. This regimen 
would allow for 5-fold increase in vaccine supply. 
2. MVA-BN 1 x 107 TCID50 ID (1/10th dose) on Days 1, 29 (Study Arm 2) – This regimen 
would test a larger dose conservation. This regimen would allow for 10-fold increase in 
vaccine supply. 
3. MVA-BN 1 x 108 TCID50 SC on Days 1, 29 (Study Arm 3) – This regimen is the licensed 
dose and route and will be used as a comparator. 
 
4.3 
Justification for Dose 
This study will use the FDA-approved, licensed dose 1 x 108 TCID50 MVA-BN administered SC 
on Day 1 and 29 as the comparator for the ID doses of MVA-BN. The ID regimens being evaluated 
in this study use lower doses of the licensed vaccine, and either match or are one dilution lower 
than the dose used in the prior ID dosing study (PMID 26143613). Therefore, it is anticipated this 
range is safe and immunogenic. 
 
5. 
STUDY POPULATION 
This study will enroll healthy, non-pregnant, non-breastfeeding adults 18 to 50 years old. 
Participants with stable medical conditions and well-controlled HIV infection can participate. The 
study will aim to enroll a population that has demographic features similar to the population being 
affected with monkeypox, yet also reflects the larger U.S. population to ensure broad applicability 
of the study findings. To this end, the goal will be to enroll: 
 

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• at least 30% female participants, 
• at least 20% African American/Black participants, 
• at least 20% Hispanic participants. 
 
These are enrollment goals and will not be a deviation if these are not ultimately met. Sites will be 
chosen based on projected ability to enroll the representative study population. Enrollment will be 
monitored and adjusted at individual sites to pursue these goals while also enrolling this study 
quickly to inform public health decisions. 
 
Participant Inclusion and Exclusion Criteria must be confirmed by an investigator named on the 
delegation log. If there is any uncertainty, the PI should make the decision on whether a potential 
participant is eligible for study enrollment. No exemptions are granted on Inclusion/Exclusion 
Criteria. 
 
5.1 
Inclusion Criteria 
To be eligible to participate in this study, an individual must meet all the following criteria: 
 
1. Individuals 18 - 50 years of age inclusive at the time of consent. 
2. Able to read the written informed consent, states willingness to comply with all study 
procedures, and is anticipated to be available for all study visits. 
3. Agreement to adhere to Lifestyle Considerations (defined in section 5.4) during the study. 
4. Females of reproductive potential who have sexual intercourse with males must agree to 
use highly effective contraception for at least 1 month prior to signing ICF and through 
Day 57. 
Note: See MOP for definitions and list of highly effective contraception 
5. In good general health as evidenced by medical history, physical examination, and 
clinical judgement of the investigator to be in stable state of health. 
Note: Participants with pre-existing stable chronic medical conditions defined as conditions not 
requiring significant change in therapy or hospitalization for worsening disease in the 4 weeks 
prior to enrollment can be included at the discretion of the investigator. This includes stable, well-
controlled HIV positive individuals. 
6. If HIV infected individual, they must be on suppressive ART for at least 6 months, report 
a CD4 count of greater than 350 cells/µL and no AIDS-defining illness in the last year. 
 
5.2 
Exclusion Criteria 
An individual who meets any of the following criteria will be excluded from participation in this 
study: 
1. Ever received a licensed or an investigational smallpox or monkeypox vaccine. 
Note: this includes Dryvax, Acam2000, LC 16 m8, MVA-based vaccine candidate or licensed 
vaccines, and Jynneos, Imvamune or Imvanex) 

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2. Any history of monkeypox, cowpox, or vaccinia infection. 
3. Close contact of anyone known to have monkeypox in the 3 weeks prior to signing ICF 
4. Immunocompromised as determined by the investigator 
5. Recent or current use of any immunosuppressing medications in the 4 weeks prior to 
signing ICF. 
Note: topical, ophthalmic, inhaled, intranasal and intraarticular corticosteroids are acceptable, 
but receipt of ≥20 mg/day of prednisone or equivalent for ≥14 consecutive days in the 4 weeks prior 
to signing ICF is exclusionary. 
6. Pregnant or breast feeding. 
7. Received or plans to receive a live vaccine in the 4 weeks prior to signing ICF and 4 
weeks after each vaccination 
8. Received or plans to receive any other vaccine in the 2 weeks prior to signing ICF 
through Day 43. 
9. Received experimental therapeutic agent or vaccine in the 3 months prior to signing ICF. 
10. Has known allergy or history of anaphylaxis or other serious adverse reaction to a 
vaccine or vaccine products. 
Note: this includes individuals with history of severe allergic reaction to gentamicin, ciprofloxacin, 
chicken or egg protein. 
11. Has tattoos, scars, or other marks which would, in the opinion of the investigator, 
interfere with assessment of the vaccination site. 
12. Has any medical disease or condition that, in the opinion of the participating site PI or 
appropriate sub-investigator, precludes study participation. 
Note: this includes acute, subacute, intermittent, or chronic medical disease or condition that would 
place the participant at an unacceptable risk of injury, render the participant unable to meet the 
requirements of the protocol, or may interfere with the evaluation of responses or the participant’s 
successful completion of this trial. 
 
5.2.1 
Exclusion of Specific Populations 
This study will enroll healthy non-pregnant, non-breastfeeding adults 18 to 50 years old. Adults 
with a history of receiving smallpox vaccine as a child and those born before 1971 will be excluded 
as they are likely to have received smallpox vaccination during the smallpox eradication campaign. 
Because the effects on the fetus are not known, pregnant individuals will not be eligible for the 
trial (see Risk/Benefit Assessment Section). In addition, individuals who are breastfeeding will 
not be eligible because it is not known if JYNNEOS is excreted in the breastmilk. Adolescents and 
children will not be included in this trial because there is no safety or efficacy data on the ID route 
of administration in this population. Should the outcome of this trial be deemed acceptable, 
additional trials may be initiated, including those in other populations. 
 
5.3 
Inclusion of Vulnerable Participants 
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impaired participants, adolescents, and children. 
5.4 
Lifestyle Considerations 
During this study, participants are asked to: 
• Follow public health guidance on preventing monkeypox infection and notify the clinical site 
if exposed to an individual with monkeypox. 
• Contact the clinical site immediately if they develop signs and symptoms consistent with 
monkeypox to schedule a study sick visit. 
• Refrain from receiving a live vaccine from enrollment through Day 57. 
• Refrain from receiving any other vaccine through Day 43. 
• Decline participation in another study evaluating investigational vaccines through Day 181. 
• Decline participation in another study evaluating an investigational MVA-based vaccine 
through end of trial. 
 
Of note, participants may enroll in non-interventional, observational studies (e.g., natural history 
study of monkeypox). However, concurrent participation in this trial and observational studies can 
only occur if the recommended blood collection volumes are not exceeded. 
 
5.5 
Screen Failures 
After the screening evaluations have been completed, the investigator or designee is to review the 
inclusion/exclusion criteria and determine the participant’s eligibility for the study. The following 
information will be collected on screen failures: demographics (age, screen number, sex, ethnicity, 
and race) and reason(s) for ineligibility. Participants who are found to be ineligible will be told the 
reason for ineligibility. 
 
A participant may be re-screened once if a protocol eligibility criterion that is not met at the initial 
time of screening, will be met by rescreening at a later date (e.g., a vaccine was received within 
exclusionary window at first screening that would not be in the exclusionary window at a later 
rescreen). 
 
5.6 
Strategies for Recruitment and Retention 
5.6.1 
Recruitment 
Potential participants will learn about the study via IRB-approved recruitment strategies, which 
may include direct mailing, recruitment from an IRB-approved trial registry, and local flyers or 
advertisements. Recruiting may begin with a brief telephone call between study staff and the 
potential participant. Information about the study will be presented to potential participants, and 
questions about their health and ability to comply with the study visit schedule will be asked of 
potential participants to presumptively determine eligibility. Information about the participant may 
be recorded from interviews or medical records. Appointments will be made at the research site for 
potential participants who are interested in the study for further screening procedures and additional 
protocol-specific information. 
 

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5.6.2 
Retention 
Study retention strategies will include education and explanation of the study schedule and 
procedures during screening and enrollment visits and restriction of enrollment to persons who can 
attend all study visits. Study participants will be reminded of subsequent visits during each visit, 
and study staff may contact participants prior to appointments. Study staff will contact participants 
who miss appointments to encourage them to return for completion of evaluations. 
 
5.6.3 
Compensation Plan for Participants 
Participants may be compensated for their participation in this trial. Compensation will be in 
accordance with local institution requirements, and pursuant to IRB approval. Reimbursements will 
be disbursed at specific timepoints during the study with the amount contingent on completing study 
procedures. 
 
5.6.4 
Costs 
There is no cost to participants for the research tests, procedures, and study product while taking 
part in this trial. Procedures and treatment for clinical care may be billed to the participant, 
participant’s insurance or third party. 
 
6. 
STUDY PRODUCT 
6.1 
Study Product(s) and Administration 
6.1.1 
Study Product Description 
JYNNEOS is FDA-approved for adults and licensed as a smallpox and monkeypox vaccine in the 
United States. The vaccine, when thawed, is a milky, light yellow to pale white colored suspension 
that is licensed for subcutaneous injection. JYNNEOS is a live vaccine produced from the strain 
Modified Vaccinia Ankara-Bavarian Nordic (MVA-BN), an attenuated, non-replicating 
orthopoxvirus. MVA-BN is grown in primary Chicken Embryo Fibroblast (CEF) cells suspended in 
a serum-free medium containing no material of direct animal origin, harvested from the CEF cells, 
purified, and concentrated by several Tangential Flow Filtration (TFF) steps including benzonase 
digestion. Each 0.5 mL dose is formulated to contain 0.5 x 108 to 3.95 x 108 infectious units of 
MVA-BN live virus in 10 mM Tris (tromethamine), 140 mM sodium chloride at pH 7.7. Each 0.5 
mL dose may contain residual amounts of host-cell DNA (≤ 20 mcg), protein (≤ 500 mcg), 
benzonase (≤0.0025 mcg), gentamicin (≤0.163 mcg), and ciprofloxacin (≤0.005 mcg). 
 
6.1.2 
Dosing and Administration 
In this trial, a licensed vaccine is being evaluated (i.e., JYNNEOS) and there is no placebo arm. Use 
of the contralateral arm is an option if there is any residual local reaction at Day 29 or if participant 
requests that this be done. 
 
 

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Table 6 Study Arms 
 
Arm 
Dose of JYNNEOS (MVA-BN) 
Route of Administration* 
Vaccination Day 
Day 1 
Day 29 
1 
2 x 107 TCID50, (0.1 mL) 
Intradermal 
X 
X 
2 
1 x 107 TCID50, (0.05 mL) 
Intradermal 
X 
X 
3 
1 x 108 TCID50, (0.5 mL) 
Subcutaneous 
X 
X 
*Subcutaneous is administered in the deltoid region, intradermal is administered in the volar aspect (inner side) 
of the forearm. 
 
6.1.3 
Dose Escalation 
Not Applicable. 
 
6.1.4 
Dose Modifications 
Not Applicable. 
 
6.1.5 
Criteria for Redosing 
If study product administration is unsuccessful, another administration will not be attempted. 
 
6.2 
Preparation/Handling/Storage/Accountability 
6.2.1 
Acquisition and Accountability 
 
Product: JYNNEOS (MVA-BN vaccine) 
The JYNNEOS (MVA-BN vaccine) will be stored and provided by DMID Repository. Study 
product will be shipped to the clinical research site upon request and approval from DMID. 
 
Accountability 
The participating site PI is responsible for study product distribution and disposition and has 
ultimate responsibility for study product accountability. The participating site PI may delegate to 
the participating site’s research pharmacist responsibility for study product accountability. The 
participating site’s research pharmacist will be responsible for maintaining complete records and 
documentation of study product receipt, accountability, dispensation, storage conditions, and final 
disposition of the study products. 
 
Time of vaccine administration to the participant will be recorded on the appropriate data collection 
form (DCF). All study product(s), including the amount of JYNNEOS (MVA-BN vaccine), and 
whether administered or not, must be documented on the appropriate study product accountability 
record or dispensing log. The sponsor’s monitoring staff will verify the participating site’s study 
product accountability records and dispensing logs per the DMID- approved clinical monitoring 
plan (CMP). 
 
Once all participant dosing is complete, the pharmacy staff should retain or dispose of used study 
products and complete study product accountability procedures in accordance with site-specific 
standard operating procedures (SOPs). This applies to: 

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• used and unused JYNNEOS (MVA-BN vaccine) vials 
• JYNNEOS (MVA-BN vaccine) cartons 
 
All used vials and cartons may either be sequestered from the unused supplies and retained until 
study conclusion or until study product accountability has occurred by the monitor and written 
notification stating retention is no longer required is received. Used syringes should be discarded 
per usual procedure. 
Destruction 
After the study treatment period has ended or as appropriate over the course of the study after 
study product accountability has been performed, disposition of unused and used JYNNEOS 
(MVA-BN vaccine) vials can be destroyed on-site following applicable site procedures. A 
certificate of destruction or documentation of destruction should be provided to the sponsor and 
retained in the Pharmacy Binder once completed. 
6.2.2 
Formulation, Appearance, Packaging, and Labeling Product: JYNNEOS (MVA-BN 
vaccine) 
JYNNEOS is supplied in a single-dose vial with turquoise and white label for SC injection. Each 
0.5 mL dose is formulated to contain 0.5 x 108 to 3.95 x 108 infectious units of MVA-BN live virus 
in 10 mM Tris (tromethamine), 140 mM sodium chloride at pH 7.7. Each 0.5 mL dose may contain 
residual amounts of host-cell DNA (≤ 20 mcg), protein (≤ 500 mcg), benzonase (≤0.0025 mcg), 
gentamicin (≤0.163 mcg), and ciprofloxacin (≤0.005 mcg). JYNNEOS is a sterile vaccine 
formulated without preservatives. The vial stoppers are not made with natural rubber latex. 
 
6.2.3 
Product Storage and Stability Product: JYNNEOS (MVA-BN vaccine) 
JYNNEOS should be kept frozen at -25°C to -15°C (-13°F to +5°F) and stored in the original 
package to protect from light. JYNNEOS should not be re-frozen once a vial has been thawed. Once 
thawed, the vaccine may be kept at +2°C to +8°C (+36°F to +46°F) for 12 hours. The package 
insert provides additional instructions for the handling and storage of JYNNEOS. 
 
6.2.4 
Preparation 
Each dose (0.5 mL) is supplied in a single-dose vial. Sites should allow the vaccine to thaw and 
reach room temperature before use (about 15 to 30 minutes). After thawing, the total time stored at 
+2°C to +8°C (+36°F to +46°F) should not exceed 12 hours. Once the vial is punctured and a dose 
is withdrawn, if it is not used in its entirety, it should be stored at +2°C to +8°C (+36°F to +46°F) 
and discarded within 8 hours of the first puncture. If the unpunctured vial is initially shipped/stored 
at 2-8C then it is stable for up to 8 weeks. Sites should not refreeze the vaccine. JYNNEOS may be 
kept frozen until the expiration date. 
JYNNEOS is a light yellow to pale white colored, milky suspension when thawed. Sites will 
visually inspect the product for particulate matter and discoloration prior to administration. If 
either condition is present, the vaccine will not be administered. Study product administrators 
will gently swirl the vial for at least 30 seconds. 
 
• For the ID injection (Arm 1), 0.1 mL of vaccine will be withdrawn from the vial into a 
sterile syringe and injected intradermally into the volar aspect (inner side) of the 
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• For the ID injection (Arm 2), 0.05 mL of vaccine will be withdrawn from the vial into a 
sterile syringe and injected intradermally into the volar aspect of the forearm. 
 
• For the SC injection (Arm 3), 0.5 mL of vaccine will be withdrawn from the vial into a 
sterile syringe and injected into the fatty tissue over the deltoid area. 
 
See the protocol-specific MOP for detailed information on the preparation, labeling, storage, and 
administration for each arm. 
 
6.3 
Measures to Minimize Bias: Randomization and Blinding 
6.3.1 
Treatment Assignment Procedures 
The randomization procedure will be described in the MOP. 
 
6.3.2 
Randomization 
There will be a 1:1:1 randomization allocation. Randomization will not be stratified. Randomized 
treatment assignments will be generated by a statistician at The Emmes Company, LLC, the 
Statistical and Data Coordinating Center (SDCC) for this study. Participants will be registered 
using a web-based application developed by The Emmes Company, LLC. Upon entry of 
demographic data and confirmation of eligibility for the trial, the participant will be enrolled and 
randomized. The randomization procedure will be described in more detail in the MOP. 
 
6.3.3 
Blinding and Masking Procedures 
This study will not utilize blinding or masking procedures as it is an open-label, non-placebo- 
controlled trial. Research laboratories will be blinded to participant study arm for the purposes of 
immunogenicity/efficacy evaluations. 
 
6.4 
Study Intervention Compliance 
Each dose of JYNNEOS will be administered by a member of the clinical research team that is 
qualified and licensed to administer the study product. Administration and date, time, and location 
of injection will be recorded on the appropriate eCRF. 
 
6.5 
Concomitant Therapy 
At screening (i.e., the screening visit or Day 1 visit if the screening visit is not conducted), 
participants will be asked about receipt of immunosuppressive therapy, experimental therapeutic 
agents and vaccines, other medications, and vaccines. At each subsequent study visit through Day 
57, new concomitant medication(s) and changes to existing medications will be recorded as well as 
receipt of a vaccine. For this study, concomitant medications to be reported in the Case Report 
Form (CRF) are prescription drugs, over-the-counter medications, and supplements. 
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consent will be recorded in the CRF. Any drug taken or vaccine received by the participant during 
the trial should be recorded on the appropriate CRF through Day 57. After Day 57, only 
concomitant medications that are associated with a related SAE or MAAE through Day 181 and 
clinically relevant to report will be recorded in the CRF. An exception to this schedule for recording 
concomitant therapy, is during sick visits for those who have laboratory-confirmed monkeypox 
(illness). During sick visits, concomitant medications and treatment will be collected. 
 
Medications that might interfere with the evaluation of the immune response to MVA-BN should 
not be used by the participant during the study-reporting period unless clinically indicated as part 
of the participant’s health care for a condition diagnosed after enrollment. This would include any 
systemic immunosuppressant medication that may impact the immunogenicity endpoints. In the 
event medical conditions dictate the use of these medications, participants are encouraged to obtain 
adequate care, comply with the course of therapy as prescribed by their physician and inform the 
study Investigator as soon as practical. 
 
6.5.1 
Rescue Medicine 
Not applicable. 
 
7. 
STUDY 
INTERVENTION 
DISCONTINUATION 
AND 
PARTICIPANT DISCONTINUATION/WITHDRAWAL 
7.1 
Halting Criteria and Discontinuation of Study Intervention 
7.1.1 
Study Halting Criteria 
The study will be paused for safety analysis if any of the following events occur: 
1. One (1) participant experiences a SAE after the administration of the vaccine that is 
considered related to the vaccine. 
2. One (1) participant experiences a Grade 4 solicited AE after the administration of the 
vaccine that is considered related to the vaccine. 
3. Three (3) or more participants experience a Grade 3 or higher unsolicited AE coded to 
the same Preferred Term based on the medical dictionary for Regulatory Activities 
(MedDRA) that are deemed related to the vaccine. 
In the event a halting rule is met, an unscheduled safety analysis by the DSMB will be required for 
approval of further enrollment. Further administration of the vaccine, including a second dose, is 
suspended for all participants until an assessment by the DSMB takes place. 
 
7.1.1.1 
Sentinel Participant Halting Rules 
Not Applicable. 
 
7.1.1.2 
Cohort Halting Rules 
Not Applicable. 

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7.1.2 
Individual Halting Criteria 
If a single participant meets an individual halting criterion, this will not halt the whole study but 
halts the participant’s involvement in terms of the administration of the second dose of the vaccine. 
However, while the participant is discontinued from receipt of vaccine, they should be encouraged 
to remain in the study to monitor safety and evaluate immunogenicity until the end of the study. 
 
4. Any participant experiences laryngospasm, bronchospasm or anaphylaxis within 24 hours 
after the administration of the vaccine that is considered related to the vaccine within the 
24 hours after vaccination. 
5. Any participant experiences generalized urticaria (defined as urticarial lesions occurring 
at more than two body parts) within 3 days after the administration of the vaccine. 
6. Any participant experiences any Grade 4 solicited AE or an SAE after the administration 
of the vaccine that is deemed related to the vaccine. 
7. Any participant that experiences ulceration, abscess or necrosis at the injection site that is 
considered related to the vaccine administration. 
 
A participant may be removed from the study if the Investigator or the medical monitor deems it in 
the best interest of the participant. The participant could be withdrawn from the study at any time 
during the trial. 
 
7.1.3 
Follow up for participants that discontinued study intervention 
Discontinuation from vaccination administration does not mean discontinuation from the study, and 
remaining study procedures should be completed as indicated by the study protocol. If a clinically 
significant finding is identified (including, but not limited to changes from baseline) after 
enrollment, the investigator or qualified designee will determine if any change in participant 
management is needed. 
 
The second vaccination will not be given, but other follow up visits will continue, if the participant: 
• Becomes pregnant. 
• Develops monkeypox (symptomatic disease) after the first vaccination 
• Meets an exclusion criterion for participation in the study (either newly developed or not 
previously recognized) that precludes further study participation. 
If a participant meets an exclusion criterion after enrollment/randomization and first dose, it does 
not necessarily mean the participant cannot receive the second dose of JYNNEOS. The decision of 
what “precludes further study participation” depends on what exclusion criteria are met, with a focus 
on what is best for participant safety. The most likely exclusion criteria to be met are participants 
that receive a licensed vaccine after randomization (i.e., exclusion criteria 7 and 8). If a participant 
receives an off-study vaccine during the study-defined restricted time periods (i.e., as defined in 
exclusion criteria and Section 5.4), receipt of the off- study vaccine should be reported as a 
deviation. The participant can receive the second study vaccination if the investigator determines 
that the participant is otherwise eligible to receive the second MVA-BN in this trial. 
 
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second dose may be administered even if there is residual erythema, induration or other 
reactogenicity from the first vaccination. Participants may decline the second vaccination due to 
residual reactogenicity at the Day 29 visit and will be discontinued from the study intervention. 
However, the participant will remain in the study and followed for safety and immunogenicity 
through Day 365 unless they withdraw from the study. 
 
The data to be collected at the time of study intervention discontinuation will include: 
• Reason for discontinuation study vaccination including, but not limited to, unacceptable 
(intolerable) reactogenicity, new medical condition identified that places participant at 
risk, participant unwillingness to have second vaccination. 
• Confirmation of willingness to remain in the study and understanding of study schedule. 
Participant Withdrawal from the Study and Replacement Participants are free to withdraw from 
participation in the study at any time upon request. An investigator may withdraw a participant 
from the study if the participant: 
• Has an AE or other medical condition that continued participation in the study would not 
be in the best interest of the participant. 
• Is lost to follow-up 
 
The reason for participant discontinuation or withdrawal from the study, whether the decision was 
made by investigator or participant, and the extent of the withdrawal (i.e., whether participant 
withdrew from all components of research study or just the study intervention) will be recorded on 
the CRF. If the participant agrees, every attempt will be made to follow all AEs through resolution 
(return to baseline) or until defined as stable. The investigator will inform the participant that 
already collected data will be retained and analyzed for this study even if the participant withdraws 
from this study. Biospecimens collected will still be used to analyze the study endpoints. 
 
Participants who withdraw, or are withdrawn from this study, or are lost to follow-up after signing 
the ICF and administration of the study product will not be replaced. 
7.2 
Lost to Follow-Up 
A participant will be considered lost to follow-up if he or she fails to return for two scheduled visits 
and is unable to be contacted by the study site staff after three attempts. Extensive effort (i.e., 
generally three documented contact attempts via telephone calls, e-mail, etc., made on separate 
occasions) will be made to locate or recall the participant, or at least to determine the participant’s 
health status. These efforts will be documented in the participant’s study file. 
 
8. 
STUDY ASSESSMENTS AND PROCEDURES 
8.1 
Screening Procedures 
In this study, screening assessments can occur in an optional screening visit on Day –7 to –1, or at 
Visit 1 on Day 1 before the first vaccination. At the time of the screening assessment, the participant 
will be provided with detailed study information and written informed consent will be obtained. The 
following assessments are performed to determine eligibility requirements as specified in the 
inclusion and exclusion criteria: 
 

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• Obtain demographic data. 
• Obtain monkeypox exposure history in the 3 weeks prior to signing ICF. 
• Review vaccination history, including any experimental vaccines, and determine receipt 
of exclusionary vaccine(s): 
o Live vaccine in the prior 4 weeks or an inactivated vaccine in the prior 2 weeks. 
o Licensed or investigation smallpox or monkeypox vaccine. 
• Obtain medical history. Ask specifically about worsening of any chronic medical 
condition or hospitalizations in the prior 4 weeks, and whether they have the following 
medical conditions: 
o HIV infection 
o History of monkeypox, cowpox or vaccinia infection 
o History of anaphylaxis or severe adverse reaction to a vaccine or vaccine product 
o History of allergy to gentamicin, ciprofloxacin, chicken or egg protein 
o History of keloid scar formation 
• Review medications and therapies up to 4 weeks prior to signing ICF and record on the 
appropriate CRF and determine receipt of exclusionary medication(s): 
o Experimental therapeutic agent (or vaccine) in the 3 months prior to consent 
o Use of immunosuppressing drugs prior to consent. 
• Perform targeted physical examination and inspect arms for smallpox vaccination scar 
• Measure vital signs (Heart rate (HR), Blood pressure (BP), and oral temperature). 
• Review of birth control history with female participants. 
o Counsel participants to use adequate birth control methods required during the 
trial to avoid pregnancy. 
o Do serum or urine pregnancy test (in participants of childbearing potential) 
• Review inclusion and exclusion criteria. 
The overall eligibility of the participant to participate in the study will be assessed once all screening 
values are available. The screening process can be suspended prior to complete assessment at any 
time if exclusions are identified by the study team. 
Study participants who qualify for inclusion will be enrolled. 
 
8.1.1 
Procedures to be Followed in the Event of Abnormal Clinical Laboratory Test 
Values or Abnormal Clinical Findings During Screening 
 
A participant may be re-screened once if a protocol eligibility criterion that is not met at the initial 
time of screening, will be met by rescreening at a later date. No participant may be screened more 
than twice due to a screening failure result. 
 
Participants will be provided the results of pregnancy testing and abnormal clinical findings 
necessitating follow-up at the discretion of the participating site PI or appropriate sub- investigator. 
8.1.2 
Sick Visit 
Participants with signs and symptoms consistent with monkeypox (e.g., vesicular or pustular 
lesions, fever, chills, lymphadenopathy, malaise, myalgias, headache, or respiratory symptoms) 
during the study are asked to call the study site. Those who have laboratory-confirmed monkeypox 
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diagnostic test done. During the visit, the participant will be asked about the current illness (e.g., 
onset date, treatment received) and for information about the diagnostic testing that was done. 
Participants will have a targeted physical examination done, and a blood sample will be taken. For 
more information about this visit, see the MOP and the CRF. 
 
8.2 
Immunogenicity Assessments 
8.2.1 
Immunogenicity/Efficacy Evaluations 
Prior comparator studies used the Bavarian Nordic (BN) Vaccina virus Western Reserve strain 
(VV-WR) plaque reduction neutralizing antibody (PRNT) assay and enzyme-linked 
immunosorbent assay (ELISA) to evaluate immunogenicity. 16,23,28 In this study, we will use the 
PRNT as the primary assay to determine immunogenicity and will test a minimum of 4 timepoints 
(i.e., at least Days 1, 29, 43, 90 from Days 1, 15, 29, 43, 57, 90, 181 and 365). 
This study will also measure a monkeypox virus specific PRNT and will test a minimum of 2 
timepoints (Days 1 and 43). The monkeypox PRNT assay is not yet developed, and therefore this 
endpoint is as an exploratory endpoint. Additional timepoints for each will be evaluated as able 
(given lab throughput and cost). 
 
8.2.2 
Exploratory Assessments 
Additional assessments of humoral immunity including ELISAs may be performed on samples from 
this trial. 
 
8.3 
Safety and Other Assessments 
Study procedures are specified in the SOA and more detailed information as needed is provided in 
the MOP. A study clinician, licensed to make medical diagnoses and listed on the Form FDA 1572 
as the participating site PI or appropriate sub-investigator, will be responsible for all study- related 
medical decisions. 
• Medical history 
o A complete medical history will be obtained by interview of participants at 
screening (i.e., the screening visit or on Day 1 if no screening visit is conducted). 
o An interim medical history will be obtained by interview of participants at 
subsequent study visits or ad hoc telephone call with participant. Any changes 
since the previous clinic visit will be noted. The interim medical history should 
include an assessment for adverse events and new medical conditions. 
• Physical examination 
o A symptom-directed (targeted) physical exam will be performed if indicated by 
medical history. 
• Reactogenicity Assessments 
o Reactogenicity assessments of solicited systemic reactogenicity occurring from 
the time of each vaccination through 14 days post each vaccination will include 
fever, chills, nausea, headache, fatigue, change in appetite, myalgia, and 
arthralgia. 
o Assessments of solicited local (injection site) reactogenicity occurring from the 
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at injection site, erythema/redness, induration/swelling, and pruritis at site. 
o Any ongoing events at Day 15 will be followed at subsequent visits in order to 
note a resolution date. See Memory Aid section below on measurement of 
ongoing erythema/redness and/or induration/swelling. 
• Memory Aid 
o All participants will complete a Memory Aid to document local and systemic 
reactogenicity from time of each vaccination through 14 days post each 
vaccination (Days 1-15 for the first vaccination and Days 29-43 for the second 
vaccination). 
o Memory Aids will be reviewed with the participants for any solicited reactions, as 
well as unsolicited AEs and SAEs. 
o The vaccination injection site will be examined at all visits until symptoms 
resolve. 
o For those with no residual systemic or local reactogenicity at the Day 15 or Day 
43 visit, no more data is collected by the participant in the Memory Aid. 
o For those with ongoing systemic and/or local reactogenicity at Day 15 or Day 43 
visit, they will be asked to do the following: 
▪ Measure erythema/redness and/or induration/swelling and record in the 
Memory Aid until it has resolved, if applicable. 
▪ Record end date of all other signs and symptoms 
o Nodules and hyperpigmentation are AEs, and not collected in the Memory Aid to 
avoid double counting these events which tend to develop at end of second week 
as a post-inflammatory reaction. 
• Assessment of tolerability 
o On Day 15 and Day 43, the participants will be asked several global assessment 
questions to evaluate how well the vaccine is tolerated. 
• Vital signs 
o Vital sign measurements will include systolic and diastolic BP, HR, and oral 
temperature. Vital signs will be measured at timepoints specified in the SOA. 
• Clinical laboratory evaluations 
o Serum or urine pregnancy test will be performed locally by the site laboratory at 
the screening and must be negative within 24 hours prior to each vaccination on 
Days 1 and 29. This means that if the screening visit is conducted more than 24 
hours prior to vaccination, pregnancy test will need to be done on Day 1. 
Pregnancy tests may be done as needed at interim or unscheduled visits for all 
women of childbearing potential. 
o Results must be confirmed as negative prior to enrollment on Day 1 and 
administration of each vaccination. 
8.3.1 
Procedures to be Followed in the Event of Abnormal Clinical Laboratory Test 
Values or Abnormal Clinical Findings During Conduct of the Trial 
In this study, there will be no clinical laboratory screening or safety tests done except for pregnancy 
testing. Participants will be notified of the results of the pregnancy test. 
 
8.4 
Adverse Events and Serious Adverse Events 
8.4.1 
Definition of Adverse Events (AE) 

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Adverse event means any untoward medical occurrence associated with the use of an intervention 
in humans, whether or not considered intervention-related (21 CFR 312.32 (a)). An AE can 
therefore be any unfavorable and unintended sign (including an abnormal laboratory finding), 
symptom, or disease temporally associated with the use of medicinal (investigational) product. 
 
Any medical condition that is present at the time the participant is screened will be considered as 
baseline and not reported as an AE. However, if the severity (i.e., grade) of any pre-existing medical 
condition increases, it should be recorded as an AE. 
 
Adverse events can be further divided into solicited adverse events and unsolicited adverse events. 
Solicited adverse events are those for which the study team will specifically query the participant 
whether they occurred. Unsolicited adverse events are those events that the participant report 
occurring without being queried about the specific event. 
 
8.4.1.1 
Solicited Adverse Events 
Reactogenicity will be especially important to document because of prior studies demonstrating 
more local (measurement) reactogenicity among participants who received the ID MVA-BN 
vaccine injection. In this study, we will collect the following solicited adverse events based on 
prior studies. This includes local (pain at the site of the injection, erythema/redness, 
induration/swelling, pruritis) and systemic (fever, chills, nausea, headache, fatigue, change in 
appetite, myalgia [exclusive of the injection site], and arthralgia) reactogenicity. In addition, we 
expect that some participants will develop skin discoloration and nodules which will be reported as 
AEs and not collected on the memory aid and followed through to resolution. For this study, we 
will use the following toxicity grading scale: 
“FDA Guidance for Industry, Toxicity Grading Scale for Healthy Adults and Adolescent Volunteers 
Enrolled in Preventive Vaccine Clinical Trials” as a reference. 
 
Of note, pruritis/itching, arthralgia, chills, and change in appetite are not included in the FDA 
toxicity table. However, the FDA Guidance allows for addition of other signs and symptoms as 
follows: 
 
Mild: 
No interference with activity 
Moderate: 
Some interference with activity 
Severe: 
Prevents daily activity 
Potentially Life Threatening: 
ER visit or hospitalization 
 
8.4.1.2 
Unsolicited Events 
Unsolicited events are all AEs spontaneously reported by the participant and/or in response to an 
open question from study personnel or revealed by observation, physical examination or other 
diagnostic procedures. 
 
8.4.2 
Definition of Serious Adverse Events 
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investigator or sponsor, it results in any of the following outcomes (21 CFR 312.32 (a)): 
• death 
• a life-threatening adverse event* 
• inpatient hospitalization or prolongation of existing hospitalization 
• a persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions, or 
• a congenital anomaly/birth defect. 
 
Important medical events that may not result in death, be life-threatening, or require hospitalization 
may be considered serious when, based upon appropriate medical judgment, they may jeopardize 
the patient or participant and may require medical or surgical intervention to prevent one of the 
outcomes listed in this definition. Examples of such medical events include allergic bronchospasm 
requiring intensive treatment in an emergency room or at home, convulsions that do not result in 
inpatient hospitalization, etc. 
 
* An adverse event is considered “life-threatening” if, in the view of either the investigator or 
sponsor, its occurrence places the patient or participant at immediate risk of death. It does not 
include grade 4 severity unless the adverse event might have caused death. 
 
8.4.2.1 
Definition of Medically Attended Adverse Events (MAAE) 
A medically attended adverse event (MAAE) is an unsolicited AE that results in unscheduled 
medical attention such as a hospitalization for less than 24 hours, an emergency room visit, or an 
otherwise unscheduled healthcare visit for any reason. All SAEs and MAAEs will be collected from 
Day 1 through Day 57, and all SAE/MAAEs related to the vaccine through Day 181. 
 
8.4.2.2 
Definition of Suspected Unexpected Serious Adverse Reactions (SUSAR) 
A SUSAR is a SAE that is considered related to study product and unexpected. 
 
Unexpectedness to study product will be determined by what is listed in the JYNNEOS package 
insert. 
 
8.4.3 
Classification of an Adverse Event 
The determination of seriousness, severity, and causality will be made by an on-site investigator or 
other staff as listed on the delegation log. 
Any potential grade 3 or 4 AE should be evaluated by someone qualified to provide a medical 
evaluation of AEs. This includes but is not limited to physicians, physician assistants, and nurse 
practitioners. 
 
8.4.3.1 
Severity of Event 
All AEs or SAEs will be assessed for severity, according to the toxicity grading scale, FDA 
Guidance for Industry, Toxicity Grading Scale for Healthy Adults and Adolescent Volunteers 
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protocol-defined grading scale, the following guidelines will be used to describe severity. 
 
Mild (Grade 1): Events that are usually transient and may require only minimal or no treatment or 
therapeutic intervention and generally do not interfere with the participant’s usual activities of daily 
living. 
 
Moderate (Grade 2): Events that are usually alleviated with additional specific therapeutic 
intervention. The event interferes with usual activities of daily living, causing discomfort but poses 
no significant or permanent risk of harm to the research participant.  
 
Severe (Grade 3): Events interrupt usual activities of daily living, or significantly affects clinical 
status, or may require intensive therapeutic intervention. Severe events are usually incapacitating. 
 
Life-threatening (Grade 4): Extreme limitation in activity, significant assistance required; 
significant medical intervention/therapy required, hospitalization or care provided. 
 
8.4.3.2 
Relationship to Study Intervention 
For each reported adverse event or reaction, the Principal Investigator or designee must assess 
the relationship of the event to the study product using the following guideline: 
 
Related – The AE is known to occur with the study intervention, there is a reasonable possibility 
that the study intervention caused the AE, or there is a temporal relationship between the study 
intervention and event. Reasonable possibility means that there is evidence to suggest a causal 
relationship between the study intervention and the AE.  
 
Not Related – There is not a reasonable possibility that the administration of the study intervention 
caused the event, there is no temporal relationship between the study intervention and event onset, 
or an alternate etiology has been established. 
 
8.4.4 
Time Period and Frequency for Event Assessment and Follow-Up 
For this study: 
• Systemic and local solicited adverse events will be collected from Day 1 through Day 15, 
and Day 29 through Day 43. However, participants with ongoing systemic and/or local 
reactogenicity at Day 15 or Day 43 visit, will be asked to measure erythema/redness and/or 
induration/swelling until it has resolved, if applicable, and record end date of all other 
signs and symptoms. 
• Unsolicited adverse events will be collected from Day 1 through Day 29, and Day 29 
through Day 57. 
• All Serious adverse events (SAEs) and MAAEs will be collected from Day 1 through 
Day 57, and all SAE/MAAEs related to the vaccine through Day 181. 
• All SAEs will be followed through resolution or until the site investigator deems the 
event to be chronic or the participant is stable. 
• AEs will be followed through resolution. 
 

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8.4.5 
Adverse Event Reporting 
8.4.5.1 
Investigators Reporting of AEs 
All clearly related signs, symptoms, and results of diagnostic procedures performed because of an 
AE should be grouped together and recorded as a single diagnosis or AE term, if available. If the 
AE is a laboratory abnormality that is part of a clinical condition or syndrome, it should be 
recorded as the syndrome or diagnosis rather than the individual laboratory abnormality. 
Each AE will also be described in terms of duration (start and stop date), severity, association with 
the study product, action(s) taken, and outcome. 
 
AEs characterized as intermittent require documentation of onset and duration of each episode. All 
AEs will be assessed for severity, relatedness to study vaccine (see Section 8.4.3), and seriousness 
(see section 8.4.2) by the study PI or sub-investigator. 
 
All AEs will be captured on the appropriate data collection form. Information to be collected for 
AEs includes event term or description, date of onset, assessment of severity, relationship to study 
product, and alternate etiology (assessed only by those with the training and authority to make a 
diagnosis and listed on the Form FDA 1572 as an investigator), date of resolution, seriousness, and 
outcome. AEs occurring during the trial collection and reporting period will be documented 
appropriately regardless of relationship. 
 
8.4.5.2 
Special Reporting of Adverse Events 
Not applicable. 
 
8.4.6 
Serious Adverse Event Reporting 
8.4.6.1 
Investigators Reporting of SAEs 
Any AE that meets a protocol-defined serious criterion must be submitted immediately (within 24 
hours of site awareness) on an SAE form to the DMID Pharmacovigilance Group, at the following 
address: 
 
DMID Pharmacovigilance Group 
Clinical Research Operations and Management Support (CROMS) 
6500 Rock Spring Dr. Suite 650 Bethesda, MD 
20817, USA 
SAE Hot Line: 1-800-537-9979 (US) or 1-301-897-1709 (outside US) 
SAE FAX Number: 1-800-275-7619 (US) or 1-301-897-1710 (outside US) 
SAE Email Address: PVG@dmidcroms.com 
 
In addition to the SAE form, select SAE data fields must also be entered into the SDCC system. 
See the protocol-specific MOP for details regarding this procedure. 
 
Other supporting documentation of the event may be requested by the DMID Pharmacovigilance 
Group and should be provided as soon as possible. The DMID Medical Monitor will review and 
assess the SAE for regulatory reporting and potential impact on study participant safety and 

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protocol conduct. 
 
At any time after completion of the study, if the site principal investigator or appropriate sub- 
investigator becomes aware of an SAE that is suspected to be related to study product, the site 
principal investigator or appropriate sub-investigator will report the event to the DMID 
Pharmacovigilance Group. 
 
8.4.6.2 
Regulatory Reporting of SAEs 
Following notification from the site Principal Investigator or appropriate sub-investigator, DMID, 
as the IND sponsor, will report any SUSAR to the FDA as an IND safety report. DMID will report 
an AE as a suspected unexpected adverse event only if there is evidence to suggest a causal 
relationship between the study intervention and the AE. 
 
The Sponsor must ensure the event meets all three of the definitions: 
• Suspected adverse reaction. 
• Serious. 
• Unexpected. 
Both serious and unexpectedness are important, but the event will be reported only if there is 
evidence to suggest a causal relationship between the drug and the adverse event, such as: 
• A single occurrence of an event that is uncommon and known to be strongly associated 
with drug exposure. 
• One or more occurrences of an event that is not commonly associated with drug exposure 
but is otherwise uncommon in the population exposed to the drug. 
• On review as an aggregate analysis when the occurrence is higher than the historical 
control. 
 
DMID will report to the FDA any unexpected fatal or life-threatening suspected adverse reaction 
as soon as possible, but in no case later than 7 calendar days after the sponsor’s initial receipt of 
the information. If the event is not fatal or life-threatening the IND safety report will be submitted 
within 15 calendar days after the sponsor determines that the information qualifies for reporting as 
specified in 21 CFR Part 312.32. Relevant follow up information to an IND safety report will be 
submitted as soon as the information is available. Upon request from FDA, DMID will submit to 
the FDA any additional data or information that the agency deems necessary, as soon as possible, 
but in no case later than 15 calendar days after receiving the request. 
 
DMID will submit an IND safety report to the FDA and will notify all participating site Principal 
Investigators (i.e., all Principal Investigators to whom the sponsor is providing drug under its 
IND(s) or under any Principal Investigator’s IND(s) of potential serious risks from clinical studies 
or any other source, as soon as possible. SAEs that are not SUSARs will be reported to the FDA at 
least annually in a summary format which includes all SAEs. 
 
8.4.7 
Reporting Events to Participants 
Participants have the right to be informed of any new findings of AEs or SAEs that may affect their 
safety or influence their choice to participate or continue participating in the study. 

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8.4.8 
Adverse Events of Special Interest (AESI) 
There are no pre-specified AESI for this trial. 
 
8.4.9 
Reporting of Pregnancy 
Pregnancy is not an AE. However, any pregnancy that occurs during study participation (through 
Day 365) should be reported to the sponsor on the appropriate DCF. Pregnancy should be followed 
for safety and outcome. This follow-up will include pregnancy outcome (termination, pre-term 
birth, term birth) and newborn outcome (live birth, fetal demise, stillbirth; presence of any 
congenital anomalies). No in-person visits will be required for pregnancy outcome determination. 
 
8.5 
Unanticipated Problems 
8.5.1 
Definition of Unanticipated Problems (UP) 
The Department of Health and Human Services Office for Human Research Protections (OHRP) 
considers unanticipated problems (UPs) involving risks to participants or others to include, in 
general, any incident, experience, or outcome that meets all of the following criteria: 
• Unexpected in terms of nature, severity, or frequency given (a) the research procedures 
that are described in the protocol-related documents, such as the Institutional Review 
Board (IRB)-approved research protocol and informed consent document; and (b) the 
characteristics of the participant population being studied; and 
• Related or possibly related to participation in the research (“possibly related” means there 
is a reasonable possibility that the incident, experience, or outcome may have been caused 
by the procedures involved in the research); and 
• Suggests that the research places participants or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or 
recognized. 
 
Incidents arising from noncompliance with study procedures should be reported as protocol 
deviations (see Section 10.1.10). An incident that qualifies as both a UP and a protocol deviation 
should be reported as both. 
8.5.2 
Unanticipated Problem Reporting 
The investigator will report unanticipated problems (UPs) to the study sponsor, the reviewing IRB 
and to the SDCC. 
 
The UP report will include the following information: 
• Protocol identifying information: protocol title and number, PI’s name, and the IRB 
project number; 
• A detailed description of the event, incident, experience, or outcome; 
• An explanation of the basis for determining that the event, incident, experience, or 
outcome represents an UP; 
• A description of any changes to the protocol or other corrective actions that have been 
taken or are proposed in response to the UP. 

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To satisfy the requirement for prompt reporting, UPs will be reported using the following timeline: 
 
• UPs that are serious adverse events (SAEs) will be reported to the IRB and to the 
SDCC/study sponsor within 24 hours of the investigator becoming aware of the event. 
• Any other UP will be reported to the IRB and to the SDCC/study sponsor within a 
timeline defined according to the relevant policies. 
• UPs will be collected through the end of the study. 
 
8.5.3 
Reporting Unanticipated Problems to Participants 
Participants will be informed of any UPs that will potentially influence their participation in this 
trial. 
 
9. 
STATISTICAL CONSIDERATIONS 
9.1 
Statistical Hypotheses 
The primary hypothesis involves a two-step hierarchical process. The study will first test non- 
inferiority of the 2 x 107 ID regimen relative to 1 x 108 SC (standard dose regimen). If the 2 x 107 
ID regimen is non-inferior to the standard dose regimen, hypothesis testing will proceed to test non-
inferiority of the 1 x 107 ID regimen relative to the standard dose regimen. 
 
Primary Hypothesis 1 
• At Day 43 the humoral immune response of the 2 x 107 MVA-BN ID regimen will be 
non-inferior to the standard 1 x 108 MVA-BN SC regimen, as assessed by PRNT GMT. 
 
Primary Hypothesis 2 
• At Day 43 the humoral immune response of the 1 x 107 MVA-BN ID regimen will be 
non-inferior to standard 1 x 108 MVA-BN SC regimen, as assessed by PRNT GMT. 
Secondary hypotheses 
• At Day 365 the humoral immune response of the 2 x 107 MVA-BN ID regimen will be 
non-inferior to the standard 1 x 108 MVA-BN SC regimen, as assessed by PRNT GMT. 
• At Day 365 the humoral immune response of the 1 x 107 MVA-BN ID regimen will be 
non-inferior to the standard 1 x 108 MVA-BN SC regimen, as assessed by PRNT GMT. 
• The humoral immune responses, as assessed by PRNT GMT, for each ID regimen will be 
similar to the SC regimen at all study days. [Note, this corresponds to two hypotheses, one 
for each ID study arm.] 
• The humoral immune responses, as assessed by vaccinia specific PRNT half-life, for each 
ID regimen will be similar to the SC regimen. [Note, this corresponds to two hypotheses, 
one for each ID study arm.] 
• The humoral immune responses, as assessed by monkeypox specific PRNT GMT, for 
each ID regimen will be similar to the SC regimen at Day 1 and 43. [Note, this 
corresponds to two hypotheses, one for each ID study arm.] 
 

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9.2 
Sample Size Determination 
Approximately 210 evaluable (mITT) participants (70 per study arm; 140 total for each test of non-
inferiority) will provide ample power for both tests of non-inferiority with a type I error rate of 0.05 
(Table 7), and assumes, conservatively, that both arms have a standard deviation of 0.6. 
 
A sample size of 140 total for the test of non-inferiority will provide 84% power with the non- 
inferiority (NI) margin of 0.5 and two-sided type I error rate of 0.05. Power calculations 
conservatively assume a standard deviation of 0.6 in both arms (Table 8 andTable 9). Data from 
prior studies by Pittman and Frey suggest that the standard deviation will be lower than 0.6 at later 
expected peak times, in which case power should be higher for the non-inferiority tests. Note that 
the power is expected to be lower for the comparison of the 1 x 107 ID regimen and the standard 
dose regimen for two reasons: 1) the hypothesis test is conditional on rejecting the null hypothesis 
comparing the 2 x 107 ID arm to the standard regimen arm, and 2) the true GMT for the 1 x 107 ID 
may be less than the standard SC dose. 
 
In a prior study that compared ID and SC routes of MVA-BN16, 10% of the randomized participants 
did not receive the second vaccination. Therefore, this trial will enroll up to 231 participants (210 x 
1.1) to have 210 evaluable participants. 
Table 7: Power calculations 
Power calculations for a non-inferiority test of means using unequal variances and two- sided type 
one error rate of 0.05. Non-inferiority margin of 0.5. Assumed standard deviation (on log10 scale) 
of 0.6. 
NI margin 
Sample Size 
per arm 
Total sample size for NI test 
Power 
0.5 
Log10(0.5) =-0.301 
60 
120 
0.78 
0.5 
70 
140 
0.84 
0.5 
80 
160 
0.88 
0.5 
85 
170 
0.90 
0.5 
90 
180 
0.92 
 
 
Table 8: Standard deviation estimates 
Standard deviation estimates computed from Table S4 of Pittman et al, 201929 
MVA-BN 
ACAM2000 
Ratio of 
GMTs 
95% CI 
Week 
N 
GMT 
95% CI 
SD 
(for 
log10 
GMT) 
N 
GMT 
95% CI 
SD 
(for 
log10 
GMT) 
2 
184 16.2 
[13.0, 20.1] 
0.65 
184 
16.2 
[13.1, 20.0] 
0.63 
0.997 
[0.738, 1.348] 
4 
185 16.9 
[13.7, 20.8] 
0.63 
186 
79.3 
[67.1, 93.8] 
0.51 
0.213 
[0.163, 0.278] 
6 
185 153.5 
[134.3, 175.6] 
0.41 
181 
64.7 
[54.9, 76.2] 
0.49 
2.372 
[1.922, 2.928] 
8 
179 118.2 
[102.9,135.8] 
0.41 
183 
67.1 
[56.9, 79.0] 
0.49 
1.763 
[1.422, 2.185] 
Peak 
185 153.5 
[134.3, 175.6] 
0.41 
186 
79.3 
[67.1, 93.8] 
0.51 
1.935 
[1.562, 2.397] 
 

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Table 9: Standard deviation estimates 
Standard deviation estimates computed from Frey et al, 201516 
Study Visit Day 
Liquid SC 1x108 N=149 
Liquid ID 2x107 N=146 
VV-WR GMT [95% CI] 
SD 
VV-WR GMT [95% CI] 
SD 
Day 14 
10.0 [9.0, 11.1] 
0.28 
10.3 [9.3, 11.3] 
0.27 
Day 28 
9.6 [8.7, 10.6] 
0.27 
10.8 [9.9, 11.9] 
0.23 
Day 42 
45.2 [36.4, 56.2] 
0.59 
54.4 [43.7, 67.8] 
0.59 
Peak post 2nd vaccination 
49.5 [40.0, 61.3] 
0.58 
59.6 [48.1, 74.0] 
0.59 
9.3 
Statistical Analyses 
9.3.1 
General Methodology 
Hypothesis testing will be stepwise, starting with the non-inferiority test of the 2 x 107 ID regimen 
relative to standard regimen, with an unequal-variance, two-sample t-test statistic and 95% two-
sided confidence intervals. The ID-dose regimen will be considered non-inferior if the lower bound 
of the confidence interval (original scale) is no less than half that of the standard dose, giving a non-
inferiority (NI) margin of 0.5 (NI= -0.301 log10 scale). The selection of this NI margin was based 
on the pivotal Phase 3 trial by Pittman et al., in 2019 comparing one dose of ACAM2000 and the 
now licensed 2-dose standard MVA-BN regimen, which provided an estimated relative (peak) 
immune response of approximately 2-times higher for MVA-BN (Table 8). An NI margin of 0.5 
will correspond an immune response of the lower-dose MVA-BN at least as high as what would be 
expected for ACAM2000. 
 
If the null hypothesis from analysis 1 is rejected in favor of non-inferiority (i.e., the lower limit of 
the 95% CI of the difference in log of GMTs for 2 x 107 TCID50 MVA-BN ID compared to 1 x 
108 MVA-BN SC is greater than log(0.5) which is equal to -0.301), testing will proceed with a 
non- inferiority test of the 1 x 107 MVA-BN ID regimen relative to the standard dose regimen, 
using an unequal variance, two-sample t-test statistic with 95% confidence interval. 
 
9.3.2 
Timing of Analyses 
9.3.2.1 
Interim Safety Analyses 
Given the need for rapid review and dissemination of study data for public health reasons, AEs and 
SAEs may be reviewed as necessary outside of DSMB reviews. The DSMB may not need to meet 
(unless halting rules are met), and materials will be provided electronically. Documentation of 
review and any concerns noted will be solicited electronically. 
 
The DSMB will review separate cumulative AE data reports for all participants within each arm. 
Given the safety database known for authorized/approved vaccines, there is no routine mandatory 
review by the DSMB unless halting rules are triggered. 
 

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9.3.2.2 
Interim Immunogenicity Analyses 
Interim data review of immunogenicity may be performed after all participants have completed 
Day 181. Analyses will be performed as needed to inform public health decisions. It is recognized 
that the data may not be frozen, but the risk of introducing bias at that point in the trial is considered 
small. The analyses will be provided to the study team. There is no blinded data in this trial. 
However, research laboratories will be blinded to participant study arm for the purposes of 
immunogenicity/efficacy evaluations. 
 
Data may be disseminated to public health officials and partners as needed and included in 
publications and presentations to inform the global scientific community. 
9.3.2.3 
Final Analyses 
The final efficacy/immunological/safety outcome(s) may be analyzed after all data for the primary 
and secondary outcome(s) have been collected and locked. 
 
9.3.3 
Populations for Analyses 
There will be three analysis populations in this study. The safety analysis population includes all 
enrolled participants who received at least one dose of study vaccine. Analyses for the safety 
population will include safety reported through the end of the study. The modified intent-to-treat 
(mITT) population includes all participants who received at least one dose of vaccine and 
contributed both pre- and at least one post-vaccination venous blood sample for immunogenicity 
testing for which valid results were reported. 
 
In the final analysis, protocol deviations will be reviewed to determine which protocol deviations 
may affect the analysis. The per protocol (PP) population will then be defined – and this includes 
all participants in the mITT subset with the following exclusions: 
• Data from all available visits for participants found to be ineligible at baseline. 
• Data from all visits after the protocol deviations that are considered to affect the science 
(as determined by the sponsor at an ad hoc meeting). 
• Data from any visit that occurs substantially out of window. 
 
For the PP and mITT analyses, participants will be analyzed according to the study product that they 
received. 
 
9.3.4 
Baseline Characteristics and Participant Disposition 
Summaries of demographic characteristics of the study population including age, sex, ethnicity, 
and race will be presented by vaccination arm and overall. In addition, this descriptive analysis 
will be done by reported HIV infection status. 
 
9.3.5 
Immunogenicity Analyses 
Descriptive summaries of immunogenicity data will be presented for the mITT population. If 
there are protocol deviations which may affect the analysis, a per-protocol (PP) analysis may 
also be performed. 

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Geometric Mean Titers (GMT) and Geometric Mean Fold Rise (GMFR) from baseline of VV- WR 
PRNT will be calculated, along with 95% CIs, for all groups, at each timepoint. Summaries will 
also be displayed graphically. Geometric Mean Titer Ratio, defined as the ratio of each ID arm to 
the control SC arm, will also be reported at each timepoint, along with 95% CIs. 
There are no imputations planned for missing data. 
 
A Statistical Analysis Plan (SAP) will be developed and will detail the full planned analysis. 
9.3.6 
Safety Analyses 
The safety outcomes for the three study arms will be evaluated including systemic reactogenicity 
for 14 days after each vaccination, local reactogenicity for 14 days after each vaccination, and 
unsolicited adverse events for 28 days after each vaccination. All SAEs and MAAE will be 
evaluated from Day 1 through Day 57 of the trial as compared to licensed dose, and all related 
SAE/MAAEs will be evaluated through Day 181. 
 
9.3.6.1 
Reactogenicity 
The number, percentage (observed rate) and exact two-sided 95% CI for participants reporting each 
solicited local (injection site) reaction and solicited systemic reaction following vaccination will be 
summarized by study arm after first and second vaccination, and overall (i.e., after any 
vaccination). In addition, the most severe local and systemic reactions recorded during the follow-
up period (i.e., maximum severity) for each participant will be determined and summarized by 
study arm following each vaccination (as well as overall) and the resulting number and percentage 
of participants will be summarized by severity grade (none, mild, 
moderate, severe, life-threatening). Last, the daily severity of local and systemic reactions will be 
determined for each participant and the proportion of participants having a sign/symptom each day 
will summarized by grade and presented by study arm following each vaccination. Rates for any 
severe (Grade 3 or 4) solicited local or systemic reaction following any vaccination will be 
compared between study arms. 
 
9.3.6.2 
Other Adverse Events 
The number of associated unsolicited AEs, MAAEs and SAEs following vaccine administration is 
expected to be small. A complete listing of all events will therefore be provided, including the nature 
of the event, timing relative to vaccination, severity, duration, and the investigator’s assessment of 
the likely relationship to vaccination. For each type of AE, the observed rate and exact two-sided 
confidence intervals will be computed for each study arm and listed by toxicity grade. AEs will be 
MedDRA® coded for preferred term and system organ class. Event rates and exact 95% confidence 
intervals for each study arm and the entire study cohort will be presented, in aggregate and by 
MedDRA® categories. Related unsolicited AEs, MAAE and SAEs rates will be compared between 
the study arms. 
 
The number, percentage (observed rate) for participants that withdrew or discontinued their 
vaccination series due to safety or reactogenicity events will be tabulated. Rates of 
withdrawal/discontinuation will be compared between study arms using Fisher’s exact test. 
 

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Refer to the SAP for additional information. 
 
10. 
SUPPORTING DOCUMENTATION AND OPERATIONAL 
CONSIDERATIONS 
10.1 
Regulatory, Ethical, and Study Oversight Considerations 
This study will be conducted in conformity with the principles set forth in The Belmont Report: 
Ethical Principles and Guidelines for the Protection of Human Participants of Research (US 
National Commission for the Protection of Human Participants of Biomedical and Behavioral 
Research; April 18, 1979), and the federal policy for the Protection of Human Participants codified 
in 45 CFR Part 46, 21 CFR Part 50 (Protection of Human Participants), and the ICH E6(R2). 
 
An OHRP-registered IRB will review and approve this protocol, associated informed consent 
documents, recruitment materials, and handouts or surveys intended for the participants, prior to 
the recruitment, screening and enrollment of participants. The IRB review shall be in accordance 
with 45 CFR 46 and 21 CFR 50, 21 CFR 56 (IRBs), and other federal, state, and local regulations 
and policies, as applicable. 
 
Each institution engaged in this research will hold a current Federalwide Assurance (FWA) issued 
by the Office for Human Research Protections (OHRP) for federally funded research. and provide 
the FWA number to DMID. Each site principal investigator will obtain IRB approval for this 
protocol and any amendments to be conducted at his/her research site(s). 
Any amendments to the protocol or informed consent documents will be approved by the IRB 
before they are implemented. IRB review and approval will occur at least annually throughout 
enrollment and follow-up of participants, in accordance with applicable regulations and the 
requirements of the IRB/IEC. The participating site PI will notify the IRB of deviations from the 
protocol and reportable SAEs, as applicable to the IRB policy. 
 
DMID must receive the documentation that verifies IRB/IEC approval for this protocol, informed 
consent documents and associated documents, prior to the recruitment, screening and enrollment 
of participants, and any IRB approvals for continuing review or amendments as required by DMID. 
 
10.1.1 
Informed Consent Process 
Informed consent is a process that is initiated prior to an individual agreeing to participate in a trial 
and continuing throughout the individual’s trial participation. Before any study procedures are 
performed, informed consent will be obtained and documented. Participants will receive a concise 
and focused presentation of key information about the clinical trial, verbally and with a written 
consent form. The key information about the purpose of the study, the procedures and experimental 
aspects of the study, study interventions/products, probability for random assignment to treatment 
groups, risks and discomforts, the expected duration of the participant’s participation in the trial, 
any expected benefits to the participant, and alternative treatments and procedures that may be 
available to the participant. The explanation will be organized and presented in lay terminology and 
language that facilitates understanding why one might or might not want to participate. 
 

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Participants will receive an explanation as to whether any compensation and any medical treatments 
are available if injury occurs, and, if so, what they consist of, or where further information may be 
obtained. Participants will be informed of the anticipated financial expenses, if any, to the 
participant for participating in the trial, as well as any anticipated prorated payments, if any, to the 
participant for participating in the trial. They will be informed of whom to contact (e.g., the 
investigator) for answers to any questions relating to the research project. 
 
Information will also include the foreseeable circumstances and/or reasons under which the 
participant’s participation in the trial may be terminated. The participants will be informed that 
participation is voluntary and that they are free to withdraw from the study for any reason at any 
time without penalty or loss of benefits to which the participant is otherwise entitled. 
 
Participants will be informed that records identifying the participant will be kept confidential, and, 
to the extent permitted by the applicable laws and/or regulations, will not be made publicly available 
and, if the results of the trial are published, the participant’s identity will remain confidential. 
Participants will be informed whether private information collected from this research and/or 
specimens will be used for additional research, even if identifiers are removed. Participants will be 
informed that the monitor(s), auditors(s), IRB, NIAID, and regulatory authority(ies) will be granted 
direct access to the participant’s original medical records for verification of clinical trial procedures 
and/or data without violating the confidentiality of the participant, to the extent permitted by the 
applicable laws and regulations, and that, by signing a written informed consent form, the 
participant is authorizing such access. 
 
Participants will be allowed sufficient time to consider participation in this research trial and can 
discuss this trial with their family, friends or legally authorized representative, or think about it 
prior to agreeing to participate. 
 
Informed consent forms will be IRB-approved, and participants will be asked to read and review 
the consent form. Participants must sign the informed consent form prior to starting any study 
procedures being done specifically for this trial. Once signed, a copy of the informed consent form 
will be given to the participant(s) for their records. 
 
New information will be communicated by the site principal investigator to participants who 
consent to participate in this trial in accordance with IRB requirements. The informed consent 
document will be updated, and participants will be re-consented per IRB requirements, if necessary. 
 
10.1.1.1 
Requirements for Permission by Parents/Guardians and Assent by Children (in case 
of a minor) 
Not applicable. 
 
10.1.1.2 
Other Informed Consent Procedures 
Participants will be asked for consent to collect blood for the use of residual specimens and samples 
for secondary research. This extra/residual blood and corresponding serum will be used as back-up 
specimens for PP defined assays or designated for secondary research use and stored indefinitely at 
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facilitate rapid follow-on analyses, if warranted, to provide more comprehensive scientific insights 
into the impact (safety and immunological) of the vaccine on the host response to vaccination. To 
maintain statistical power in follow-on analyses it is important that extra blood collection and 
secondary research use be included in as many participants as possible, due to the limited sample 
size per treatment arm. For this reason, if participants choose not to provide permission for extra 
blood and secondary research use, they will not be eligible for enrollment into the study. 
 
The stored samples will be labeled with barcodes to maintain confidentiality. Research with 
identifiable samples and data may occur as needed, however, participant confidentiality will be 
maintained as described for this protocol and with IRB approval. Samples designated for secondary 
research use may be used for additional immunological assessments that may include but are not 
limited to antibody epitope mapping, B and T cell repertoire determination, non- traditional immune 
assay development, determination of innate immune factors and the ability of vaccine-induced 
antibodies to cross-react to different proteins and virus strains. These blood samples might be used 
in new or different immunological laboratory tests, to provide information for the development of 
new vaccines or therapeutics, or for the studies of monkeypox virus or other related viruses. 
Samples will not be sold for commercial profit. 
Although the results of any future research may be patentable or have commercial profit, 
participants will have no legal or financial interest in any commercial development resulting from 
any future research. There are no direct benefits to the participant for extra specimens collected or 
from the secondary research. No results from secondary research will be entered into the 
participant’s medical record. Incidental findings will not be shared with the participant, including 
medically actionable incidental findings, unless required by law. 
 
Risks are associated with the additional volume of blood collected, such as anemia. Risks for loss 
of privacy and confidentiality are described below. Participants may withdraw permission to use 
samples for secondary use at any time. They will need to contact the participating site and the 
samples will be removed from the study repository after this study is completed and documentation 
will be completed that outlines the reason for withdrawal of permission for secondary use of 
samples. Participants who withdraw consent before the last visit will not have the extra blood drawn 
for secondary use. 
 
Participants will be asked to consent specifically on primary and secondary research samples. 
The consent process will include an explanation of the potential risks to the individual 
participants associated with data submitted to an NIH data repository and subsequent sharing. 
Data that may potentially identify human participants will not be released in unrestricted 
databases. Participants will be informed that analytical methods are associated with the risk of 
re-identification, even when specimens are de-identified. The consent will include whether 
individual participant data will be shared through a NIH controlled access data repository. 
 
10.1.2 
Study Termination and Closure 
Section 7, Study Intervention Discontinuation and Participant Discontinuation/Withdrawal, 
describes the temporary halting of the study. 
This study may be prematurely terminated if there is sufficient reasonable cause, including but not 
limited to: 
• Determination of unexpected, significant, or unacceptable risk to participants 

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• Results of interim efficacy or futility analysis 
• Insufficient compliance to protocol requirements 
• Data that are not sufficiently complete and/or evaluable 
• Regulatory authorities’ determination 
• Sponsor’s determination 
 
If the study is prematurely terminated, the Principal Investigator (PI) will promptly inform study 
participants and the Institutional Review Board (IRB) and regulatory authorities as applicable. 
 
Study participants will be contacted, as applicable, and be informed of changes to study visit 
schedule. The PI will assure appropriate follow-up for the participants, as necessary. The sponsor 
will notify regulatory authorities as applicable. 
 
10.1.3 
Confidentiality and Privacy 
Participant confidentiality is strictly held in trust by the participating investigators, their staff, and 
the sponsor(s) and their agents. This confidentiality is extended to cover clinical information 
relating to participants, test results of biological samples and genetic tests, and all other information 
generated during participation in the study. No identifiable information concerning participants in 
the study will be released to any unauthorized third party. Participant confidentiality will be 
maintained when study results are published or discussed in conferences. 
 
The study monitor, other authorized representatives of the sponsor, representatives of the 
Institutional Review Board (IRB), and/or regulatory agencies may inspect all documents and 
records required to be maintained by the investigator, including but not limited to, medical records 
(office, clinic, or hospital) and pharmacy records for the participants in this study. The clinical study 
site will permit access to such records. 
 
All source records including electronic data will be stored in secured systems in accordance with 
institutional policies and federal regulations. All study data and research specimens that leave the 
site (including any electronic transmission of data) will be identified only by a coded number that 
cannot be linked to a participant. 
 
As this research is funded by the NIH, it is covered by NIH policy which effectively issues the 
research a Certificate of Confidentiality. By this policy, researchers cannot be forced to disclose or 
provide, in any Federal, State, or local civil, criminal, administrative, legislative, or other 
proceeding, the name of such individual or any such information, document, or biospecimen that 
contains identifiable, sensitive information about the individual and that was created or compiled 
for purposes of the research, unless such disclosure or use is made with the consent of the individual 
to whom the information, document, or biospecimen pertains. 
 
The Certificate cannot be used to resist a demand for information from personnel of the United 
States Government that is used for auditing or evaluation of federally funded projects, like this 
study, or for information that must be released in order to meet the requirements of the Federal 
Food and Drug Administration (FDA). 
 

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A Certificate of Confidentiality does not prevent the participant from voluntarily releasing 
information about themselves or their involvement in this research. If any person or agency obtains 
a written consent to receive research information, then the researchers may not use the Certificate 
to withhold that information. 
 
The Certificate of Confidentiality does not prevent the researchers from reporting without the 
participant’s consent, information that would identify the participant as a participant in the research 
project regarding matters that must be legally reported including child and elder abuse, sexual abuse, 
or wanting to harm themselves or others. 
 
The release of individual private information or specimens for other research will only occur if 
consent was obtained from the individual to whom the information, document, or biospecimen 
pertains, or for the purposes of other research that the release is in compliance with applicable 
Federal regulations governing the protection of human participants in research. 
 
10.1.4 
Secondary Use of Stored Specimens and Data 
 
10.1.4.1 
Samples for Secondary Research 
Repository Research Sample 
To participate in this study, participants will be asked for consent for storage of samples for 
secondary use. Samples will be stored indefinitely at a DMID-designated storage facility. Each 
sample will be encoded (labeled) only with a barcode and a unique tracking number to protect 
participant confidentiality. Secondary research with coded samples and data may occur, however, 
participant confidentiality will be maintained as described for this protocol. An IRB review of the 
secondary research using coded specimens is required. 
 
Repository Research Samples, upon written request and approval from DMID and any approvals 
required by the site, may be shared for secondary research with investigators at the participating 
site, with researchers at other sites or other institutions, or company-designated research 
laboratories. The samples will not be sold or used directly for production of any commercial 
product. DMID will authorize shipment from the repository. 
 
Reports from secondary research will not be kept in the participants’ health records or shared with 
participants, unless required by law. Reports will not be sent to the specimen repository. The 
participant’s decision for secondary research can be changed at any time by notifying the study 
doctors or nurses in writing. If the participant changes his/her decision, the samples will be 
destroyed if the samples have not been used for research or released for a specific research project. 
10.1.4.2 
Data Sharing for Secondary Research 
Data from this study may be used for secondary research. Individual participant data collected 
during the trial that are sufficient to reanalyzed primary and secondary endpoints will be made 
available after deidentification. The Statistical Analysis Plan and Analytic Code will also be made 
available. This data will be available following publication, with no end date. The data will be made 
available to researchers who provide a methodologically sound proposal. The data will be available 
for any purpose outlined in the approved proposal. Proposals should be directed to DMID. To gain 

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access, data requestors will need to sign a data access agreement. 
 
The investigator may request removal of data on individual study participants from NIH data 
repositories in the event that a research participant withdraws or changes his or her consent. 
However, data that have been distributed for approved research use cannot be retrieved. 
 
10.1.5 
Key Roles and Study Governance 
This is a multi-site clinical trial and as such, all study team members and roles are listed in the 
Manual of Procedures (MOP). 
 
10.1.6 
Safety Oversight 
Safety oversight will be conducted by a DSMB that is an independent group of experts that monitors 
participant safety and advises DMID. The DSMB members will be separate and independent of 
study personnel participating in this trial and should not have scientific, financial or other conflict 
of interest related to this trial. The DSMB will consist of members with appropriate expertise to 
contribute to the interpretation of the data from this trial. The DSMB will operate under the rules 
of a DMID-approved charter that will be written at the organizational meeting of the DSMB. 
Procedures for DSMB reviews/meetings will be defined in the charter. 
 
Reports may include enrollment and demographic information and solicited and unsolicited 
AE/SAEs. The DSMB will review SAEs on a regular basis and ad hoc during this trial. The 
DMID Medical Monitor will be responsible for reviewing SAEs in real time. 
 
The DSMB will conduct the following reviews: 
• Approximately Day 22-29 after study start. Given the planned short enrollment period (3- 
4 weeks) and second dose of vaccine given on day 29, there is a narrow window for review. 
As such the review will focus on AEs utilizing real time reports where able. 
• Ad hoc meeting: 
o When trial-level halting criteria are met 
o At the request of DMID to review a potential safety concern identified in the trial. 
• Interim and final data will be shared with the DSMB, but the DSMB does not need to 
meet to review the final data. 
 
Additional data may be requested by the DSMB. The DSMB may receive data in aggregate and 
presented by treatment arm. The DSMB may also be provided with expected and observed rates of 
the expected AEs in an unblinded fashion and may request the treatment assignment be unblinded 
for an individual participant if required for safety assessment. The DSMB will review grouped and 
unblinded data in the closed session only. As an outcome of each review/meeting, the DSMB will 
make a recommendation as to the advisability of proceeding with study interventions (as 
applicable), and to continue, modify, or terminate this trial. 
 
The DSMB will operate under the rules of a DMID-approved charter that will be written at the 
organizational meeting of the DSMB. At this time, each data element that the DSMB needs to assess 
will be clearly defined. Procedures for DSMB reviews/meetings will be defined in the charter. The 

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DSMB will review applicable data to include, but not limited to, study progress and participant, 
clinical, safety and safety related data. Reports may include enrollment and demographic 
information, medical history, concomitant medications, physical assessments, clinical laboratory 
values, dosing compliance, and solicited and unsolicited AE/SAEs. 
 
DMID or the DSMB chair may convene the DSMB on an ad hoc basis according to protocol criteria 
or if there are immediate concerns regarding observations during the course of this trial. The DMID 
Medical Monitor is empowered to stop enrollment and study product administration if AEs that 
meet the halting criteria are reported. The DMID Medical Monitor will be responsible for reviewing 
SAEs in real time. The DSMB will review SAEs on a regular basis and ad hoc during this trial. 
 
10.1.7 
Clinical Monitoring 
Clinical site monitoring is conducted to ensure that the rights and well-being of trial participants 
are protected, that the reported trial data are accurate, complete, and verifiable. Clinical Monitoring 
ensures that the conduct of the trial is in compliance with the currently approved 
protocol/amendment(s), International Council for Harmonisation (ICH), Good Clinical Practice, 
and with applicable regulatory requirement(s) and sponsor requirements. 
 
Monitoring for this study will be overseen by NIAID/DMID and conducted by NIAID/DMID 
contractors. Details of clinical site monitoring are documented in a Clinical Monitoring Plan 
(CMP). The CMP describes in detail who will conduct the monitoring, at what frequency 
monitoring will be done, at what level of detail monitoring will be performed, and the distribution 
of monitoring reports. Monitoring visits will include, but are not limited to, review of regulatory 
files, investigational product administration and accountability records, eCRFs, informed consent 
forms, medical and laboratory reports, site study storage records, training records, and protocol 
and GCP compliance. Site monitors will have access to each participating site, study personnel, 
and all study documentation according to the NIAID or DMID-approved site monitoring plan. 
Study monitors will meet with site principal investigators (or designee) to discuss any problems 
and outstanding issues and will document site visit findings and discussions. 
 
10.1.8 
Quality Assurance and Quality Control 
Quality control (QC) and quality assurance (QA) activities are essential to the safety of 
participants, and the reliability of study data. Each site participating in the study is responsible for 
integrating quality control checks throughout the study and implementing a QA Checklist or 
Clinical Quality Management Plan (CQMP). The site will conduct the following: 
 
8. Routine internal QC and QA activities for the purposes of measuring, documenting and 
reporting study conduct, protocol adherence, human participants’ protections, and 
reliability of the protocol-driven data collected. 
9. Processes for addressing data quality issues (i.e., collecting, recording), and reporting 
findings in a timely manner. 
10. Identify systemic issues (e.g., protocol or human participant protections non-compliance), 
and implementation and evaluation of Corrective and Preventative Action Plan (CAPA) 
procedures, if applicable. 

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10.1.9 
Data Handling and Record Keeping 
10.1.9.1 
Data Collection and Management Responsibilities 
Data collection is the responsibility of the clinical trial staff at the site under the supervision of the 
site investigator. The investigator is responsible for ensuring the accuracy, completeness, legibility, 
and timeliness of the data reported. All source documents should be completed in a neat, legible 
manner to ensure accurate interpretation of data. 
 
10.1.9.2 
Data Coordinating Center / Biostatistician Responsibilities 
The data coordinating center for this study will be responsible for data management, quality 
review, analysis, and reporting of the study data. Adverse events and medical history will be coded 
according to the MedDRA dictionary. Concomitant medications will be coded according to the 
WHO Drug dictionary. At the end of the study, a copy of all datasets including annotated case 
report forms and data dictionary will be provided to DMID. 
 
A separate Study Data Standardization Plan (SDSP) will be developed which describes the 
technical recommendations for the submission of human study data and related information in a 
standardized electronic format throughout product development. 
 
10.1.9.3 
Data Capture Methods 
Clinical research data, including, but not limited to, AE/SAEs, concomitant medications, medical 
history, physical assessments will be abstracted from the source documentation and/or collected on 
source document worksheet by study personnel then entered into an eCRFs via a 21 CFR Part 11-
compliant internet data entry system provided by the study data coordinating center. The data 
system includes password protection and internal quality checks, such as automatic range checks, to 
identify data that appear inconsistent, incomplete, or inaccurate. 
 
The IND Sponsor is responsible for review of data collection tools and processes, and review of 
data and reports. 
 
Study data will be collected on paper CRFs and then entered into the eCRF or data will be entered 
directly into the eCRF. 
 
10.1.9.4 
Study Record Retention 
Study related records, including the regulatory file, study product accountability records, consent 
forms, participant source documents and electronic records should be maintained for a period of 2 
years following the date a marketing application is approved for the investigational product for the 
indication for which it is being investigated; or, if no application is to be filed or if the application 
is not approved for such indication, until 3 years after the investigation is discontinued and FDA is 
notified. These documents should be retained for a longer period, however, if required by local 
policies or regulations. No records will be destroyed without the written consent of DMID. Consent 
forms with specimen retention linked to identifiable specimens will be maintained for as long as 

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the specimens remain in identifiable format, and a minimum of three years after use of the 
identifiable specimens in nonexempt human participant research. 
 
10.1.9.5 
Source Records 
Source data are all information, original records of clinical findings, observations, or other activities 
documented in a clinical trial necessary for the reconstruction and evaluation of the trial. Each 
participating site will maintain appropriate medical and research records for this trial, in compliance 
with ICH GCP, regulatory, and institutional requirements. Data recorded in the electronic case 
report form (eCRF) derived from source documents should be consistent with the data recorded on 
the source documents. Data entered directly into the eCRFs will be considered the source document. 
All source documents should be completed in a neat, legible manner to ensure accurate 
interpretation of data. 
 
Interview of participants is sufficient for obtaining medical history. Solicitation of medical records 
from the participant’s primary care provider is not required. 
 
10.1.10 
Protocol Deviations 
A protocol deviation is any noncompliance with the clinical trial protocol, any process that is noted 
in the protocol and refers to details in the MOP, or GCP requirements. 
 
The noncompliance may be either on the part of the participant, the investigator, or the study site 
staff. Following a deviation(s), corrective actions should be developed by the site and implemented 
promptly. All individual protocol deviations will be addressed in participant study records. 
 
It is the responsibility of the site principal investigator and personnel to use continuous vigilance to 
identify and report deviations within five working days of identification of the protocol deviation, 
or within five working days of the scheduled protocol-required activity. All deviations must be 
promptly reported to DMID per the protocol deviation reporting procedures. Protocol deviations 
must be sent to the local IRB/IEC per their guidelines. The site principal investigator and personnel 
are responsible for knowing and adhering to their IRB requirements. 
 
10.1.11 
Publication and Data Sharing Policy 
10.1.11.1 Human Data Sharing Plan 
All NIH protocols are required to have a Data Sharing Plan describe provisions for protecting the 
participants’ privacy and the confidentiality of the data. This study will be conducted in accordance 
with the following publication and data sharing policies and regulations: 
 
National Institutes of Health (NIH) Public Access Policy, which ensures that the public has access 
to the published results of NIH funded research. It requires scientists to submit final peer-reviewed 
journal manuscripts that arise from NIH funds to the digital archive PubMed Central upon 
acceptance for publication. 
 
As of January 2018, all clinical trials supported by the NIH must be registered on ClinicalTrials.gov, 

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no later than 21 days after the enrollment of the first participant. Results of all clinical trials 
supported by the NIH, generally, need to be submitted no later than 12 months following the primary 
completion date. As part of the result posting, a copy of this protocol and a copy of the Statistical 
Analysis Plan will be posted on ClinicalTrials.gov. 
 
10.1.11.2 Genomic Data Sharing Plan 
Not Applicable. 
 
10.1.11.3 Publication 
This study will comply with the NIH Public Access Policy, which ensures that the public has access 
to the published results of NIH funded research. As such, the final peer-reviewed journal 
manuscripts will be accessible to the public on PubMed Central no later than 12 months after 
publication. 
 
10.1.12 
Conflict of Interest Policy 
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical. Therefore, any actual conflict of interest of persons who have a 
role in the design, conduct, analysis, publication, or any aspect of this trial will be disclosed and 
managed. Furthermore, persons who have a perceived conflict of interest will be required to have 
such conflicts managed in a way that is appropriate to their participation in the design and conduct 
of this trial. DMID has established policies and procedures for all study group members to disclose 
all conflicts of interest and will establish a mechanism for the management of all reported dualities 
of interest. 
 
10.2 
Additional Considerations 
10.2.1 
Research Related Injuries 
For any potential research related injury, the site principal investigator or designee will assess the 
participant. The site principal investigator should then determine if an injury occurred as a direct 
result of the tests or treatments that are done for this trial. As needed, referrals to appropriate health 
care facilities will be provided to the participant. No financial compensation will be provided by 
the NIAID, NIH, or the federal government to the participant, for any injury suffered due to 
participation in this trial. 
 
10.2.2 
PREP Act 
The study vaccine and the efforts for this clinical trial are covered under the Public Readiness and 
Emergency Preparedness Act (PREP Act). The PREP Act applies under the terms of the PREP 
Act declaration in place for smallpox/orthopoxvirus countermeasures for activities conducted 
pursuant 
to 
federal 
agreements 
or 
federal 
programs 
(ref: 
www.federalregister.gov/documents/2015/12/09/2015-31092/smallpox-medical- countermeasures-
amendment). JYNNEOS is used under an IND for monkeypox pursuant to a federal 
agreement/program and is therefore covered under the PREP Act. The PREP Act covers persons 

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(such as manufacturers, distributers, program planners, and other qualified persons who prescribe, 
administer or dispense study product) are immune from liability from the administration, or use of 
a covered countermeasure, such as JYNNEOS. The PREP Act provides immunity for covered 
persons from liability, unless the injury was caused by willful misconduct. 
 
The PREP Act also established the Countermeasures Injury Compensation Program (CICP) to 
provide compensation for serious injuries or death that occur as the direct result of the 
administration or use of certain countermeasures. Any requests for compensation must be filed 
within one year of the administration or use of the covered countermeasure. Requests for Benefits 
must be made to the Health Resources and Services Administration’s (HRSA) Countermeasures 
Injury Compensation Program (http://www.hrsa.gov/cicp/) by filing a Request for Benefits Form 
and all required medical records and supporting documentation. Additional information on filing a 
Request for Benefits is available on the CICP’s website at http://www.hrsa.gov/cicp/. 
Compensation may then be available for reasonable and necessary medical benefits, lost wages 
and/or death benefits to eligible individuals for certain injuries in accordance with regulations 
published by the Secretary of HHS (found at 42 CFR part 110). 
 
If an individual suffers a serious physical injury or death from the administration or use of a covered 
countermeasure in this study, the individual, the individual’s legal or personal representative, the 
administrator/executor of a deceased individual’s estate, or certain survivors may request benefits 
from the CICP. A serious physical injury means an injury that warranted hospitalization (whether 
or not the person was actually hospitalized) or that led to a significant loss of function or disability. 
The CICP is the payer of last resort. This means that it only covers expenses or provides benefits 
that other third-party payers (such as health insurance, the Department of Veterans Affairs, or 
Workers’ Compensation programs) do not have an obligation to pay. 
 
If the Secretary of HHS does not make a final determination on the individual’s request within 240 
days, or if the individual decides not to accept the compensation, the injured individual or his 
representative may pursue a tort claim in the US District Court for the District of Columbia, but 
only if the claim involves willful misconduct and meets the other requirements for suit under the 
PREP Act. Any award is reduced by any public or private insurance or worker’s compensation 
available to the injured individual. Awards for non-economic damages, such as pain, suffering, 
physical impairment, mental anguish, and loss of consortium are also limited. If the individual 
accepts compensation, or if there is no willful misconduct, then the individual does not have a tort 
claim that can be filed in a US Federal or a State court. 

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11. 
REFERENCES 
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Emergence of monkeypox in West Africa and Central Africa, 1970-2017. Wkly 
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Centers for Disease C, Prevention. Multistate outbreak of monkeypox--Illinois, Indiana, 
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Erez N, Achdout H, Milrot E, et al. Diagnosis of Imported Monkeypox, Israel, 2018. 
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Yong SEF, Ng OT, Ho ZJM, et al. Imported Monkeypox, Singapore. Emerging infectious 
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Rao AK, Schulte J, Chen TH, et al. Monkeypox in a Traveler Returning from Nigeria - 
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Mauldin MR, McCollum AM, Nakazawa YJ, et al. Exportation of Monkeypox Virus 
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Yinka-Ogunleye A, Aruna O, Dalhat M, et al. Outbreak of human monkeypox in Nigeria 
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Durski KN, McCollum AM, Nakazawa Y, et al. Emergence of Monkeypox - West and 
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10.15585/mmwr.mm6710a5. 
15. 
Vollmar J, Arndtz N, Eckl KM, et al. Safety and immunogenicity of IMVAMUNE, a 
promising candidate as a third generation smallpox vaccine. Vaccine 2006;24(12):2065- 
70. DOI: 10.1016/j.vaccine.2005.11.022. 
16. 
Frey SE, Wald A, Edupuganti S, et al. Comparison of lyophilized versus liquid modified 
vaccinia Ankara (MVA) formulations and subcutaneous versus intradermal routes of 
administration in healthy vaccinia-naive subjects. Vaccine 2015;33(39):5225-34. DOI: 
10.1016/j.vaccine.2015.06.075. 

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17. 
Wilck MB, Seaman MS, Baden LR, et al. Safety and immunogenicity of modified 
vaccinia Ankara (ACAM3000): effect of dose and route of administration. The Journal of 
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Drug 
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Regulatory 
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https://www.fda.gov/media/131802/download. 
(https://www.fda.gov/media/131802/download). 
19. 
Overton ET, Lawrence SJ, Wagner E, et al. Immunogenicity and safety of three 
consecutive production lots of the non replicating smallpox vaccine MVA: A randomised, 
double blind, placebo controlled phase III trial. PLoS One 2018;13(4):e0195897. DOI: 
10.1371/journal.pone.0195897. 
20. 
Suter M, Meisinger-Henschel C, Tzatzaris M, et al. Modified vaccinia Ankara strains with 
identical coding sequences actually represent complex mixtures of viruses that determine 
the biological properties of each strain. Vaccine 2009;27(52):7442-50. DOI: 
10.1016/j.vaccine.2009.05.095. 
21. 
Stittelaar KJ, Kuiken T, de Swart RL, et al. Safety of modified vaccinia virus Ankara 
(MVA) in immune-suppressed macaques. Vaccine 2001;19(27):3700-9. DOI: 
10.1016/s0264-410x(01)00075-5. 
22. 
Overton ET, Stapleton J, Frank I, et al. Safety and Immunogenicity of Modified Vaccinia 
Ankara-Bavarian Nordic Smallpox Vaccine in Vaccinia-Naive and Experienced Human 
Immunodeficiency Virus-Infected Individuals: An Open-Label, Controlled Clinical Phase 
II Trial. Open Forum Infect Dis 2015;2(2). DOI: 10.1093/ofid/ofv040. 
23. 
Greenberg RN, Overton ET, Haas DW, et al. Safety, immunogenicity, and surrogate 
markers of clinical efficacy for modified vaccinia Ankara as a smallpox vaccine in HIV- 
infected subjects. The Journal of infectious diseases 2013;207(5):749-58. DOI: 
10.1093/infdis/jis753. 
24. 
Overton ET, Lawrence SJ, Stapleton JT, et al. A randomized phase II trial to compare 
safety and immunogenicity of the MVA-BN smallpox vaccine at various doses in adults 
with 
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Vaccine 
2020;38(11):2600-2607. 
DOI: 
10.1016/j.vaccine.2020.01.058. 
25. 
von Sonnenburg F, Perona P, Darsow U, et al. Safety and immunogenicity of modified 
vaccinia Ankara as a smallpox vaccine in people with atopic dermatitis. Vaccine 
2014;32(43):5696-702. DOI: 10.1016/j.vaccine.2014.08.022. 
26. 
Greenberg RN, Hurley MY, Dinh DV, et al. A Multicenter, Open-Label, Controlled Phase 
II Study to Evaluate Safety and Immunogenicity of MVA Smallpox Vaccine 
(IMVAMUNE) in 18-40 Year Old Subjects with Diagnosed Atopic Dermatitis. PLoS One 
2015;10(10):e0138348. DOI: 10.1371/journal.pone.0138348. 
27. 
Cassimatis DC, Atwood JE, Engler RM, Linz PE, Grabenstein JD, Vernalis MN. 
Smallpox vaccination and myopericarditis: a clinical review. J Am Coll Cardiol 
2004;43(9):1503-10. DOI: 10.1016/j.jacc.2003.11.053. 
28. 
von Krempelhuber A, Vollmar J, Pokorny R, et al. A randomized, double-blind, dose- 
finding Phase II study to evaluate immunogenicity and safety of the third generation 
smallpox vaccine candidate IMVAMUNE. Vaccine 2010;28(5):1209-16. DOI: 
10.1016/j.vaccine.2009.11.030. 
29. 
Pittman PR, Hahn M, Lee HS, et al. Phase 3 Efficacy Trial of Modified Vaccinia Ankara 
as a Vaccine against Smallpox. The New England journal of medicine 
2019;381(20):1897-1908. DOI: 10.1056/NEJMoa1817307. 

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APPENDIX B – STAGE 2: ADOLESCENT AND ADULT NONINFERIORITY 
STUDY 
 
 

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TABLE OF CONTENTS 
 
APPENDIX B – Stage 2: Adolescent and Adult Noninferiority Study ................................................ 99 
1. 
Introduction ................................................................................................................................ 103 
1.1 
Study Rationale ............................................................................................................103 
1.2 
Background ..................................................................................................................103 
1.3 
Risk/Benefit Assessment .............................................................................................104 
1.3.1 
Known Potential Risks .........................................................................................104 
1.3.2 
1.3.2 Known Potential Benefits ...........................................................................107 
1.3.3 
Assessment of Potential Risks and Benefits ........................................................108 
2. 
OBJECTIVES AND ENDPOINTS ........................................................................................... 108 
3. 
STUDY DESIGN....................................................................................................................... 109 
3.1 
Overall Design .............................................................................................................109 
3.2 
Scientific Rationale for Study Design..........................................................................111 
3.3 
Justification for Dose ...................................................................................................111 
4. 
STUDY POPULATION ............................................................................................................ 111 
4.1 
Inclusion Criteria .........................................................................................................112 
4.2 
Exclusion Criteria ........................................................................................................112 
4.2.1 
Exclusion of Specific Populations .......................................................................114 
4.3 
Inclusion of Vulnerable Participants ............................................................................114 
4.4 
Lifestyle Considerations ..............................................................................................114 
4.5 
Screen Failures .............................................................................................................115 
4.6 
Strategies for Recruitment and Retention ....................................................................115 
4.6.1 
Recruitment ..........................................................................................................115 
4.6.2 
Retention ..............................................................................................................115 
4.6.3 
Compensation Plan for Participants .....................................................................115 
4.6.4 
Costs .....................................................................................................................116 
5. 
STUDY PRODUCT ................................................................................................................... 116 
5.1 
Study Product(s) and Administration...........................................................................116 
5.1.1 
Study Product Description ...................................................................................116 
5.1.2 
Dosing and Administration ..................................................................................116 
5.1.3 
Dose Modifications ..............................................................................................117 
5.1.4 
Criteria for Redosing............................................................................................117 
5.2 
Preparation/Handling/Storage/Accountability .............................................................117 
5.2.1 
Acquisition and Accountability ...........................................................................117 
5.2.2 
Formulation, Appearance, Packaging, and Labeling ...........................................117 
5.2.3 
Product Storage and Stability...............................................................................117 
5.2.4 
Preparation ...........................................................................................................117 
5.3 
Measures to Minimize Bias: Randomization and Blinding .........................................118 
5.3.1 
Treatment Assignment Procedures ......................................................................118 

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5.3.2 
Randomization .....................................................................................................118 
5.3.3 
Blinding and Masking Procedures .......................................................................118 
5.4 
Study Intervention Compliance ...................................................................................118 
5.5 
Concomitant Therapy...................................................................................................118 
6. 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL .......................................................................................... 119 
6.1 
Halting Criteria and Discontinuation of Study Intervention ........................................119 
6.1.1 
Study Halting Criteria ..........................................................................................119 
6.1.2 
Individual Halting Criteria ...................................................................................119 
6.1.3 
Follow up for participants that discontinued study intervention .........................120 
6.2 
Participant Withdrawal from the Study and Replacement ...........................................121 
6.3 
Lost to Follow-Up ........................................................................................................121 
7. 
STUDY ASSESSMENTS AND PROCEDURES ..................................................................... 121 
7.1 
Screening Procedures ...................................................................................................121 
7.1.1 
Procedures to be Followed in the Event of Abnormal Clinical Laboratory Test 
Values or Abnormal Clinical Findings During Screening ...................................................122 
7.2 
Sick Visit ......................................................................................................................123 
7.3 
Additional Study Procedures in Stage 2 ......................................................................123 
7.3.1 
Phone Visits .........................................................................................................123 
7.3.2 
Photography .........................................................................................................123 
7.4 
Immunogenicity Assessments ......................................................................................123 
7.4.1 
Immunogenicity/Efficacy Evaluations .................................................................123 
7.4.2 
Exploratory Assessments .....................................................................................124 
7.5 
Safety and Other Assessments .....................................................................................124 
7.5.1 
Alternative Schedules ..........................................................................................125 
7.5.2 
Procedures to be Followed in the Event of Abnormal Clinical Laboratory Test 
Values or Abnormal Clinical Findings During the Trial .....................................................126 
7.6 
Adverse Events and Serious Adverse Events ..............................................................126 
7.6.2 
Classification of an Adverse Event ......................................................................127 
See main section of the protocol for a description of the classification of an AE in terms of 
severity and causality. ..........................................................................................................127 
7.6.3 
Time Period and Frequency for Event Assessment and Follow-Up ....................127 
7.6.4 
Adverse Event Reporting .....................................................................................127 
7.7 
Unanticipated Problems ...............................................................................................127 
8. 
STATISTICAL CONSIDERATIONS ....................................................................................... 127 
8.1 
Statistical Hypotheses ..................................................................................................127 
8.2 
Sample Size Determination..........................................................................................128 
8.3 
Statistical Analyses ......................................................................................................130 
8.3.1 
General Methodology ..........................................................................................130 
8.3.2 
Timing of Analyses ..............................................................................................130 
8.3.3 
Populations for Analyses .....................................................................................131 
8.3.4 
Baseline Characteristics and Participant Disposition ..........................................131 
8.3.5 
Immunogenicity Analyses ...................................................................................131 
8.3.6 
Safety Analyses ....................................................................................................132 

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9. 
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS .............. 133 
9.1 
Regulatory, Ethical, and Study Oversight Considerations...........................................133 
9.1.1 
Informed Consent Process ...................................................................................133 
9.1.2 
Study Termination and Closure ...........................................................................136 
9.1.3 
Confidentiality and Privacy .................................................................................136 
9.1.4 
Secondary Use of Stored Specimens and Data ....................................................137 
9.1.5 
Key Roles and Study Governance .......................................................................138 
9.1.6 
Safety Oversight...................................................................................................138 
9.1.7 
Clinical Monitoring ..............................................................................................139 
9.1.8 
Quality Assurance and Quality Control ...............................................................140 
9.1.9 
Data Handling and Record Keeping ....................................................................140 
9.1.10 
Protocol Deviations ..............................................................................................141 
9.1.11 
Publication and Data Sharing Policy ...................................................................142 
9.1.12 
Conflict of Interest Policy ....................................................................................142 
9.2 
Additional Considerations ...........................................................................................142 
9.2.1 
Research Related Injuries ....................................................................................142 
9.2.2 
PREP Act .............................................................................................................143 
10. References .................................................................................................................................. 145 
 

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1. 
INTRODUCTION 
 
1.1 
Study Rationale 
On July 23, 2022, the WHO Director-General declared that the multi-country outbreak of mpox 
constitutes a Public Health Emergency of International Concern (PHEIC). Since the first case of 
mpox was detected in the United Kingdom in a returning traveler from Nigeria on May 6, 2022, 
the outbreak has rapidly spread to 110 countries or locations worldwide, including 103 that are 
non-endemic, marking the first time mpox has spread widely outside Central and West Africa. By 
August of 2022, the number of confirmed mpox cases in the U.S. surpassed that of any other 
country2,3. To mitigate the consequences of this outbreak in the U.S., JYNNEOS vaccine is being 
offered to individuals considered to be at high risk for acquiring the disease. In Stage 1 of this 
platform study, we evaluated dose sparing strategies in adults because JYNNEOS, the only 
licensed vaccine for mpox, was in short supply. In Stage 2 of this study, we will evaluate vaccine 
safety and immunogenicity among adolescents ages 12 to 17 years to extend eligibility to 
adolescent population, a population that may be at risk if the outbreak persists in 2023. 
 
1.2 
Background 
Mpox is a reemerging infectious disease caused by Monkeypox virus (MPXV), a large double-
stranded DNA virus belonging to the genus, Orthopoxvirus.4 MPXV is a zoonotic orthopoxvirus, 
primarily transmitted to humans via contact with infected animals, and causing disease similar to 
smallpox, although with substantially lower mortality.4-6 MPXV is endemic to West and Central 
Africa, where the incidence of human mpox cases has increased as much as 20-fold since the end 
of the smallpox vaccination campaign in 1980.7,8 Outbreaks in non-endemic countries have been 
related to the exotic pet trade9 and international travel.10-12 Prior to the current global mpox 
outbreak, secondary human-to-human transmission in non-endemic countries was rare, and 
documented only twice since 2018, both cases involving travelers returning from Nigeria. The first 
case involved transmission between the index patient and a healthcare provider13 and second case 
involved transmission to another adult and an infant within the household of the index case.14,15 
Mpox reemerged in Nigeria in 2017 after more than 40 years with no reported cases.16,17  
 
On May 18, 2022, the first U.S. case of mpox was detected as part of the larger global outbreak.18 
The U.S. was the fourth non-endemic country to detect a case in a returning traveler. On August 
4, the U.S. Department of Health and Human Services declared the U.S. mpox outbreak to be a 
public health emergency with 7,510 confirmed cases of mpox detected in all U.S. states, D.C, and 
Puerto Rico.19 As of January 11, 2023, there have been 84,648 confirmed mpox cases worldwide 
including 29,980 confirmed cases and 21 deaths in the United States.2  
 
Vaccination is being used as a mitigation strategy in the current mpox outbreak for those exposed 
to and those deemed to be at higher risk of being exposed to mpox. There is one FDA-approved 
vaccine for mpox: JYNNEOS Modified Vaccinia Ankara-Bavarian Nordic (MVA-BN). A second 
vaccine, ACAM2000, is likely effective but is not FDA-approved for mpox and associated with 
moderate risk of myocarditis and pericarditis (5.7 cases per 1,000 vaccinated) as well as 
encephalomyelitis, progressive vaccinia, generalized vaccinia, and ocular complications. 

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ACAM2000 should not be given to people with a weakened immune system, eczema, cardiac 
disease, infants <12 months, or pregnant women. Given these attributes, JYNNEOS is the 
preferred vaccine during the current outbreak however it is only FDA approved for individuals age 
18 and older. On August 9, 2022, the U.S. Food and Drug Administration (FDA) issued an 
Emergency Use Authorization (EUA) for the emergency use of the licensed SC dose for 
individuals less than 18 years of age determined to be at high risk for mpox for the emergency use 
of a lower (2 x 107 TCID50) ID dose of JYNNEOS for individuals 18 years of age and older 
determined to be at high risk for MPXV infection. In addition, because of limited vaccine supply, 
the EUA allowed for the use of a lower (2 x 107 TCID50) ID dose of JYNNEOS for individuals 18 
years of age and older determined to be at high risk for mpox. 
 
While JYNNEOS is available under EUA for individuals younger than 18 years of age, an FDA 
approved mpox vaccine for adolescents is lacking yet remains a public health need. Most reported 
cases in the global 2022 mpox outbreak have involved men who have sex with men, with a median 
age of 34 years.  Among global cases with age data available, 1.2% are individuals ages 0-17 
years;23 in the United States, from May 17 through September 24, 2022, MPXV infections in 
persons under 18 years of age accounted for 0.3% of reported cases.24  Among 55 adolescents ages 
13-17 years, 89% were male, and the most common route of exposure was through male-to-male 
sexual contact (66%). Prior to the global 2022 outbreak, mpox occurred primarily in children and 
adolescents in endemic countries.25,26 Increased MPXV transmission within adolescent 
populations could occur if the outbreak continues, or in future outbreaks, given the mode of 
transmission through skin and mucosal contact during sexual activity or other activities involving 
close contact with an infected individual.  
 
1.3 
Risk/Benefit Assessment 
1.3.1 
Known Potential Risks 
The potential risks to the participants in the study are those related to venipuncture and local 
reactogenicity as well as possible systemic adverse reactions to the vaccine and vaccination 
procedure. 
 
Venipuncture 
Venipuncture may cause transient mild discomfort and/or fainting. Bruising at the site of the 
venipuncture may occur but can be prevented or lessened by applying pressure for several minutes 
after the injection. Infection at the site is possible but highly unlikely with the use of aseptic 
technique. 
 
Adverse Reactions  
MVA-BN administered SC was approved by the FDA as the vaccine JYNNEOS for smallpox and 
mpox on September 24, 2019.27 At the time of licensure, the clinical development program for 
JYNNEOS included 22 studies involving 7,093 smallpox vaccine-naïve and 766 smallpox vaccine-
experienced participants who received at least 1 dose of JYNNEOS and were monitored for safety 
for at least 6 months following the first vaccination. There were mostly local and systemic 
reactogenicity and rare cases of allergy/hypersensitivity observed. Within 8 days of administration 
of a first or second dose of JYNNEOS, the most common solicited local (injection site) reactions 
among 2,943 smallpox vaccine-naïve healthy adult participants included pain (84.9%), redness 

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(60.8%), swelling (51.6%), induration (45.4%), and itching (43.1%). The most common solicited 
systemic adverse reactions were muscle pain (42.8%), headache (34.8%), fatigue (30.4%), nausea 
(17.3%), and chills (10.4%). The majority of these solicited AEs were mild and moderate severity. 
However, there were severe (Grade3) solicited AEs the most common being pain in 7.4% of 
participants. In a large clinical trial involving 3,003 participants who received at least one dose of 
MVA-BN, the majority of solicited local and systemic adverse reactions had a median duration of 1 
to 6 days, and there was a similar frequency of reported adverse reactions after the first and second 
dose of JYNNEOS except for site pain which was more common after the first dose (79.3% versus 
69.9%).28 
 
An analysis of serious adverse events (SAEs) among 7,093 smallpox vaccine-naïve and 766 
smallpox vaccine-experienced participants who received at least 1 dose of JYNNEOS identified 
only four SAEs (0.05%) in which a causal relationship could not be ruled out. All were non-fatal 
SAEs and included Crohn’s disease, sarcoidosis, extraocular muscle paresis, and throat tightness 
(angioedema). The trial that had the related angioedema had three other post-vaccination 
hypersensitivity reactions which were non-serious and judged to be related to the vaccine.  
 
As with all injectable vaccines, there is a risk of an allergic reaction or an anaphylactic event. To 
mitigate the risk, individuals with known allergy or history of anaphylaxis or other serious adverse 
reaction to a vaccine or vaccine products will not be eligible to participate in the study. In addition, 
sites must observe participants for 30 minutes after each vaccination and will have appropriate 
medical treatment available to manage possible anaphylactic reactions. Participants who have an 
allergic reaction that is temporally associated with vaccination and that the PI believes to be 
related, will not receive any more study product. However, the participant will be encouraged not 
to withdraw from the study so that they may be followed for safety and immunogenicity until the 
end of the study. 
 
Risk During Pregnancy 
There were four developmental toxicity studies that evaluated the effect of JYNNEOS on fetal and 
postnatal development and found no vaccine-related fetal malformations or adverse effects on 
postnatal development. JYNNEOS has not been evaluated in preclinical studies for carcinogenicity 
or mutagenicity. 
 
No safety signals were observed in 29 pregnancies that occurred during the clinical development 
program of MVA-BN and the rate of spontaneous abortions observed was similar to the published 
background incidence. However, there is insufficient data to assess the vaccine risk to the pregnant 
woman and her fetus and because of this, participants who are pregnant will not be eligible to 
participate in this study and female of reproductive potential who are having sexual intercourse 
with male partners will be asked to use effective birth control through Day 57.  
 
Risk to Breast Feeding Infant 
It is not known whether JYNNEOS is excreted in human milk. Data are not available to assess the 
effects of JYNNEOS in the breastfed infant or on milk production/excretion. For this reason, 
woman who are breastfeeding will not be eligible to participate in this study.  
 
 

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Risk to Children and Adolescents  
Safety and immunogenicity of JYNNEOS have not been established in individuals less than 18 
years of age. In stage 2 of this study, adolescents ages 12 to 17 years will be enrolled.  This data 
will be used to inform a label change for JYNNEOS in the United States to include full licensure 
for adolescents of the 1x108 TCID50 MVA-BN given subcutaneously 4 weeks apart. 
 
An EUA was issued on August 9, 2022, for the use of a 2-dose 1 x 108 regimen of JYNNEOS 
administered subcutaneously for prevention of mpox disease in individuals younger than 18 years 
of age who were at high risk for MPXV infection.29 The EUA was based on “safety and 
effectiveness data from clinical trials in adults and efficacy data from animal challenge studies and 
historical data with use of live vaccinia virus (smallpox vaccine) in pediatric populations”.  Per the 
EUA, the vaccination provider was responsible for mandatory reporting to the Vaccine Adverse 
Event Reporting System (VAERS) of all serious adverse events (irrespective of attribution to 
vaccination); cases of cardiac events, including myocarditis and pericarditis; and cases of 
thromboembolic events and neurovascular events following vaccination with JYNNEOS. The 
FDA initially required cardiac screening and prospective monitoring for cardiac events in all early 
clinical trials of MVA-BN vaccine. A review of six Phase 1 trials conducted between 2004 and 
2012 found no myo/pericarditis cases that met the CDC case definition and were judged to be 
related to vaccine in 382 subjects receiving at least one dose of MVA-BN.30  Moreover, the MVA 
vector has been studied in multiple adolescent and pediatric populations in other vaccine trials 
with no serious safety concerns identified.31-33 
 
Risk to Individuals with Chronic Diseases  
JYNNEOS does not replicate in human cell lines and therefore the vaccine can be safely 
administered to immunocompromised individuals. Safety has been demonstrated in clinical trials 
and studies involving severely immunocompromised animals34,35 and humans with HIV 
infection.36-38 The safety of JYNNEOS in HIV-infected individuals was evaluated in an open label 
trial that included 351 HIV-infected smallpox vaccine-naïve participants, 131 HIV-infected 
participants who previously received smallpox vaccine, 88 non-HIV-infected smallpox vaccine-
naïve participants, and 9 non-HIV-infected participants who had previously received a smallpox 
vaccine.36 HIV-infected participants had CD4 counts ≥ 200 and ≤ 750 cells/μL at study entry.  
Among smallpox vaccine-naïve participants, solicited local and systemic adverse reactions were 
reported at similar or lower frequencies in HIV-infected participants than in non-HIV-infected 
participants. Frequencies of other solicited local and systemic adverse reactions were similar to 
those reported in other trials.37,38 In this study, individuals infected with HIV can participate in the 
study unless they had an AIDS defining illness within the last year or their viral load is not well-
controlled with antiretroviral therapy (ART) (see Section 5.1). 
 
Individuals with atopic dermatitis (AD) are not able to receive replicating smallpox vaccines 
including ACAM2000. However, two clinical trials have shown that they can safely be given 
JYNNEOS.39,40 The larger of the two studies was a multicenter, open-label clinical trial that 
evaluated the safety of JYNNEOS in 350 smallpox vaccine-naïve participants either with active 
or a history of AD and in 282 participants without AD.40 The proportion of participants reporting 
solicited local and systemic adverse reactions was similar between the arms, except for redness 
(61.2% with AD vs. 49.3% without AD), swelling (52.2% with AD vs. 40.8% without AD), chills 
(15.9% with AD vs. 7.8% without AD) and headache (47.2% with AD vs. 34.8% without AD). 

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However, most adverse events were mild to moderate in severity. In this study, individuals with 
AD are eligible to participate. 
 
Cardiac Adverse Events of Special Interest (AESI) 
During the 2002-2004 smallpox vaccination campaign initiated by the US Department of Defense 
(DoD) and Department of Health and Human Services (DHHS) to protect military personnel and 
civilian first-responders, there were high rates of pericarditis and myocarditis reported among 
those vaccinated with Dryvax. Similarly, high rates were detected after receipt of ACAM2000.41 
Because of this, during the clinical development of MVA-BN, participants were monitored for 
cardiac-related signs or symptoms through at least 6 months after the last vaccination. In 22 
studies, cardiac AESIs were reported to occur in 1.3% (95/7,093) of JYNNEOS recipients and in 
0.2% (3/1,206) of placebo recipients who were smallpox vaccine naïve. The higher proportion of 
JYNNEOS recipients who experienced cardiac AESIs was driven by cases of asymptomatic post-
vaccination elevation of troponin I, the clinical significance of which is unknown.  
 
Among the cardiac AESIs reported, there were six, non-serious cases (0.08%) deemed causally 
related to JYNNEOS vaccination including tachycardia, electrocardiogram (ECG) T wave 
inversion, unspecified ECG abnormality, ECG ST segment elevation, ECG T wave abnormality, 
and palpitations. These data are consistent with findings from a randomized, double-blind, 
placebo-controlled Phase 3 trial that evaluated the immunogenicity and safety of three consecutive 
production lots of MVA-BN. In that trial, eight out of 3,003 (0.3%) participants who received at 
least one dose of MVA-BN had a cardiac AESI. Of these events, two of the eight were considered 
possibly related to MVA-BN vaccination; one participant had a right bundle branch block on ECG, 
and the other participant had clinical symptoms consistent with acute pericarditis but had a 
negative cardiac work-up. This same participant had positive serology to Coxsackie B virus 
suggesting that an acute viral infection may have been the cause of their symptoms. Given these 
data, we are not monitoring for cardiac AESI during Stage 1 of this study which involves adults 
ages 18 to 50 years, inclusive. However, in Stage 2, which involves adolescent participants, 
monitoring for protocol specified AESI (see Section 8.6.3.2) will be part of the study as less is 
known about the product’s safety profile in this population. In addition, an exclusion criterion for 
adolescents and adults with relevant cardiac history that could place them at risk was added in 
Stage 2.  In Stage 1 and Stage 2, the occurrence of AE, MAAE, and SAE will be monitored 
allowing detection of symptomatic cardiac events as well as cases of thromboembolic events and 
neurovascular events following vaccination with JYNNEOS. 
 
1.3.2 
Known Potential Benefits 
JYNNEOS was licensed in 2019 based on pre-clinical studies and clinical trial data showing that 
the vaccinia virus-specific (VV-WR) geometric mean titer (GMT) elicited by two doses of 
JYNNEOS was non-inferior to that elicited by ACAM2000; ACAM2000 was licensed based on 
non-inferiority to Dryvax. Participation in this study may result in protection against mpox during 
this current outbreak.  However, participation may also provide no direct benefit to the participant 
and/or if they develop an immune response to vaccinia virus the immune response may not be fully 
protective against mpox. Data from Stage 2 may benefit society by expanding the population for 
whom JYNNEOS is FDA approved.  
 

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1.3.3 
Assessment of Potential Risks and Benefits 
JYNNEOS is a licensed product with a good safety profile for the adult population. Stage 2 
compares the standard 2-dose SC dosing regimen which is licensed for adults and under EUA for 
adolescents. Because the safety profile of JYNNEOS is largely unknown among adolescents, 
research in Stage 2 is categorized as greater than minimal risk but presenting the prospect of benefit 
for individual subjects (45 CFR 46.405). Risk to participants will be minimized by excluding 
groups of individuals identified to be at greatest risk for serious adverse reactions following 
vaccination with JYNNEOS. 
2. 
OBJECTIVES AND ENDPOINTS 
 
Table 1 Stage 2 Objectives and Endpoints 
OBJECTIVES 
ENDPOINTS 
(OUTCOME MEASURES) 
Primary 
 
To determine if peak (Day 43) humoral immune 
responses in adolescents ages 12 to 17 years are 
non-inferior to adults after receipt of a 2-dose SC 
regimen of 1 x 108 TCID50 MVA-BN. 
 
Vaccinia virus specific PRNT GMT at Day 43 
 
To describe safety of a 2-dose 1 x 108 TCID50 
MVA-BN regimen administered SC in 
adolescents ages 12 to 17 years. 
Frequency and severity of solicited systemic and 
local AE for 7 days after each vaccination. 
Frequency severity, and relatedness of unsolicited 
AEs for 28 days after each vaccination. 
Frequency and description of protocol specified 
AESIs from Day 1 through 210. 
Frequency and description of related MAAEs 
from Day 1 through 210.  
Frequency and relatedness of SAEs for duration 
of the study. 
Frequency and description of withdrawals and 
discontinuations of vaccination. 
 
Secondary 
 
To evaluate humoral immune responses at 
baseline, prior to the second vaccination, and 
following receipt of the 2-dose SC regimen of 1 x 
108 TCID50 MVA-BN in adolescents compared to 
adults on each study day.  
 
Vaccinia virus specific PRNT GMT at Study Day 
1, 29, 43, 210, and 394 
 
To evaluate the kinetics of the humoral immune 
responses to the 2-dose SC regimen of 1 x 108 
TCID50 MVA-BN in adolescents and adults 
through Day 365 after the second dose is 
administered. 
 
Vaccinia virus specific PRNT half-life (t ½)  
 

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To compare relative safety and reactogenicity 
between adolescent and adult study arms. 
Frequency and severity of solicited systemic and 
local AE for 7 days after each vaccination. 
Frequency severity, and relatedness of unsolicited 
AEs for 28 days after each vaccination. 
Frequency and description of protocol specified 
AESIs from Day 1 through 210. 
Frequency and description of related MAAEs 
from Day 1 through 210. 
Frequency and relatedness of SAEs for duration 
of the study. 
Frequency of withdrawals or discontinuation of 
vaccination in each study arm. 
 
To evaluate seroconversion between adolescent 
and adult study arms. 
 
Vaccinia virus specific PRNT GMT at Study Day 
29, 43, 210, and 394 
Exploratory 
 
To evaluate other measures of the humoral 
immune responses for each regimen 
Results from additional immunologic assays for 
vaccinia and other related viruses. 
 
To evaluate humoral immune responses of the 2-
dose SC regimen of 1 x 108 TCID50 MVA-BN to 
monkeypox virus in adolescents compared to 
adults. 
 
Monkeypox virus specific PRNT GMT at Day 1 
and 43. 
 
 
3. 
STUDY DESIGN 
3.1 
Overall Design 
This study is a Phase 2 open-label, non-placebo controlled, multi-site clinical trial that will 
evaluate the standard SC regimen in adolescents ages 12 through 17 years, inclusive, and compared 
to the standard SC regimen in adults ages 18 to 50, inclusive.  Approximately 135 healthy, 
vaccinia-naïve adults will be enrolled in a comparator arm (Arm 4) and will be given the standard, 
licensed regimen of 1x108 TCID50 MVA-BN administered SC on Day 1 and 29. These adults (Arm 
4) will be combined with the 76 healthy, vaccinia-naïve adults that received the standard SC 
regimen in Stage 1 (Arm 3). Together, this will be the comparator group for non-inferiority testing 
for the primary endpoint. Approximately 315 healthy, vaccinia-naïve adolescents will be enrolled 
and given 1x108 TCID50 MVA-BN administered SC on Days 1 and 29 (Arm 5). The study will 
have a set target enrollment of at least 25% adolescents ages 12 to 14 years, inclusive, to ensure 
that adequate numbers of younger adolescents are enrolled. Participants will be followed as 
outlined in the Schedule of Activities (Table 2): 

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Table 2 Stage 2 Schedule of Activities (SOA)  
Procedures  
Optional 
Screening 
Visit  
Day -7 to 
-1  
Visit 1 
Enroll 
Baseline  
Day 1  
  
Visit 
2 
Day 
8 +/- 
1 
day 
  
Visit 
3 
Day 
29 +/- 
3 
days  
Visit 4 
Day 
36 +/- 
1 day 
Visit 5  
Day 43 
+/- 3 
days  
 Visit 6 
Day 57 
+/- 3 
days 6 
 Visit 7 
Day 90 
+/- 5 
days 6 
Visit 8 
Day 210 
+/- 7 
days  
Visit 9  
Day 394 
+/- 14 
days  
Sick or 
Unscheduled 
Visit 7   
Days post 
second 
vaccination 
 
 
 
 
7 +/-1 
days 
14 +/-3 
days 
28 +/-3 
days 
61 +/-5 
days  
181 +/-
7 days 
365 +/-
14 days  
 
Informed 
consent and 
assent where 
appropriate  
X  
X1  
  
  
  
  
  
  
  
  
  
  
Demographics  
X  
X1  
  
  
  
  
  
  
  
  
  
  
Medical history  
X  
X1  
X 
X  
X 
X  
X  
X  
X  
X  
X  
Vaccine 
administration  
  
X  
  
X  
  
  
  
  
  
  
  
Targeted 
physical exam  
X  
X1  
X2 
 X2  
X2 
X2  
X2  
X6 
X2  
X2  
X2  
Vital signs  
X  
X1  
X2 
X2  
X2 
X2  
X2  
X6 
X2  
X2  
X2  
Concomitant 
medicine 
review 3 
X  
  
X  
  
X 
X  
  
X 
X 
 
X  
  
X 
  
X  
  
 X  
 
X  
  
SAE4   
  
 All SAE, Day 1 through 394 
  
X4  
Protocol 
specified AESI 
and related 
MAAE 4 
 
Protocol specified AESI and related MAAEs, Day 1 through 210 
 
X4 
Unsolicited 
AEs4  
  
 Unsolicited AEs, Day 1 through Day 57  
  
  
  
  
X4  
Solicited (Local 
and Systemic) 
AEs 
 
Day 1 through 
Day 8 
 
Day 29 through 
Day 36 
 
 
 
 
 
X 
Pregnancy  
test 5   
X  
X1  
  
 X  
  
  
  
  
  
  
  
Maximum 
blood volume 
per visit (ml) 8 
  
15 
 
  
 
 15 
  
15 
  
  
15  
15 
 
Maximum 
blood volume 
total (ml) 8 
 
15 
 
 
30 
 
45 
 
 
60 
75 
 
Blood 
collection visits 
8  
  
X  
  
X  
  
X  
  
  
X  
X  
  
  
1 If there is no screening visit, these activities should be conducted at the Day 1 visit prior to enrollment.  
2 A targeted (symptom-driven) physical exam will be done at screening (i.e., screening visit or Day 1), on Days 8, 
29, 36, and 43 (at least assessment of vaccination site and presence of skin reactogenicity will be done), and as 
needed in all other visits if interim change in medical status reported by participant. Vital signs (temperature, blood 

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pressure and heart rate) will be done on Day 1 and 29 prior to vaccination. However, if there was a separate 
screening visit and vital signs (temperature, BP, and HR) were done at that visit, only a temperature is needed on 
Day 1.  Vital signs can be done at other visits on an as needed basis.  
3 For Stage 2, after Day 57, only concomitant medications that are associated with a protocol specified AESI or related 
MAAE through Day 210, and all SAE through Day 394 and clinically relevant to report, will be recorded in the CRF. 
In addition, during sick visits concomitant medications will be collected.  
4 If SAE/MAAE/AESI or unsolicited AE are reported during a sick visit or unscheduled visit and within the reporting 
window, it will be reported. See more information about collection of AEs in the safety section of the protocol.  See 
section 8.6.3.2 for additional details on AESIs.  
5 A pregnancy test will be done at the screening visit (if conducted) and on Day 1 prior to enrollment. If there is no 
screening visit, then pregnancy test done will be done on Day 1 only. Females of reproductive potential must have 
negative serum or urine pregnancy test in the 24 hours prior to Day 1 and 29 study vaccinations and results confirmed 
prior to enrollment. Pregnancy testing is required only for adolescents who have reached menarche based on medical 
history. 
6 The Day 57 visit may occur via phone call visit if the participant has no skin changes at either injection site 
documented at the Day 43 visit. All Day 90 visits in Stage 2 will occur via phone call by a delegated study staff 
member. For both Day 57 and Day 90 visits, the site may opt to have the participant come in for an in-person visit if 
deemed necessary.  In addition, those who qualify for a phone visit at Day 57 and all Day 90 visits may be conducted 
virtually via video teleconference (e.g., Zoom, FaceTime) if deemed necessary. If an in-person visit is deemed 
necessary, site may do vital signs and a physical examination on an as needed basis.  
7 Participants reporting mpox-like illness who have a positive diagnostic test result will be seen at a sick visit. An 
unscheduled visit may also occur for reasons including, but not limited to AE follow up, blood draw, or early 
termination final visit.   
8 Stage 2 participants will have blood drawn on Days 1, 29, 43, 210 and 394. For Stage 2, a minimally acceptable 
blood volume on Day 1 and on Day 43 is set at 5-mL of whole blood (SST for serum), regardless of age. Should the 
site not be able to collect that blood before the first vaccination, the participant will not be permitted to continue. 
Maximum blood draw at the pre-specified visits in Stage 2 is 15 mL  
 
3.2 
Scientific Rationale for Study Design 
The rationale for each of the study arms in Stage 2 are as follows: 
 
1 x 108 TCID50 MVA-BN SC on Days 1, 29 (Study Arms 4, and 5) – This regimen is the licensed 
dose and route for adults ages 18 and above. Arms 4 (adult) and 5 (adolescent) will be used to 
evaluate noninferiority of this regimen among adolescents compared to adults. 
3.3 
Justification for Dose 
This study will use the FDA-approved, licensed dose 1 x 108 administered SC on Day 1 and 29 in 
Stage 2 of the study. It is anticipated that the licensed, 2-dose SC regimen will be safe and 
immunogenic in adolescents.  
4. 
STUDY POPULATION 
Stage 2 will enroll healthy, non-pregnant, non-breastfeeding, vaccinia-naïve adolescents ages 12 
to 17 years, inclusive and a comparator arm of healthy, non-pregnant, non-breastfeeding, vaccinia-
naïve adults ages 18 to 50 years, inclusive. Participants with stable medical conditions and well-
controlled HIV infection can participate. Stage 2 will aim to enroll a population that is 
representative of the U.S. population based on the 2020 U.S. Census data to ensure broad 
applicability of the study findings given the aim of obtaining full licensure of JYNNEOS in 
adolescents. In addition, the goal is to enroll at least 25% adolescent participants ages 12 to14 
years. 

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Participant Eligibility Criteria must be confirmed by an investigator named on the delegation log. 
If there is any uncertainty, the PI should make the decision on whether a potential participant is 
eligible for study enrollment. They may also contact DMID Medical Officers to discuss. No 
exemptions are granted on Inclusion/Exclusion Criteria. 
4.1 
Inclusion Criteria 
Study inclusion criteria are similar between stages. To be eligible to participate in Stage 2, an 
individual must meet the following inclusion criteria:  
1 Adult ages 18 to 50 years inclusive at the time of consent; OR 
Adolescent ages 12 to 17 years inclusive at the time of consent. 
2 Adult participant is able to read the written informed consent, states willingness to comply 
with all study procedures and is anticipated to be available for all study visits; OR 
Parent(s)/Legal Authorized Representative (LAR)(s) of the participating adolescent is able 
to read and provides written informed permission and participating adolescent provides 
assent as appropriate for age or development and approved by IRB. Adolescent states 
willingness to comply with all study procedures and is anticipated to be available for all 
study visits.  
3 Adult participant is able to understand and agrees to adhere to Lifestyle Considerations 
(section 5.4) during the study; OR 
Parent(s)/LAR(s) of the participating adolescent is able to understand and states willingness 
to comply with Lifestyle Considerations (section 5.4).  
4 Females of reproductive potential who have sexual intercourse with male partners must be 
using highly effective contraception for at least 1 month prior to signing ICF and agrees to 
use acceptable method of contraception through Day 57. 
 
Note: See MOP for definitions and list of acceptable method of contraception 
 
5 In good general health as evidenced by medical history, physical examination, and clinical 
judgement of the investigator to be in stable state of health.  
 
Note: Participants with pre-existing stable chronic medical conditions defined as conditions 
not requiring significant change in therapy or hospitalization for worsening disease in the 4 
weeks prior to enrollment can be included at the discretion of the investigator. This includes 
stable, well-controlled HIV positive individuals. 
 
6 Individuals with HIV must be on suppressive ART for at least 6 months, report a CD4 count 
of greater than 350 cells/µL and no AIDS-defining illness in the last year. 
 
4.2 
Exclusion Criteria 

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For Stage 2 of the study, an individual who meets any of the following criteria will be excluded 
from participation in this study. Of note, the only differences between exclusion criteria in Stage 
1 and Stage 2 is criterion 8 and the addition of criterion 13: 
1. Ever received a licensed or an investigational smallpox or mpox vaccine. 
Note: this includes Dryvax, Acam2000, LC 16 m8, MVA-based vaccine candidate or 
licensed vaccines, and Jynneos, Imvamune or Imvanex) 
2. Any history of mpox, cowpox, or vaccinia infection. 
3. Close contact of anyone known to have mpox in the 3 weeks prior to signing ICF 
4. Immunocompromised as determined by the investigator  
5. Recent or current use of any immunosuppressing medications in the 4 weeks prior to 
signing ICF.  
Note: topical, ophthalmic, inhaled, intranasal and intraarticular corticosteroids are 
acceptable, but receipt of ≥20 mg/day of prednisone or equivalent for ≥14 consecutive 
days in the 4 weeks prior to signing ICF is exclusionary.  
6. Pregnant or breast feeding. 
7. Received or plans to receive a live vaccine or any COVID-19 vaccine in the 4 weeks before 
or after each study vaccination. 
8. Received or plans to receive any other vaccine in the one week before or after each study 
vaccination.  
9. Received experimental therapeutic agent or vaccine in the 3 months prior to signing ICF. 
10. Has known allergy or history of anaphylaxis or other serious adverse reaction to a vaccine 
or vaccine products.  
Note: this includes individuals with history of severe allergic reaction to gentamicin, 
ciprofloxacin, chicken or egg protein. 
11. Has tattoos, scars, or other marks which would, in the opinion of the investigator, interfere 
with assessment of the vaccination site. 
12. Has any medical disease or condition that, in the opinion of the participating site PI or 
appropriate sub-investigator, precludes study participation. 
Note: this includes acute, subacute, intermittent, or chronic medical disease or 
condition that would place the participant at an unacceptable risk of injury, render the 
participant unable to meet the requirements of the protocol, or may interfere with the 
evaluation of responses or the participant’s successful completion of this trial. 
13. Adolescent or adult participant has a history of myocarditis/pericarditis or a history of 
structural congenital heart defect/cardiac dysrhythmia that, in the opinion of the 
investigator, poses increased risk to the participant. 
14. Adolescent or adult participant has a history of COVID-19 (with positive test for SARS-
CoV-2) in the 4 weeks prior to receipt of the first study vaccination. 
Note: This includes positive rapid antigen test, polymerase chain reaction (PCR) assay, 
or other nucleic acid amplification (NAAT) test including those performed by the 
participant at home. 

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4.2.1 
Exclusion of Specific Populations 
As in Stage 1, Stage 2 of this study will enroll healthy non-pregnant, non-breastfeeding adults ages 
18 to 50 years, inclusive. Adults with a history of receiving smallpox vaccine as a child and those 
born before 1971 will be excluded as they are likely to have received smallpox vaccination during 
the smallpox eradication campaign. Because the effects on the fetus are not known, pregnant 
individuals will not be eligible for the trial (see Risk/Benefit Assessment Section). In addition, 
individuals who are breastfeeding will not be eligible because it is not known if JYNNEOS is 
excreted in the breastmilk. Stage 2 of the study will also enroll healthy non-pregnant, non-
breastfeeding adolescents ages 12 to 17 years, inclusive. Should the outcome of this trial be 
deemed acceptable, additional trials may be initiated, including those in other populations. 
 
Given that safety of MVA-BN among adolescents ages 12 to 17 years is largely unknown and 
myocarditis and pericarditis were found to be associated with vaccination with ACAM2000 and 
Dryvax, replicating smallpox vaccines, adolescents with a history of myocarditis/pericarditis or a 
history of structural congenital heart defect/cardiac dysrhythmia that, in the opinion of the 
investigator, poses increased risk to the participant will not be eligible to participate.  
4.3 
Inclusion of Vulnerable Participants 
This study will enroll vulnerable participants in Stage 2, including adolescents ages 12 to 17 years. 
This research can be categorized as greater than minimal risk but presenting the prospect of direct 
benefit to the participant (45 CFR 46.405) given that MPXV continues to cause disease in the U.S., 
and may spread into additional populations, including sexually active adolescents. Adolescents 
will be recruited from communities that represent the general population that attend the clinics 
associated with the institution for research sites, or individuals who respond to advertisements 
posted publicly. 
4.4 
Lifestyle Considerations 
During Stage 2 of this study, participants are asked to: 
• Follow public health guidance on preventing mpox infection and notify the clinical site if 
exposed to an individual with mpox. 
• Contact the clinical site immediately if they develop signs and symptoms consistent with mpox 
and a positive MPXV diagnostic test to schedule a study sick visit. See Section 8.2 and the 
MOP. 
• Contact the clinical site if they develop COVID-19 illness (with positive test for SARS-CoV-
2 including those performed at home by the participant) during the study. 
• Refrain from receiving a live vaccine or COVID-19 vaccine in the 4 weeks before or after each 
study vaccination. 
• Refrain from receiving any other vaccine in the one week before or after each study 
vaccination.  
• Decline participation in another study evaluating investigational vaccines through Day 210 in 
Stage 2.  

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• Decline participation in another study evaluating an investigational mpox vaccine, smallpox 
vaccine, or MVA-based vaccine through end of trial. 
 
Of note, participants may enroll in non-interventional, observational studies (e.g., natural history 
study of mpox). However, concurrent participation in this trial and observational studies can only 
occur if the recommended blood collection volumes as specified by site Institutional Review Board 
guidance are not exceeded.42  
 
4.5 
Screen Failures 
After the screening evaluations have been completed, the investigator or designee is to review the 
inclusion/exclusion criteria and determine the participant’s eligibility for the study. The following 
information will be collected on screen failures: demographics (age, screen number, sex, ethnicity, 
and race) and reason(s) for ineligibility. Participants who are found to be ineligible will be told the 
reason for ineligibility. 
 
A participant may be re-screened once if a protocol eligibility criterion that is not met at the initial 
time of screening, will be met by rescreening at a later date (e.g., a vaccine was received within 
exclusionary window at first screening that would not be in the exclusionary window at a later 
rescreen). 
 
4.6 
Strategies for Recruitment and Retention 
4.6.1 
Recruitment 
Potential participants will learn about the study via IRB-approved recruitment strategies, which 
may include direct mailing, recruitment from an IRB-approved trial registry, and local flyers or 
advertisements. Recruiting may begin with a brief telephone call between study staff and the 
potential participant. Information about the study will be presented to potential participants, and 
questions about their health and ability to comply with the study visit schedule will be asked of 
potential participants to presumptively determine eligibility. Information about the participant may 
be recorded from interviews or medical records. Appointments will be made at the research site 
for potential participants who are interested in the study for further screening procedures and 
additional protocol-specific information. 
  
4.6.2 
Retention 
Study retention strategies will include education and explanation of the study schedule and 
procedures during screening and enrollment visits and restriction of enrollment to persons who can 
attend all study visits. Study participants will be reminded of subsequent visits during each visit, 
and study staff may contact participants prior to appointments. Study staff will contact participants 
who miss appointments to encourage them to return for completion of evaluations. 
 
4.6.3 
Compensation Plan for Participants  
Participants may be compensated for their participation in this trial. Compensation will be in 
accordance with local institution requirements, and pursuant to IRB approval. Reimbursements 

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will be disbursed at specific timepoints during the study with the amount contingent on completing 
study procedures. 
 
4.6.4 
Costs 
There is no cost to participants for the research tests, procedures, and study product while taking 
part in this trial. Procedures and treatment for clinical care may be billed to the participant, 
participant’s insurance or third party.  
 
 
5. 
STUDY PRODUCT 
5.1 
Study Product(s) and Administration 
5.1.1 
Study Product Description 
JYNNEOS is FDA-approved and licensed for adults as a smallpox and mpox vaccine in the United 
States. The vaccine, when thawed, is a milky, light yellow to pale white colored suspension that is 
licensed for subcutaneous injection. JYNNEOS is a live vaccine produced from the strain Modified 
Vaccinia Ankara-Bavarian Nordic (MVA-BN), an attenuated, non-replicating orthopoxvirus. 
MVA-BN is grown in primary Chicken Embryo Fibroblast (CEF) cells suspended in a serum-free 
medium containing no material of direct animal origin, harvested from the CEF cells, purified, and 
concentrated by several Tangential Flow Filtration (TFF) steps including benzonase digestion. 
Each 0.5 mL dose is formulated to contain 0.5 x 108 to 3.95 x 108 infectious units of MVA-BN 
live virus in 10 mM Tris (tromethamine), 140 mM sodium chloride at pH 7.7. Each 0.5 mL dose 
may contain residual amounts of host-cell DNA (≤ 20 mcg), protein (≤ 500 mcg), benzonase 
(≤0.0025 mcg), gentamicin (≤0.163 mcg), and ciprofloxacin (≤0.005 mcg).  
 
5.1.2 
Dosing and Administration 
In this platform trial, only JYNNEOS (MVA-BN vaccine) is being evaluated and there is no 
placebo group.  Vaccine will be administered by subcutaneous injection in the fatty subcutaneous 
tissue of the upper arm.  See the MOP for additional details.    
 
In Stage 2, the second vaccination will be given in the contralateral arm unless the site deems that 
using the same arm is in the best interest of the participant in terms of safety or using the same arm 
(for the second injection) will enable the site to better evaluate reactogenicity (e.g., tattoo on 
opposite upper arm). If the second vaccination is given in the same arm as the first vaccination, 
the second injection should be given approximately 5 cm away from the first injection site if 
physically possible. 
 
Table 3 Study Arms Stage 2 (Adult and Adolescent) 
Arm 
Dose of JYNNEOS (MVA-
BN) 
Route of 
Administration* 
Vaccination Day 
Day 1 
Day 29 
4 (Adult) 
 1 x 108 TCID50 (0.5 mL) 
Subcutaneous 
X 
X 

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5 (Adolescent) 
1 x 108 TCID50 (0.5 mL) 
 
Subcutaneous 
X 
X 
*Subcutaneous is administered in the fatty subcutaneous tissue of the upper arm. 
5.1.3 
Dose Escalation 
Not Applicable. 
 
5.1.4 
Dose Modifications 
Not Applicable. 
 
5.1.5 
Criteria for Redosing 
If study product administration is unsuccessful, another administration will not be attempted.  
 
5.2 
Preparation/Handling/Storage/Accountability 
5.2.1 
Acquisition and Accountability 
See main section of this document for information about accountability and disposition of the study 
product, JYNNEOS (MVA-BN vaccine). 
 
5.2.2 
Formulation, Appearance, Packaging, and Labeling 
See main section of this document for information about JYNNEOS. 
 
5.2.3 
Product Storage and Stability 
See main section of this document for information about storage and stability of JYNNEOS.  
 
5.2.4 
Preparation 
Each dose (0.5 mL) is supplied in a single-dose vial. Sites should allow the vaccine to thaw and 
reach room temperature before use (about 15 to 30 minutes). After thawing, the total time stored 
at +2°C to +8°C (+36°F to +46°F) should not exceed 4 weeks. Once the vial is punctured and a 
dose is withdrawn, if it is not used in its entirety, it should be stored at +2°C to +8°C (+36°F to 
+46°F) and discarded within 8 hours of the first puncture. If the unpunctured vial is initially 
shipped/stored at 2-8C then it is stable for up to 8 weeks. Sites should not refreeze the vaccine. 
JYNNEOS may be kept frozen until the expiration date.  
 
JYNNEOS is a light yellow to pale white colored, milky suspension when thawed. Sites will 
visually inspect the product for particulate matter and discoloration prior to administration. If 
either condition is present, the vaccine will not be administered. Study product administrators will 
gently swirl the vial for at least 30 seconds.  
 
For the SC injection (Arms 4 and 5), 0.5 mL of vaccine will be withdrawn from the vial into a 
sterile syringe and injected into the fatty subcutaneous tissue of the upper arm. 
 

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See the protocol-specific MOP for detailed information on the preparation, labeling, storage, and 
administration for each study arm. 
 
5.3 
Measures to Minimize Bias: Randomization and Blinding 
5.3.1 
Treatment Assignment Procedures 
All participants in Stage 2 will receive the 2-dose SC regimen of 1 x 108 TCID50 MVA-BN.   
 
5.3.2 
Randomization  
Stage 2 is not randomized.  All Stage 2 participants will receive the 2-dose SC regimen of 1 x 108 
TCID50 MVA-BN.  For Stage 2, the aim is to enroll at least 25% adolescents ages 12 to 14 years. 
 
5.3.3 
Blinding and Masking Procedures 
This study will not utilize blinding or masking procedures as it is an open-label, non-placebo-
controlled trial. Research laboratories will be blinded to participant study arm for the purposes of 
immunogenicity/efficacy evaluations.  
5.4 
Study Intervention Compliance 
Each dose of JYNNEOS will be administered by a member of the clinical research team that is 
qualified per state and institution policies to administer the study product. Administration and date, 
time, and location of injection will be recorded on the appropriate eCRF. 
5.5 
Concomitant Therapy 
At screening (i.e., the screening visit or Day 1 visit if the screening visit is not conducted), 
participants will be asked about receipt of immunosuppressive therapy, experimental therapeutic 
agents and vaccines, other medications, and vaccines. At each subsequent study visit through Day 
57, new concomitant medication(s) and changes to existing medications will be recorded as well 
as receipt of a vaccine. For this study, concomitant medications to be reported in the Case Report 
Form (CRF) are prescription drugs, over-the-counter medications, and supplements. Concomitant 
medications taken and vaccines received in the 4 weeks prior to providing informed consent will 
be recorded in the CRF. Any drug taken or vaccine received by the participant during the trial 
should be recorded on the appropriate CRF through Day 57. In Stage 2, after Day 57, concomitant 
medication associated with a protocol specified AESI or related MAAE occurring through Day 
210 and clinically relevant to report will be recorded in the CRF. After Day 57, concomitant 
medication associated with a related SAE occurring through the end of study and clinically 
relevant to report will be recorded in the CRF. Clinically relevant is defined as a medication that 
is prescribed or dose of an existing medication changed because of a SAE, AESI or MAAE. 
Medications taken that are unrelated to the adverse event do not need to be recorded (e.g., topical 
medication for acne). An exception to this schedule for recording concomitant therapy is during 
sick visits for those who have laboratory-confirmed mpox (illness). During sick visits, concomitant 
medications and treatment will be collected. 
 
Medications that might interfere with the evaluation of the immune response to MVA-BN should 
not be used by the participant during the study-reporting period unless clinically indicated as part 

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of the participant’s health care for a condition diagnosed after enrollment. This would include any 
systemic immunosuppressant medication that may impact the immunogenicity endpoints. In the 
event medical conditions dictate the use of these medications, participants are encouraged to obtain 
adequate care, comply with the course of therapy as prescribed by their physician and inform the 
study Investigator as soon as practical.  
 
6. 
STUDY INTERVENTION DISCONTINUATION AND 
PARTICIPANT DISCONTINUATION/WITHDRAWAL 
6.1 
Halting Criteria and Discontinuation of Study Intervention 
6.1.1 
Study Halting Criteria 
Stage 2 will be paused if any of the following four events occur: 
 
1. One (1) participant experiences a SAE after the administration of the vaccine that is 
considered related to the vaccine. 
2. One (1) participant experiences a Grade 4 solicited AE after the administration of the 
vaccine that is considered related to the vaccine. 
3. Three (3) or more participants experience a Grade 3 or higher unsolicited AE coded to the 
same High-Level Term based on the medical dictionary for Regulatory Activities 
(MedDRA) that are deemed related to the vaccine.  
4. Two or more participants experience a protocol specified AESI regardless of relatedness 
or severity. 
 
In the event a halting rule is met, an unscheduled safety analysis by the DSMB will be required 
for approval of further enrollment. Further administration of the vaccine, including a second dose, 
is suspended for all participants until an assessment by the DSMB takes place. 
 
6.1.1.1 
Sentinel Participant Halting Rules 
Not Applicable.  
 
6.1.1.2 
Cohort Halting Rules 
Not Applicable. 
 
6.1.2 
Individual Halting Criteria 
If a single participant meets an individual halting criterion, this will not halt the whole study but 
halts the participant’s involvement in terms of the administration of the second dose of the vaccine. 
However, while the participant is discontinued from receipt of vaccine, they should be encouraged 
to remain in the study to monitor safety and evaluate immunogenicity until the end of the study. 
 
For Stage 2, all five criteria listed below apply: 
  

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1. Any participant experiences laryngospasm, bronchospasm, or anaphylaxis within 24 hours 
after the administration of the vaccine that is considered related to the vaccine within the 
24 hours after vaccination.  
2. Any participant experiences generalized urticaria (defined as urticarial lesions occurring at 
more than two body parts) within 3 days after the administration of the vaccine. 
3. Any participant experiences any Grade 4 solicited AE or an SAE after the administration 
of the vaccine that is deemed related to the vaccine. 
4. Any participant that experiences ulceration, abscess or necrosis at the injection site that is 
considered related to the vaccine administration.  
5. Any participant experiences signs and symptoms consistent with myocarditis or 
pericarditis after the first vaccination and before the second vaccination is given. 
 
A participant may be removed from the study if the Investigator or the medical monitor deems it 
in the best interest of the participant. The participant could be withdrawn from the study at any 
time during the trial.  
6.1.3 
Follow up for participants that discontinued study intervention 
Discontinuation from vaccination administration does not mean discontinuation from the study, 
and remaining study procedures should be completed as indicated by the study protocol. If a 
clinically significant finding is identified (including, but not limited to changes from baseline) after 
enrollment, the investigator or qualified designee will determine if any change in participant 
management is needed.  
 
The second vaccination will not be given, but other follow up visits will continue, if the participant: 
• Becomes pregnant.  
• Develops mpox (symptomatic, laboratory-confirmed disease) after the first vaccination 
• Meets an exclusion criterion for participation in the study (either newly developed or not 
previously recognized) that precludes further study participation. 
If a participant meets an exclusion criterion after enrollment and first dose, it does 
not necessarily mean the participant cannot receive the second dose of 
JYNNEOS.  The decision of what “precludes further study participation” depends 
on what exclusion criteria are met, with a focus on what is best for participant 
safety. The most likely exclusion criteria to be met are participants that receive a 
licensed vaccine after enrollment (i.e., exclusion criteria 7 and 8).  If a 
participant receives an off-study vaccine during the study-defined restricted time 
periods (i.e., as defined in exclusion criteria and Section 5.4), receipt of the off-
study vaccine should be reported as a deviation. The participant can receive the 
second study vaccination if the investigator determines that the participant is 
otherwise eligible to receive the second MVA-BN in this trial. 
 
There is no reactogenicity threshold for administration of the second dose of vaccine, that is the 
second dose may be administered even if there is residual erythema, induration or other 
reactogenicity from the first vaccination. Participants and if applicable parent(s)/legal authorized 
representative (LAR) may decline the second vaccination for any reason at the Day 29 visit and 
will be discontinued from the study intervention. Parental/LAR permission is ongoing throughout 
the study and will be confirmed prior to the second vaccination.  See MOP for operational details.  

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However, if second vaccination is declined, the participant should remain in the study and followed 
for safety and immunogenicity through Day 394 visit unless they withdraw from the study. 
 
The data to be collected at the time of study intervention discontinuation will include: 
• Reason for discontinuation study vaccination including, but not limited to, unacceptable 
(intolerable) reactogenicity, new medical condition identified that places participant at risk, 
participant or parent(s)/LAR(s) unwillingness to have second vaccination. 
• Confirmation of willingness to remain in the study and understanding of study schedule. 
6.2 
Participant Withdrawal from the Study and Replacement  
Participants and if applicable parent(s)/LAR(s) are free to withdraw from participation in the study 
at any time upon request. An investigator may withdraw a participant from the study if the 
participant: 
• Has an AE or other medical condition that continued participation in the study would not 
be in the best interest of the participant. 
• Is lost to follow-up 
 
The reason for participant discontinuation or withdrawal from the study, whether the decision was 
made by investigator, participant, or parent(s)/LAR(s), and the extent of the withdrawal (i.e., 
whether participant withdrew from all components of research study or just the study intervention) 
will be recorded on the CRF. If the participant agrees, every attempt will be made to follow all 
AEs through resolution (return to baseline) or until defined as stable. The investigator will inform 
the participant and if applicable parent(s)/LAR(s) that already collected data will be retained and 
analyzed for this study even if the participant withdraws from this study. Biospecimens collected 
will still be used to analyze the study endpoints. 
 
Participants who withdraw, or are withdrawn from this study, or are lost to follow-up after signing 
the ICF and administration of the study product will not be replaced.  
6.3 
Lost to Follow-Up 
A participant will be considered lost to follow-up if he or she fails to return for two scheduled 
visits and is unable to be contacted by the study site staff after three attempts. Extensive effort (i.e., 
generally three documented contact attempts via telephone calls, e-mail, etc., made on separate 
occasions) will be made to locate or recall the participant, or at least to determine the participant’s 
health status. These efforts will be documented in the participant’s study file. 
 
7. 
STUDY ASSESSMENTS AND PROCEDURES 
7.1 
Screening Procedures 
In this study, screening assessments can occur in an optional screening visit on Day –7 to –1, or at 
Visit 1 on Day 1 before the first vaccination. At the time of the screening assessment, the 
participant and if applicable parent(s)/LAR(s) will be provided with detailed study information 
and written informed consent or parental/LAR permission and informed assent, where appropriate, 

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will be obtained. The following assessments are performed to determine eligibility requirements 
as specified in the inclusion and exclusion criteria: 
 
• Obtain demographic data. 
• Obtain mpox exposure history in the 3 weeks prior to signing ICF.  
• Review vaccination history, including any experimental vaccines, and determine receipt of 
exclusionary vaccine(s): 
o Live vaccine or a COVID-19 vaccine in the prior 4 weeks or an inactivated non-
COVID-19 vaccine in the prior 1 weeks.  
o Licensed or investigation smallpox or mpox vaccine.  
• Obtain medical history. Ask specifically about worsening of any chronic medical 
condition, hospitalizations, or history of COVID-19 (with positive test for SARS-CoV-2, 
including those performed at home) in the prior 4 weeks, and whether they have the 
following medical conditions: 
o HIV infection  
o History of mpox, cowpox or vaccinia infection 
o History of anaphylaxis or severe adverse reaction to a vaccine or vaccine product 
o History of allergy to gentamicin, ciprofloxacin, chicken or egg protein 
o History of myocarditis or pericarditis, congenital heart defect or cardiac 
dysrhythmia (Stage 2 only, adolescents and adults)  
• Review medications and therapies up to 4 weeks prior to signing ICF and record on the 
appropriate CRF and determine receipt of exclusionary medication(s): 
o Experimental therapeutic agent (or vaccine) in the 3 months prior to consent. 
o Use of immunosuppressing drugs prior to consent.  
• Perform targeted physical examination and inspect arms for smallpox vaccination scar 
• Measure vital signs (HR, BP, and temperature). 
• Review of birth control history with female of reproductive potential who are having sexual 
intercourse with male partners. 
o Counsel participants to use adequate birth control methods required during the trial 
to avoid pregnancy. 
o Do serum or urine pregnancy test (in female participants of reproductive potential). 
• Review inclusion and exclusion criteria. 
 
The overall eligibility of the participant to participate in the study will be assessed once all 
screening values are available. The screening process can be suspended prior to complete 
assessment at any time if exclusions are identified by the study team. 
Study participants who qualify for inclusion will be enrolled. 
 
7.1.1 
Procedures to be Followed in the Event of Abnormal Clinical Laboratory Test 
Values or Abnormal Clinical Findings During Screening  
A participant may be re-screened once if a protocol eligibility criterion that is not met at the initial 
time of screening, will be met by rescreening at a later date. No participant may be screened more 
than twice due to a screening failure result.  
 

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Participants will be provided the results of pregnancy testing and abnormal clinical findings 
necessitating follow-up at the discretion of the participating site PI or appropriate sub-investigator.  
 
 
7.2 
Sick Visit 
Participants with signs and symptoms consistent with mpox (e.g., vesicular or pustular lesions, 
fever, chills, lymphadenopathy, malaise, myalgias, headache, or respiratory symptoms) during the 
study are asked to call the study site.  Those who have laboratory-confirmed mpox will be 
evaluated at the clinical site; those who have not been tested will be asked to have a diagnostic test 
done. During the visit, the participant will be asked about the current illness (e.g., onset date, 
treatment received) and for information about the diagnostic testing that was done. Participants 
will have a targeted physical examination done. For more information about this visit, see the MOP 
and the CRF. 
 
7.3 
Additional Study Procedures in Stage 2  
7.3.1 
Phone Visits 
In Stage 2, the Day 57 visit may occur via phone call visit if the participant has no skin changes 
found on physical examination at either injection site documented at the Day 43 visit. However, 
the site may opt to have the participant come in for an in-person visit if deemed necessary.  In 
addition, those who qualify for a phone visit at Day 57 may have the visit conducted virtually via 
video teleconference (e.g., Zoom, FaceTime) if deemed necessary. If an in-person visit is thought 
to be necessary, the clinical site may do a physical examination on an as needed basis.  
 
In Stage 2, Visit 7 (Day 90) is conducted by phone (teleconference call) by a delegated study staff 
member. However, the site may choose to conduct the visit by virtual method (e.g., Zoom, 
FaceTime) or in-person. 
 
7.3.2 
Photography  
 
In Stage 2, study staff may ask participants for permission to photograph the vaccination site for 
purposes of clinical documentation and follow-up.  Photographs will contain no participant 
identifying information. Participants may grant or decline permission for photography without any 
effect on their participation in the study.  Photographs will not be entered into the study database 
or used for determination of study objectives. 
7.3.3 
Missed Study Visits  
Participants should complete all study visits as specified in the SOA. Phone or virtual video 
teleconferences may be considered for subjects who cannot return for protocol specified in-clinic 
visits but are willing to be contacted by alternate means. See MOP for additional details. 
7.4 
Immunogenicity Assessments 
7.4.1 
Immunogenicity/Efficacy Evaluations 

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Prior comparator studies used the Bavarian Nordic (BN) Vaccina virus Western Reserve strain 
(VV-WR) plaque reduction neutralizing antibody (PRNT) assay and enzyme-linked 
immunosorbent assay (ELISA) to evaluate immunogenicity. For Stage 2, VV-WR PRNT will be 
used as the primary assay and plan to test timepoints of Days 1, 29, 43, 210, and 394. 
  
This study will also measure a MPXV specific PRNT and will test a minimum of 2 timepoints 
(Days 1 and 43). The MPXV PRNT assay is not yet developed, and therefore this endpoint is as 
an exploratory endpoint. Additional timepoints for each will be evaluated as able (given lab 
throughput and cost).  
 
7.4.2 
Exploratory Assessments 
Additional assessments of humoral immunity including ELISAs may be performed on samples 
from this trial.  
 
7.5 
Safety and Other Assessments 
Study procedures are specified in the SOA and more detailed information as needed is provided in 
the MOP. A study clinician, licensed to make medical diagnoses and listed on the Form FDA 1572 
as the participating site PI or appropriate sub-investigator, will be responsible for all study-related 
medical decisions. 
• Medical history 
o A complete medical history will be obtained by interview of participants at 
screening (i.e., the screening visit or on Day 1 if no screening visit is conducted).  
o An interim medical history will be obtained by interview of participants at 
subsequent study visits or ad hoc telephone call with participant. Any changes 
since the previous clinic visit will be noted. The interim medical history should 
include an assessment for adverse events and new medical conditions. 
• Physical examination 
o Stage 2: A targeted (symptom-driven) physical exam will be done at screening 
(i.e., screening visit or Day 1), on Days 8, 29, 36, and 43 (at least assessment of 
vaccination site and presence of skin discoloration and nodules will be done), and 
as needed in all other visits if interim change in medical status reported by 
participant. 
• Reactogenicity Assessments 
o Reactogenicity assessments of solicited systemic reactogenicity occurring from 
the time of each vaccination through 7 days post each vaccination (Days 8 and 36 
respectively) in Stage 2 will include fever, chills, nausea, headache, fatigue, 
change in appetite, myalgia, and arthralgia.  
o Assessments of solicited local (injection site) reactogenicity occurring from the 
time of each vaccination 7 days post each vaccination in Stage 2 will include pain 
at injection site, erythema/redness, induration/swelling, and pruritis at site.  
o In Stage 2, any ongoing events at Day 8, Day 36, or Day 43 will be followed at 
subsequent visits in order to note a resolution date. See Memory Aid section below 
on measurement of ongoing erythema/redness and/or induration/swelling. 
• Memory Aid 

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o For Stage 2, the participant will document local and systemic reactogenicity from 
the time of each vaccination through 7 days post vaccination (Days 1 through 8 
and Days 29 through 36).  
o Memory Aids will be reviewed with the participants for any solicited reactions, as 
well as unsolicited AEs and SAEs.  
o The vaccination injection site will be examined at all visits until symptoms resolve. 
o In Stage 2, for those with no residual systemic or local reactogenicity at the Day 8 
or Day 36 visit, no more data is collected by the participant in the Memory Aid. 
o For those with ongoing systemic and/or local reactogenicity at Day 8 and 36 in 
Stage 2, they will be asked to do the following:  
▪ Measure erythema/redness and/or induration/swelling and record in the 
Memory Aid until it has resolved, if applicable. 
▪ Record end date of all other signs and symptoms.  
o Nodules and hyperpigmentation are unsolicited AEs, and not collected in the 
Memory Aid to avoid double counting these events which tend to develop at end 
of second week as a post-inflammatory reaction. Occurrence will be documented 
on the physical examination eCRF and the unsolicited AE eCRF, and severity 
assessed per Section 8.6.3.1. 
▪ Nodules and hyperpigmentation will be followed through resolution. 
o Site research teams will review and align the subject responses on the memory aid 
with clinical assessments.  
• Vital signs  
o Vital sign measurements will include systolic and diastolic BP, HR, and oral 
temperature. Vital signs will be measured at timepoints specified in the SOA.  
• Clinical laboratory evaluations 
o Serum or urine pregnancy test will be performed locally by the site laboratory at 
the screening and must be negative within 24 hours prior to each vaccination on 
Days 1 and 29. This means that if the screening visit is conducted more than 24 
hours prior to vaccination, pregnancy test will need to be done on Day 1. 
Pregnancy tests may be done as needed at interim or unscheduled visits for all 
females of reproductive potential.  
o Results must be confirmed as negative prior to enrollment on Day 1 and 
administration of each vaccination. 
 
7.5.1 
Alternative Schedules 
Given that peak humoral response after the second JYNNEOS vaccination is the primary endpoint 
and is likely to occur approximately two weeks (Day 43) to four weeks (Day 57) after the second 
dose is administered, it is important that subsequent visits occur within the protocol-specified 
window after the second dose is given.  If a participant is unable to receive the second dose within 
the pre-specified window, the site should contact DMID to discuss an alternate schedule. If a 
participant receives the second dose on any day other than Day 29, the target date of the remaining 
scheduled visits will be shifted, as appropriate so that immunogenicity timepoints post-second 
vaccination are consistent among participants.   
 
Participants may not receive Dose 1 or Dose 2 of JYNNEOS within 4 weeks of COVID-19 illness 
(with positive test for SARS-CoV-2 including those performed at home by the participant) or 

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receipt of a COVID-19 vaccine.  This may require the second JYNNEOS dose to be delayed if a 
participant develops COVID-19 or receives a COVID-19 vaccine while enrolled in the study but 
after receiving Dose 1.  See MOP for additional information. 
 
7.5.2 
Procedures to be Followed in the Event of Abnormal Clinical Laboratory Test 
Values or Abnormal Clinical Findings During the Trial 
In this study, there will be no clinical laboratory screening or safety tests done except for pregnancy 
testing. Participants will be notified of the results of the pregnancy test. 
 
7.6 
Adverse Events and Serious Adverse Events 
See the main document for standard definitions of adverse events (AE), solicited AEs, 
unsolicited AEs, and serious adverse events (SAE). 
 
7.6.1.1 
Definition of Medically Attended Adverse Events (MAAE) 
A medically attended adverse event (MAAE) is defined as AEs with medically attended visits 
including hospital, emergency room, urgent care clinic, or other visits to or from medical personnel 
for any reason. Adverse events (e.g., abnormal vitals) identified at a routine study visit will not be 
considered MAAEs. In Stage 2, MAAEs that are deemed related to the vaccine or vaccination 
procedure will be collected from Day 1 through 210 and all SAEs will be collected from Day 1 
through the end of the study.  
   
7.6.1.2 
Definition of Suspected Unexpected Serious Adverse Reactions (SUSAR) 
A SUSAR is a SAE that is considered related to study product and unexpected. Unexpectedness 
to study product will be determined by what is listed in the JYNNEOS package insert.  
 
7.6.1.3 
Definition of Adverse Event of Special Interest (AESI)  
In Stage 2, protocol specified Adverse Events of Special Interest (AESIs) will be collected. AESIs 
are any adverse events for which additional data (in addition to standard AE data) are desired. The 
Sponsor (DMID), regulatory agency, or industry partner may request AESI reporting; the decision 
to collect AESI may be driven by a regulatory requirement or a known/potential risk from the 
study product or class. Non-structured data similar to SAEs will be collected for AESIs. AESIs 
encompass the following terms:  
  
Protocol Specified AESIs 
For Stage 2 of this trial, a protocol specified AESI is defined as a case of myocarditis or 
pericarditis.  All participants with signs and symptoms of myocarditis/pericarditis (e.g., chest pain, 
shortness of breath, palpitations, etc.) in whom myocarditis/pericarditis is excluded, or for whom 
an alternative diagnosis is made, will not be considered a suspect case and as such, not reported as 
an AESI.  All other suspected cases of myocarditis or pericarditis should be reported as an AESI 
and the case adjudicated using the Brighton Collaboration case definitions for myocarditis and 
pericarditis.  The Brighton Collaboration case definitions will be used to classify into possible, 
probable, or definite myocarditis or pericarditis cases.43 In Stage 2, protocol specified AESIs will 
be collected from Day 1 through 210. 

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7.6.2 
Classification of an Adverse Event 
See main section of the protocol for a description of the classification of an AE in terms of 
severity and causality. 
  
7.6.3 
Time Period and Frequency for Event Assessment and Follow-Up 
For Stage 2, adverse events will be collected during the following time periods: 
• Systemic and local solicited adverse events will be collected from Day 1 through Day 8, 
and Day 29 through Day 36. However, participants with ongoing systemic and/or local 
reactogenicity at Day 8 or Day 36 visit, will be asked to measure erythema/redness and/or 
induration/swelling until it has resolved, if applicable, and record end date of all other signs 
and symptoms. 
• Unsolicited adverse events will be collected from Day 1 through Day 57. 
• For Stage 2, all SAEs will be collected from Day 1 through Day 394 (i.e., the end of study). 
Protocol specified AESIs, and related MAAEs will be collected from Day 1 through 210. 
 
All AEs, related MAAEs, protocol specified AESIs, and SAEs will be followed through resolution 
or until the site investigator deems the event to be chronic or the participant is stable. 
 
7.6.4 
Adverse Event Reporting 
See the main section of the protocol for a description of AE reporting. 
 
7.7 
Unanticipated Problems 
See the main section of the protocol for a definition of Unanticipated Problems (UP) and 
information regarding UP reporting. 
 
8. 
STATISTICAL CONSIDERATIONS 
8.1 
Statistical Hypotheses 
 
Stage 2 will test non-inferiority of the 1 x 108 TCID50 MVA-BN SC regimen (standard dose 
regimen) in adolescents compared to adults.  
 
Primary Hypothesis  
• At Day 43 the humoral immune response of the 1 x 108 TCID50 MVA-BN SC (standard 
dose regimen) in adolescents will be non-inferior to the standard 1 x 108 MVA-BN SC 
regimen in adults, as assessed by PRNT GMT.  
  
Secondary Hypotheses 

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• At Day 394 the humoral immune response of the 1 x 108 TCID50 MVA-BN SC regimen in 
adolescents will be non-inferior to the standard 1 x 108 TCID50 MVA-BN SC regimen in 
adults, as assessed by PRNT GMT. 
• The humoral immune response of the 1 x 108 TCID50 MVA-BN SC regimen in adolescents, 
as assessed by PRNT GMT, will be similar to the 1 x 108 TCID50 MVA-BN SC regimen in 
adults at all study days.  
• The humoral immune response of the 1 x 108 TCID50 MVA-BN SC regimen in adolescents 
as assessed by vaccinia specific PRNT half-life, will be similar to the 1 x 108 TCID50 MVA-
BN SC regimen in adults.  
• The humoral immune response of the 1 x 108 TCID50 MVA-BN SC regimen in adolescents, 
as assessed by monkeypox specific PRNT GMT, will be similar to the 1 x 108 TCID50 
MVA-BN SC regimen in adults at Day 1 and 43.  
8.2 
Sample Size Determination 
As a primary endpoint in Stage 2, 500 participants (130 adults in Arm 4; 70 adults in Arm 3 (Stage 
1); 300 adolescents in Arm 5) will provide approximately 92% power for a test of non-inferiority 
of geometric mean titers using unequal variances and two-sided, type I error of 0.05 (Table 4). 
This assumes that the adult arm will have a standard deviation of 0.6 and adolescent arm will have 
a standard deviation of 0.5. The standard deviation on Day 42 in prior large studies using the SC 
route was 0.41 (Pittman, NEJM 2019) and 0.59 (Frey, Vaccine 2015), so the estimates used in 
calculations are justifiable (Table 5 and Table 6). Stage 2 will enroll approximately 450 
participants (135 adults in Arm 4; 315 adolescents in Arm 5) assuming a 5% drop-out rate. 
Participant enrollment into the adolescent cohort will be stratified into two 3-year age groups, at 
least 78, adolescents ages 12 to 14 years and a maximum of 237, adolescents ages 15 to 17 years, 
in order to ensure that adequate numbers of younger adolescents are enrolled (i.e., about 25% of 
all adolescents enrolled). Arms 3 and 4 will be combined as a comparator group in the primary 
analysis. It is not anticipated that there will be significant differences in immunogenicity outcomes 
between these two groups, however, a sensitivity analysis excluding Arm 3 participants will be 
performed, and will be described in the statistical analysis plan (SAP).  
 
Table 4: Power Calculation 
Power calculations for a non-inferiority test of means using unequal variances and two-sided type 
one error rate of 0.05. Non-inferiority margin of 0.67. 
NI Margin  
 
Sample Size 
Arm 5 
(Standard 
Deviation 
0.5) 
Sample Size 
Arm 3+4 
(Standard 
Deviation 0.6) 
 
  
Total sample size 
for NI test 
Power 
0.67  
Log10(0.67) =-0.174 
300 
200 
500 
0.92 
 
Table 5: Standard Deviation Estimates  
Standard deviation estimates computed from Table S4 of Pittman et al, 201944 
  
MVA-BN 
ACAM2000 
Ratio of 
GMTs 
95% CI 
Week 
N 
GMT 
95% CI 
SD 
N 
GMT 
95% CI 
SD 

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 (for 
log10 
GMT) 
 (for 
log10 
GMT) 
  
2 
184 
16.2 
[13.0, 20.1] 
0.65 
184 
16.2 
[13.1, 20.0] 
0.63 
0.997 
[0.738, 1.348] 
4 
185 
16.9 
[13.7, 20.8] 
0.63 
186 
79.3 
[67.1, 93.8] 
0.51 
0.213 
[0.163, 0.278] 
6 
185 
153.5 
[134.3, 175.6] 
0.41 
181 
64.7 
[54.9, 76.2] 
0.49 
2.372 
[1.922, 2.928] 
8 
179 
118.2 
[102.9,135.8] 
0.41 
183 
67.1 
[56.9, 79.0] 
0.49 
1.763 
[1.422, 2.185] 
Peak 
185 
153.5 
[134.3, 175.6] 
0.41 
186 
79.3 
[67.1, 93.8] 
0.51 
1.935 
[1.562, 2.397] 
 

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Table 6: Standard Deviation Estimates  
Standard deviation estimates computed from Frey et al, 201521 
Study visit day 
Liquid SC 1x108 
N=149 
Liquid ID 2x107 
N=146 
 
VV-WR GMT [95% CI] 
SD 
VV-WR GMT [95% CI] 
SD 
Day 14 
10.0 [9.0, 11.1] 
0.28 
10.3 [9.3, 11.3] 
0.27 
Day 28 
9.6 [8.7, 10.6] 
0.27 
10.8 [9.9, 11.9] 
0.23 
Day 42 
45.2 [36.4, 56.2] 
0.59 
54.4 [43.7, 67.8] 
0.59 
Peak post 2nd vaccination 
49.5 [40.0, 61.3] 
0.58 
59.6 [48.1, 74.0] 
0.59 
 
 
8.3 
Statistical Analyses 
8.3.1 
General Methodology 
For Stage 2, the non-inferiority of adolescent immune response relative to adult immune response 
will be determined using a non-inferiority (NI) margin of 0.67 (NI=-0.174 log10 scale).  No 
stepwise testing will be done in Stage 2.  The primary safety endpoint is descriptive with no 
hypothesis testing planned. 
 
8.3.2 
Timing of Analyses 
8.3.2.1 
Interim Safety Analyses 
AEs and SAEs may be reviewed as necessary outside of DSMB reviews. The DSMB may not need 
to meet (unless halting rules are met) and materials will be provided electronically. Documentation 
of review and any concerns noted will be solicited electronically. 
 
The DSMB will review separate cumulative AE data reports for all participants within each arm. 
Given the safety database known for authorized/approved vaccines, there is no routine mandatory 
review by the DSMB unless halting rules are triggered.  
 
8.3.2.2 
Interim Immunogenicity Analyses 
For Stage 2, interim immunogenicity analyses may be conducted and will include at least an 
analysis of Vaccinia virus specific PRNT GMT at Day 1 and 43 and Monkeypox virus specific 
PRNT GMT at Day 1 and 43. 
 
Data may be disseminated to public health officials and partners as needed and included 
in publications and presentations to inform the global scientific community. 
 
 
8.3.2.3 
Final Analyses  
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Clinical Study Report (CSR), including an analysis of immunogenicity through Day 43 and safety 
through Day 210, will be produced to inform public health needs. The interim CSR will be 
prepared once all participants have completed the Day 210 visit and all of the relevant data have 
been cleaned and the database has been locked. The results in the interim CSR will be considered 
final for all immunogenicity endpoints through Day 43 and the clinical and safety endpoints 
followed up to Day 210. Any SAEs or study withdrawals occurring after Day 210, along with 
results from the analysis of outstanding immunogenicity data, will be detailed in an addendum to 
the CSR after the study is complete.  
 
Results from the interim CSR and the subsequent CSR addendum will be disseminated to public 
health officials and partners as needed and included in publications and presentations to inform the 
global scientific community. 
 
8.3.3 
Populations for Analyses 
There will be three analysis populations in this study. The safety analysis population includes all 
enrolled participants who received at least one dose of study vaccine. Analyses for the safety 
population will include safety reported through the end of the study. The modified intent-to-treat 
(mITT) population includes all participants who received at least one dose of vaccine and 
contributed both pre- and at least one post-vaccination venous blood sample for immunogenicity 
testing for which valid results were reported. 
 
In the final analysis, protocol deviations will be reviewed to determine which protocol deviations 
may affect the analysis. The per protocol (PP) population will then be defined – and this includes 
all participants in the mITT subset with the following exclusions: 
• Data from all available visits for participants found to be ineligible at baseline. 
• Data from all visits after the protocol deviations that are considered to affect the science 
(as determined by the sponsor at an ad hoc meeting). 
• Data from any visit that occurs substantially out of window. 
 
For the PP and mITT analyses, participants will be analyzed according to the study product that 
they received. 
 
8.3.4 
Baseline Characteristics and Participant Disposition 
Summaries of demographic characteristics of the study population including age, sex, ethnicity, 
and race will be presented by vaccination arm and overall. In addition, this descriptive analysis 
will be done by reported HIV infection status.  
 
8.3.5 
Immunogenicity Analyses 
Descriptive summaries of immunogenicity data will be presented for the mITT population. If there 
are protocol deviations which may affect the analysis, a PP analysis may also be performed. 
 
Geometric Mean Titers (GMT) and Geometric Mean Fold Rise (GMFR) from baseline of VV-WR 
PRNT will be calculated, along with 95% CIs, for all groups, at each timepoint. Summaries will 

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also be displayed graphically. Geometric Mean Titer Ratio, defined as the ratio of each ID arm to 
the control SC arm, will also be reported at each timepoint, along with 95% CIs.  
There are no imputations planned for missing data. 
 
A SAP for Stage 2 will be developed and will detail the full planned analysis. 
 
8.3.6 
Safety Analyses 
In Stage 2 of this study, the safety outcomes for the two study arms will be evaluated including 
systemic reactogenicity for 7 days after each vaccination, local reactogenicity for 7 days after each 
vaccination, and unsolicited adverse events for 28 days after each vaccination. In Stage 2, protocol 
specified AESIs, and related MAAEs will be evaluated from Day 1 through Day 210. All SAEs 
will be evaluated from Day 1 through Day 394 or the end of the study (see SOA). 
  
8.3.6.1 
Reactogenicity 
The number, percentage (observed rate) and exact two-sided 95% CI for participants reporting 
each solicited local (injection site) reaction and solicited systemic reaction following vaccination 
will be summarized by study arm after first and second vaccination, and overall (i.e., after any 
vaccination). In addition, the most severe local and systemic reactions recorded during the follow-
up period (i.e., maximum severity) for each participant will be determined and summarized by 
study arm following each vaccination (as well as overall) and the resulting number and percentage 
of participants will be summarized by severity grade (none, mild, moderate, severe, life-
threatening). Last, the daily severity of local and systemic reactions will be determined for each 
participant and the proportion of participants having a sign/symptom each day will summarized 
by grade and presented by study arm following each vaccination. Rates for any severe (Grade 3 or 
4) solicited local or systemic reaction following any vaccination will be compared between study 
arms. 
  
8.3.6.2 
Other Adverse Events 
The number of associated unsolicited AEs, protocol specified AESIs (Stage 2 only), MAAEs and 
SAEs following vaccine administration is expected to be small. A complete listing of all events 
will therefore be provided, including the nature of the event, timing relative to vaccination, 
severity, duration, and the investigator’s assessment of the likely relationship to vaccination. For 
each type of AE, the observed rate and exact two-sided confidence intervals will be computed for 
each study arm and listed by toxicity grade. AEs will be MedDRA® coded for preferred term and 
system organ class. Event rates and exact 95% confidence intervals for each study arm and the 
entire study cohort will be presented, in aggregate and by MedDRA® categories. Related 
unsolicited AE, protocol specified AESI (Stage 2 only), MAAE and SAE rates will be compared 
between the study arms. 
  
The number, percentage (observed rate) for participants that withdrew or discontinued their 
vaccination series due to safety or reactogenicity events will be tabulated. Rates of 
withdrawal/discontinuation will be compared between study arms using Fisher’s exact test.  
  
Refer to the SAP for additional information. 

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9. 
SUPPORTING DOCUMENTATION AND OPERATIONAL 
CONSIDERATIONS 
9.1 
Regulatory, Ethical, and Study Oversight Considerations 
This study will be conducted in conformity with the principles set forth in The Belmont Report: 
Ethical Principles and Guidelines for the Protection of Human Participants of Research (US 
National Commission for the Protection of Human Participants of Biomedical and Behavioral 
Research; April 18, 1979), and the federal policy for the Protection of Human Participants codified 
in 45 CFR Part 46, 21 CFR Part 50 (Protection of Human Participants), and the ICH E6(R2). 
 
An OHRP-registered IRB will review and approve this protocol, associated informed consent, 
parental permission and assent documents, recruitment materials, and handouts or surveys 
intended for the participants, prior to the recruitment, screening and enrollment of participants. 
The IRB review shall be in accordance with 45 CFR 46 and 21 CFR 50, 21 CFR 56 (IRBs), and 
other federal, state, and local regulations and policies, as applicable. 
 
Each institution engaged in this research will hold a current Federalwide Assurance (FWA) issued 
by the Office for Human Research Protections (OHRP) for federally funded research. and provide 
the FWA number to DMID. Each site principal investigator will obtain IRB approval for this 
protocol and any amendments to be conducted at his/her research site(s).  
 
Any amendments to the protocol or informed consent, parental permission and assent documents 
will be approved by the IRB before they are implemented. IRB review and approval will occur at 
least annually throughout enrollment and follow-up of participants, in accordance with applicable 
regulations and the requirements of the IRB/IEC. The participating site PI will notify the IRB of 
deviations from the protocol and reportable SAEs, as applicable to the IRB policy. 
 
DMID must receive the documentation that verifies IRB/IEC approval for this protocol, informed 
consent, parental permission and assent documents and associated documents, prior to the 
recruitment, screening and enrollment of participants, and any IRB approvals for continuing 
review or amendments as required by DMID. 
  
9.1.1 
Informed Consent Process 
Informed consent is a process that is initiated prior to an individual agreeing to participate in a trial 
and continuing throughout the individual’s trial participation. Before any study procedures are 
performed, informed consent or parental permission and assent, where appropriate, will be 
obtained and documented. This research can be categorized as greater than minimal risk but 
presenting the prospect of direct benefit to the participant (45 CFR 46.405) given that MPXV may 
continue to cause disease in the U.S. in 2023.  Given this, permission of one parent is sufficient 
for the adolescent participant.  
 
Participants and the adolescent participant’s parent or LAR will receive a concise and focused 
presentation of key information about the clinical trial, that includes both a verbal discussion as 

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well as written documentation. The key information about the purpose of the study, the procedures 
and experimental aspects of the study, study interventions/products, risks and discomforts, the 
expected duration of the participant’s participation in the trial, any expected benefits to the 
participant, and alternative treatments and procedures that may be available to the participant. The 
explanation will be organized and presented in lay terminology and language that facilitates 
understanding why one might or might not want to participate, why one might or might not want 
to allow one’s adolescent to participate or, in the case of assenting minors, why they themselves 
might or might not want to participate. 
 
Participants and the adolescent participant’s parent or LAR will receive an explanation as to 
whether any compensation and any medical treatments are available if injury occurs, and, if so, 
what they consist of, or where further information may be obtained. Participants and the adolescent 
participant’s parent or LAR will be informed of the anticipated financial expenses, if any, to the 
participant for participating in the trial, as well as any anticipated prorated payments, if any, to the 
participant for participating in the trial. They will be informed of whom to contact (e.g., the 
investigator) for answers to any questions relating to the research project. Information will also 
include the foreseeable circumstances and/or reasons under which the participant’s participation 
in the trial may be terminated. The participants and the adolescent participant’s parent or LAR will 
be informed that participation is voluntary and that they are free to withdraw from the study for 
any reason at any time without penalty or loss of benefits to which the participant is otherwise 
entitled.  
 
Participants and the adolescent participant’s parent or LAR will be informed that records 
identifying the participant will be kept confidential, and, to the extent permitted by the applicable 
laws and/or regulations, will not be made publicly available and, if the results of the trial are 
published, the participant’s identity will remain confidential. Participants and the adolescent 
participant’s parent or LAR will be informed whether private information collected from this 
research and/or specimens will be used for additional research, even if identifiers are removed. 
They will be informed that the monitor(s), auditors(s), IRB, NIAID, and regulatory authority(ies) 
will be granted direct access to the participant’s original medical records for verification of clinical 
trial procedures and/or data without violating the confidentiality of the participant, to the extent 
permitted by the applicable laws and regulations, and that, by signing a written informed consent 
or assent form, the participant is authorizing such access. Participants and the adolescent 
participant’s parent or LAR will be allowed sufficient time to consider participation in this research 
trial and can discuss this trial with their family, friends or legally authorized representative, or 
think about it prior to agreeing to participate. 
 
Informed consent, parental permission and assent forms will be IRB-approved, and participants 
will be asked to read and review the consent or assent form. Participants must sign the informed 
consent or assent form, where appropriate, prior to starting any study procedures being done 
specifically for this trial. Once signed, a copy of the informed consent or assent form will be given 
to the participant and the adolescent participant’s parent or LAR for their records. 
 
New information will be communicated by the site principal investigator to participants who 
consent to participate in this trial in accordance with IRB requirements. The informed consent and 

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parental permission and assent documents will be updated, and participants will be re-consented 
per IRB requirements, if necessary.  
 
9.1.1.1 
Requirements for Permission by Parents/LARs and Assent by Children (in case 
of a minor)  
Stage 2 of this study will enroll participants ages 12 to 17 years. Investigators or their designee 
will conduct the consent process with the parent or LAR, who will be given an IRB-approved 
permission form, which may be referred to as a consent form, to read, review, and sign prior to 
any study procedures. In addition, assent will be obtained in accordance with the approval by the 
site or central IRB. 
  
The participant who reaches the age of majority or becomes emancipated during the study will be 
consented at the next visit prior to study procedures being performed. When no further visits are 
planned but the participant’s participation is ongoing, the consent will be obtained via IRB-
approved processes. 
9.1.1.2 
Other Informed Consent Procedures 
Participants and the adolescent participant’s parent or LAR will be asked for consent and assent, 
where appropriate, to collect blood for the use of residual specimens and samples for secondary 
research. This extra/residual blood and corresponding serum will be used as back-up specimens 
for PP defined assays or designated for secondary research use and stored indefinitely at a 
designated storage facility. Collection of extra/residual samples during the study will help facilitate 
rapid follow-on analyses, if warranted, to provide more comprehensive scientific insights into the 
impact (safety and immunological) of the vaccine on the host response to vaccination. To maintain 
statistical power in follow-on analyses it is important that extra blood collection and secondary 
research use be included in as many participants as possible, due to the limited sample size per 
treatment arm. For this reason, if participants choose not to provide permission for extra blood and 
secondary research use, they will not be eligible for enrollment into the study.  
 
The stored samples will be labeled with barcodes to maintain confidentiality. Research with 
identifiable samples and data may occur as needed, however, participant confidentiality will be 
maintained as described for this protocol and with IRB approval. Samples designated for 
secondary research use may be used for additional immunological assessments that may include 
but are not limited to antibody epitope mapping, B and T cell repertoire determination, non-
traditional immune assay development, determination of innate immune factors and the ability of 
vaccine-induced antibodies to cross-react to different proteins and virus strains. These blood 
samples might be used in new or different immunological laboratory tests, to provide information 
for the development of new vaccines or therapeutics, or for the studies of monkeypox virus or 
other related viruses. Samples will not be sold for commercial profit. Although the results of any 
future research may be patentable or have commercial profit, participants will have no legal or 
financial interest in any commercial development resulting from any future research. There are no 
direct benefits to the participant for extra specimens collected or from the secondary research. No 
results from secondary research will be entered into the participant’s medical record. Incidental 
findings will not be shared with the participant, including medically actionable incidental findings, 
unless required by law.  
 

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Risks are associated with the additional volume of blood collected, such as anemia. Risks for loss 
of privacy and confidentiality are described below. Participants may withdraw permission to use 
samples for secondary use at any time. They will need to contact the participating site and the 
samples will be removed from the study repository after this study is completed and documentation 
will be completed that outlines the reason for withdrawal of permission for secondary use of 
samples. Participants who withdraw consent before the last visit will not have the extra blood 
drawn for secondary use.  
 
Participants will be asked to consent specifically on primary and secondary research samples. The 
consent process will include an explanation of the potential risks to the individual participants 
associated with data submitted to an NIH data repository and subsequent sharing. Data that may 
potentially identify human participants will not be released in unrestricted databases. Participants 
will be informed that analytical methods are associated with the risk of re-identification, even 
when specimens are de-identified. The consent will include whether individual participant data 
will be shared through a NIH controlled access data repository. 
 
9.1.2 
Study Termination and Closure 
Section 7, Study Intervention Discontinuation and Participant Discontinuation/Withdrawal, 
describes the temporary halting of the study. This study may be prematurely terminated if there is 
sufficient reasonable cause, including but not limited to: 
• Determination of unexpected, significant, or unacceptable risk to participants 
• Results of interim efficacy or futility analysis  
• Insufficient compliance to protocol requirements 
• Data that are not sufficiently complete and/or evaluable 
• Regulatory authorities’ determination 
• Sponsor’s determination 
 
If the study is prematurely terminated, the Principal Investigator (PI) will promptly inform study 
participants and the IRB  and regulatory authorities as applicable. Study participants will be 
contacted, as applicable, and be informed of changes to study visit schedule. The PI will assure 
appropriate follow-up for the participants, as necessary. The sponsor will notify regulatory 
authorities as applicable.  
  
9.1.3 
Confidentiality and Privacy 
Participant confidentiality is strictly held in trust by the participating investigators, their staff, and 
the sponsor(s) and their agents. This confidentiality is extended to cover clinical information 
relating to participants, test results of biological samples and genetic tests, and all other 
information generated during participation in the study. No identifiable information concerning 
participants in the study will be released to any unauthorized third party. Participant confidentiality 
will be maintained when study results are published or discussed in conferences.  
  
The study monitor, other authorized representatives of the sponsor, representatives of the 
Institutional Review Board (IRB), and/or regulatory agencies may inspect all documents and 
records required to be maintained by the investigator, including but not limited to, medical records 

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(office, clinic, or hospital) and pharmacy records for the participants in this study. The clinical 
study site will permit access to such records. 
 
All source records including electronic data will be stored in secured systems in accordance with 
institutional policies and federal regulations. All study data and research specimens that leave the 
site (including any electronic transmission of data) will be identified only by a coded number that 
cannot be linked to a participant. 
 
As this research is funded by the NIH, it is covered by NIH policy which effectively issues the 
research a Certificate of Confidentiality. By this policy, researchers cannot be forced to disclose 
or provide, in any Federal, State, or local civil, criminal, administrative, legislative, or other 
proceeding, the name of such individual or any such information, document, or biospecimen that 
contains identifiable, sensitive information about the individual and that was created or compiled 
for purposes of the research, unless such disclosure or use is made with the consent of the 
individual to whom the information, document, or biospecimen pertains. 
 
The Certificate cannot be used to resist a demand for information from personnel of the United 
States Government that is used for auditing or evaluation of federally funded projects, like this 
study, or for information that must be released in order to meet the requirements of the FDA. 
 
A Certificate of Confidentiality does not prevent the participant from voluntarily releasing 
information about themselves or their involvement in this research. If any person or agency obtains 
a written consent to receive research information, then the researchers may not use the Certificate 
to withhold that information.  
 
The Certificate of Confidentiality does not prevent the researchers from reporting without the 
participant’s consent, information that would identify the participant as a participant in the research 
project regarding matters that must be legally reported including child and elder abuse, sexual 
abuse, or wanting to harm themselves or others. 
  
The release of individual private information or specimens for other research will only occur if 
consent was obtained from the individual or the parent(s) or LAR of the adolescent participants to 
whom the information, document, or biospecimen pertains, or for the purposes of other research 
that the release is in compliance with applicable Federal regulations governing the protection of 
human participants in research.  
 
9.1.4 
Secondary Use of Stored Specimens and Data  
 
9.1.4.1 
Samples for Secondary Research 
Repository Research Sample 
To participate in this study, participants and the parent or LAR of adolescent participants will be 
asked for consent for storage of samples for secondary use. Samples will be stored indefinitely at 
a DMID-designated storage facility. Each sample will be encoded (labeled) only with a barcode 
and a unique tracking number to protect participant confidentiality. Secondary research with coded 

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samples and data may occur, however, participant confidentiality will be maintained as described 
for this protocol. An IRB review of the secondary research using coded specimens is required. 
 
Repository Research Samples, upon written request and approval from DMID and any approvals 
required by the site, may be shared for secondary research with investigators at the participating 
site, with researchers at other sites or other institutions, or company-designated research 
laboratories. The samples will not be sold or used directly for production of any commercial 
product. DMID will authorize shipment from the repository. 
 
Reports from secondary research will not be kept in the participants’ health records or shared with 
participants, unless required by law. Reports will not be sent to the specimen repository. The 
participant’s decision for secondary research can be changed at any time by notifying the study 
doctors or nurses in writing. If the participant changes his/her decision, the samples will be 
destroyed if the samples have not been used for research or released for a specific research project. 
9.1.4.2 
Data Sharing for Secondary Research 
Data from this study may be used for secondary research. Individual participant data collected 
during the trial that are sufficient to reanalyzed primary and secondary endpoints will be made 
available after deidentification. The SAP and Analytic Code will also be made available. This data 
will be available following publication, with no end date. The data will be made available to 
researchers who provide a methodologically sound proposal. The data will be available for any 
purpose outlined in the approved proposal. Proposals should be directed to DMID. To gain access, 
data requestors will need to sign a data access agreement. The investigator may request removal 
of data on individual study participants from NIH data repositories in the event that a research 
participant withdraws or changes his or her consent. However, data that have been distributed for 
approved research use cannot be retrieved. 
 
9.1.5 
Key Roles and Study Governance 
This is a multi-site clinical trial and as such, all study team members and roles are listed in the 
Manual of Procedures (MOP). 
9.1.6 
Safety Oversight 
Safety oversight will be conducted by a DSMB that is an independent group of experts that 
monitors participant safety and advises DMID. The DSMB members will be separate and 
independent of study personnel participating in this trial and should not have scientific, financial 
or other conflict of interest related to this trial. The DSMB will consist of members with 
appropriate expertise to contribute to the interpretation of the data from this trial. The DSMB will 
operate under the rules of a DMID-approved charter that will be written at the organizational 
meeting of the DSMB. Procedures for DSMB reviews/meetings will be defined in the charter. 
Reports may include enrollment and demographic information and solicited and unsolicited 
AE/SAEs. The DSMB will review SAEs on a regular basis and ad hoc during this trial. The DMID 
Medical Monitor will be responsible for reviewing SAEs in real time.  
 
For Stage 2 of the study, the DSMB will conduct the following reviews: 
• Approximately 115 to 130 days after the study start. Given the planned 8 to 10-week 
enrollment period, and second dose of vaccine given on day 29, the window for review in 

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Stage 2 was extended. As such, the review will focus on AEs utilizing real time reports 
where able.  
• Ad hoc meeting:  
o When trial-level halting criteria are met 
o At the request of DMID to review a potential safety concern identified in the trial.  
• Interim and final data will be shared with the DSMB, but the DSMB does not need to meet 
to review the final data. 
 
Additional data may be requested by the DSMB. The DSMB may receive data in aggregate and 
presented by treatment arm. The DSMB may also be provided with expected and observed rates 
of the expected AEs in an unblinded fashion. As an outcome of each review/meeting, the DSMB 
will make a recommendation as to the advisability of proceeding with study interventions (as 
applicable), and to continue, modify, or terminate this trial. 
 
The DSMB will operate under the rules of a DMID-approved charter that will be written at the 
organizational meeting of the DSMB. At this time, each data element that the DSMB needs to 
assess will be clearly defined. Procedures for DSMB reviews/meetings will be defined in the 
charter. The DSMB will review applicable data to include, but not limited to, study progress and 
participant, clinical, safety and safety related data. Reports may include enrollment and 
demographic information, medical history, concomitant medications, physical assessments, 
clinical laboratory values, dosing compliance, and solicited and unsolicited AE/SAEs. 
 
DMID or the DSMB chair may convene the DSMB on an ad hoc basis according to protocol 
criteria or if there are immediate concerns regarding observations during the course of this trial. 
The DMID Medical Monitor is empowered to stop enrollment and study product administration if 
AEs that meet the halting criteria are reported. The DMID Medical Monitor will be responsible 
for reviewing SAEs in real time. The DSMB will review SAEs on a regular basis and ad hoc during 
this trial. 
9.1.7 
Clinical Monitoring 
Clinical site monitoring is conducted to ensure that the rights and well-being of trial participants 
are protected, that the reported trial data are accurate, complete, and verifiable. Clinical Monitoring 
ensures that the conduct of the trial is in compliance with the currently approved 
protocol/amendment(s), International Council for Harmonisation (ICH), Good Clinical Practice, 
and with applicable regulatory requirement(s) and sponsor requirements.  
 
Monitoring for this study will be overseen by NIAID/DMID and conducted by NIAID/DMID 
contractors. Details of clinical site monitoring are documented in a Clinical Monitoring Plan 
(CMP). The CMP describes in detail who will conduct the monitoring, at what frequency 
monitoring will be done, at what level of detail monitoring will be performed, and the distribution 
of monitoring reports. Monitoring visits will include, but are not limited to, review of regulatory 
files, investigational product administration and accountability records, eCRFs, informed consent, 
parental permission and assent forms, medical and laboratory reports, site study storage records, 
training records, and protocol and GCP compliance. Site monitors will have access to each 
participating site, study personnel, and all study documentation according to the NIAID or DMID-
approved site monitoring plan.  Study monitors will meet with site principal investigators (or 

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designee) to discuss any problems and outstanding issues and will document site visit findings and 
discussions.  
 
9.1.8 
Quality Assurance and Quality Control 
Quality control (QC) and quality assurance (QA) activities are essential to the safety of 
participants, and the reliability of study data. Each site participating in the study is responsible for 
integrating quality control checks throughout the study and implementing a QA Checklist or 
Clinical Quality Management Plan (CQMP). The site will conduct the following:  
 
4. Routine internal QC and QA activities for the purposes of measuring, documenting and 
reporting study conduct, protocol adherence, human participants’ protections, and 
reliability of the protocol-driven data collected.  
5. Processes for addressing data quality issues (i.e., collecting, recording), and reporting 
findings in a timely manner.  
6. Identify systemic issues (e.g., protocol or human participant protections non-compliance), 
and implementation and evaluation of Corrective and Preventative Action Plan (CAPA) 
procedures, if applicable. 
 
9.1.9 
Data Handling and Record Keeping 
9.1.9.1 
Data Collection and Management Responsibilities 
Data collection is the responsibility of the clinical trial staff at the site under the supervision of the 
site investigator. The investigator is responsible for ensuring the accuracy, completeness, 
legibility, and timeliness of the data reported. All source documents should be completed in a neat, 
legible manner to ensure accurate interpretation of data.  
 
9.1.9.2 
Data Coordinating Center / Biostatistician Responsibilities 
The data coordinating center for this study will be responsible for data management, quality 
review, analysis, and reporting of the study data. Adverse events and medical history will be coded 
according to the MedDRA dictionary. Concomitant medications will be coded according to the 
WHO Drug dictionary. At the end of the study, a copy of all datasets including annotated case 
report forms and data dictionary will be provided to DMID.  
 
A separate Study Data Standardization Plan (SDSP) will be developed which describes the 
technical recommendations for the submission of human study data and related information in a 
standardized electronic format throughout product development. 
 
9.1.9.3 
Data Capture Methods 
Clinical research data, including, but not limited to, AE/SAEs, concomitant medications, medical 
history, physical assessments will be abstracted from the source documentation and/or collected 
on source document worksheet by study personnel then entered into an eCRFs via a 21 CFR Part 
11-compliant internet data entry system provided by the study data coordinating center. The data 
system includes password protection and internal quality checks, such as automatic range checks, 
to identify data that appear inconsistent, incomplete, or inaccurate.  

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The IND Sponsor is responsible for review of data collection tools and processes, and review of 
data and reports. 
 
Study data will be collected on paper CRFs and then entered into the eCRF or data will be entered 
directly into the eCRF.  
  
9.1.9.4 
Study Record Retention 
Study related records, including the regulatory file, study product accountability records, consent, 
parental permission and assent forms, participant source documents and electronic records should 
be maintained for a minimum period of 2 years following the date a marketing application is 
approved for the investigational product for the indication for which it is being investigated; or, if 
no application is to be filed or if the application is not approved for such indication, until 3 years 
after the investigation is discontinued and FDA is notified. These documents should be retained in 
compliance with all federal and local regulations and institutional policies; which may be longer. 
No records will be destroyed without the written consent of DMID. Consent and assent forms with 
specimen retention linked to identifiable specimens will be maintained for as long as the specimens 
remain in identifiable format, and a minimum of three years after use of the identifiable specimens 
in nonexempt human participant research. 
 
9.1.9.5 
Source Records 
Source data are all information, original records of clinical findings, observations, or other 
activities documented in a clinical trial necessary for the reconstruction and evaluation of the trial. 
Each participating site will maintain appropriate medical and research records for this trial, in 
compliance with ICH GCP, regulatory, and institutional requirements. Data recorded in the 
electronic case report form (eCRF) derived from source documents should be consistent with the 
data recorded on the source documents. Data entered directly into the eCRFs will be considered 
the source document. All source documents should be completed in a neat, legible manner to 
ensure accurate interpretation of data.  
 
Interview of participants is sufficient for obtaining medical history. Solicitation of medical records 
from the participant’s primary care provider is not required. 
 
9.1.10 
Protocol Deviations 
A protocol deviation is any noncompliance with the clinical trial protocol, any process that is noted 
in the protocol and refers to details in the MOP, or GCP requirements.  
 
The noncompliance may be either on the part of the participant, the investigator, or the study site 
staff. Following a deviation(s), corrective actions should be developed by the site and implemented 
promptly. All individual protocol deviations will be addressed in participant study records.  
 
It is the responsibility of the site principal investigator and personnel to use continuous vigilance 
to identify and report deviations within five working days of identification of the protocol 
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must be promptly reported to DMID per the protocol deviation reporting procedures. Protocol 
deviations must be sent to the local IRB/IEC per their guidelines. The site principal investigator 
and personnel are responsible for knowing and adhering to their IRB requirements.  
 
9.1.11 
Publication and Data Sharing Policy 
9.1.11.1 
Human Data Sharing Plan 
All NIH protocols are required to have a Data Sharing Plan describe provisions for protecting the 
participants’ privacy and the confidentiality of the data. This study will be conducted in accordance 
with the following publication and data sharing policies and regulations: 
National Institutes of Health (NIH) Public Access Policy, which ensures that the public has access 
to the published results of NIH funded research. It requires scientists to submit final peer-reviewed 
journal manuscripts that arise from NIH funds to the digital archive PubMed Central upon 
acceptance for publication. 
 
As of January 2018, all clinical trials supported by the NIH must be registered on 
ClinicalTrials.gov, no later than 21 days after the enrollment of the first participant. Results of all 
clinical trials supported by the NIH, generally, need to be submitted no later than 12 months 
following the primary completion date. As part of the result posting, a copy of this protocol and a 
copy of the Statistical Analysis Plan will be posted on ClinicalTrials.gov.  
 
9.1.11.2 
Genomic Data Sharing Plan 
Not Applicable. 
 
9.1.11.3 
Publication 
This study will comply with the NIH Public Access Policy, which ensures that the public has 
access to the published results of NIH funded research. As such, the final peer-reviewed journal 
manuscripts will be accessible to the public on PubMed Central no later than 12 months after 
publication. 
 
9.1.12 
Conflict of Interest Policy 
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical. Therefore, any actual conflict of interest of persons who have 
a role in the design, conduct, analysis, publication, or any aspect of this trial will be disclosed and 
managed. Furthermore, persons who have a perceived conflict of interest will be required to have 
such conflicts managed in a way that is appropriate to their participation in the design and conduct 
of this trial. DMID has established policies and procedures for all study group members to disclose 
all conflicts of interest and will establish a mechanism for the management of all reported dualities 
of interest. 
 
9.2 
Additional Considerations 
9.2.1 
Research Related Injuries 

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For any potential research related injury, the site principal investigator or designee will assess the 
participant. The site principal investigator should then determine if an injury occurred as a direct 
result of the tests or treatments that are done for this trial. As needed, referrals to appropriate health 
care facilities will be provided to the participant. No financial compensation will be provided by 
the NIAID, NIH, or the federal government to the participant, for any injury suffered due to 
participation in this trial. 
 
9.2.2 
PREP Act 
The study vaccine and the efforts for this clinical trial are covered under the Public Readiness and 
Emergency Preparedness Act (PREP Act). The PREP Act applies under the terms of the PREP 
Act declaration in place for smallpox/orthopoxvirus countermeasures for activities conducted 
pursuant 
to 
federal 
agreements 
or 
federal 
programs 
(ref: 
www.federalregister.gov/documents/2015/12/09/2015-31092/smallpox-medical-
countermeasures-amendment). JYNNEOS is used under an IND for mpox pursuant to a federal 
agreement/program and is therefore covered under the PREP Act. The PREP Act covers persons 
(such as manufacturers, distributers, program planners, and other qualified persons who prescribe, 
administer or dispense study product) are immune from liability from the administration, or use of 
a covered countermeasure, such as JYNNEOS. The PREP Act provides immunity for covered 
persons from liability, unless the injury was caused by willful misconduct.  
 
The PREP Act also established the Countermeasures Injury Compensation Program (CICP) to 
provide compensation for serious injuries or death that occur as the direct result of the 
administration or use of certain countermeasures. Any requests for compensation must be filed 
within one year of the administration or use of the covered countermeasure. Requests for Benefits 
must be made to the Health Resources and Services Administration’s (HRSA) Countermeasures 
Injury Compensation Program (http://www.hrsa.gov/cicp/) by filing a Request for Benefits Form 
and all required medical records and supporting documentation. Additional information on filing 
a Request for Benefits is available on the CICP’s website at http://www.hrsa.gov/cicp/. 
Compensation may then be available for reasonable and necessary medical benefits, lost wages 
and/or death benefits to eligible individuals for certain injuries in accordance with regulations 
published by the Secretary of HHS (found at 42 CFR part 110). 
 
If an individual suffers a serious physical injury or death from the administration or use of a 
covered countermeasure in this study, the individual, the individual’s legal or personal 
representative, the administrator/executor of a deceased individual’s estate, or certain survivors 
may request benefits from the CICP. A serious physical injury means an injury that warranted 
hospitalization (whether or not the person was actually hospitalized) or that led to a significant loss 
of function or disability. The CICP is the payer of last resort. This means that it only covers 
expenses or provides benefits that other third-party payers (such as health insurance, the 
Department of Veterans Affairs, or Workers’ Compensation programs) do not have an obligation 
to pay. 
 
If the Secretary of HHS does not make a final determination on the individual’s request within 240 
days, or if the individual decides not to accept the compensation, the injured individual or his 
representative may pursue a tort claim in the US District Court for the District of Columbia, but 
only if the claim involves willful misconduct and meets the other requirements for suit under the 

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PREP Act. Any award is reduced by any public or private insurance or worker’s compensation 
available to the injured individual. Awards for non-economic damages, such as pain, suffering, 
physical impairment, mental anguish, and loss of consortium are also limited. If the individual 
accepts compensation, or if there is no willful misconduct, then the individual does not have a tort 
claim that can be filed in a US Federal or a State court. 
 
 

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10. 
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