A Phase 2 Randomized, Open-Label, Multisite Trial to Evaluate the Immunogenicity of Dose Reduction Strategies of the MVA-BN Vaccine
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 2.0 
 
 
22 September 2022 
 
 
DMID/NIAID/NIH 
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Page 1 of 59 
 
A Phase 2 Randomized, Open-Label, Multisite Trial to Evaluate the 
Immunogenicity of Dose Reduction Strategies of the MVA-BN Vaccine 
 
 
 
 
DMID Protocol Number: 22-0020 
 
Sponsor: Division of Microbiology and Infectious Diseases (DMID) 
 
Version Number: 2.0 
 
22 September 2022 
 
 
 

Protocol 22-0020 
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22 September 2022 
 
 
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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................................................................................................................................ 6 
LIST OF FIGURES .............................................................................................................................. 6 
1. 
PROTOCOL SUMMARY ........................................................................................................... 7 
1.1 
Synopsis ................................................................................................................................ 7 
1.2 
Schedule of Activities (SoA) ............................................................................................... 9 
1.3 
Study Schema ..................................................................................................................... 10 
2. 
Introduction................................................................................................................................. 10 
2.1 
Study Rationale .................................................................................................................. 10 
2.2 
Background......................................................................................................................... 10 
2.3 
Risk/Benefit Assessment ................................................................................................... 13 
2.3.1 
Known Potential Risks .............................................................................................. 13 
2.3.2 
Known Potential Benefits.......................................................................................... 16 
2.3.3 
Assessment of Potential Risks and Benefits ............................................................ 16 
3. 
OBJECTIVES AND ENDPOINTS .......................................................................................... 17 
4. 
STUDY DESIGN ....................................................................................................................... 18 
4.1 
Overall Design.................................................................................................................... 18 
4.2 
Scientific Rationale for Study Design .............................................................................. 18 
4.3 
Justification for Dose ......................................................................................................... 18 
5. 
STUDY POPULATION ............................................................................................................ 18 
5.1 
Inclusion Criteria ................................................................................................................ 19 
5.2 
Exclusion Criteria............................................................................................................... 19 
5.2.1 
Exclusion of Specific Populations ............................................................................ 20 
5.3 
Inclusion of Vulnerable Participants ................................................................................. 20 
5.4 
Lifestyle Considerations .................................................................................................... 21 
5.5 
Screen Failures ................................................................................................................... 21 
5.6 
Strategies for Recruitment and Retention ......................................................................... 21 
5.6.1 
Recruitment ................................................................................................................ 21 
5.6.2 
Retention .................................................................................................................... 22 
5.6.3 
Compensation Plan for Participants ......................................................................... 22 
5.6.4 
Costs ........................................................................................................................... 22 
6. 
STUDY PRODUCT ................................................................................................................... 22 
6.1 
Study Product(s) and Administration ............................................................................... 22 
6.1.1 
Study Product Description ........................................................................................ 22 
6.1.2 
Dosing and Administration ....................................................................................... 22 
6.1.3 
Dose Escalation.......................................................................................................... 23 

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6.1.4 
Dose Modifications.................................................................................................... 23 
6.1.5 
Criteria for Redosing ................................................................................................. 23 
6.2 
Preparation/Handling/Storage/Accountability ................................................................. 23 
6.2.1 
Acquisition and Accountability ................................................................................ 23 
6.2.2 
Formulation, Appearance, Packaging, and Labeling............................................... 24 
6.2.3 
Product Storage and Stability.................................................................................... 24 
6.2.4 
Preparation ................................................................................................................. 24 
6.3 
Measures to Minimize Bias: Randomization and Blinding ............................................. 25 
6.3.1 
Treatment Assignment Procedures ........................................................................... 25 
6.3.2 
Randomization ........................................................................................................... 25 
6.3.3 
Blinding and Masking Procedures ............................................................................ 25 
6.4 
Study Intervention Compliance ......................................................................................... 25 
6.5 
Concomitant Therapy ........................................................................................................ 25 
6.5.1 
Rescue Medicine ........................................................................................................ 26 
7. 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL ......................................................................................... 26 
7.1 
Halting Criteria and Discontinuation of Study Intervention ........................................... 26 
7.1.1 
Study Halting Criteria................................................................................................ 26 
7.1.1.1 
Sentinel Participant Halting Rules ........................................................................ 27 
7.1.1.2 
Cohort Halting Rules ............................................................................................. 27 
7.1.2 
Individual Halting Criteria ........................................................................................ 27 
7.1.3 
Follow up for participants that discontinued study intervention ............................ 27 
7.2 
Participant Withdrawal from the Study and Replacement .............................................. 28 
7.3 
Lost to Follow-Up .............................................................................................................. 29 
8. 
STUDY ASSESSMENTS AND PROCEDURES ................................................................... 29 
8.1 
Screening Procedures ......................................................................................................... 29 
8.1.1 
Procedures to be Followed in the Event of Abnormal Clinical Laboratory Test 
Values or Abnormal Clinical Findings During Screening ....................................................... 30 
8.1.2 
Sick Visit .................................................................................................................... 30 
8.2 
Immunogenicity Assessments ........................................................................................... 30 
8.2.1 
Immunogenicity/Efficacy Evaluations ..................................................................... 30 
8.2.2 
Exploratory Assessments .......................................................................................... 30 
8.3 
Safety and Other Assessments .......................................................................................... 30 
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...................................... 33 
8.4 
Adverse Events and Serious Adverse Events ................................................................... 33 
8.4.1 
Definition of Adverse Events (AE) .......................................................................... 33 
8.4.1.1 
Solicited Adverse Events ...................................................................................... 33 
8.4.1.2 
Unsolicited Events ................................................................................................. 34 
8.4.2 
Definition of Serious Adverse Events ...................................................................... 34 
8.4.2.1 
Definition of Suspected Unexpected Serious Adverse Reactions (SUSAR) ..... 34 
8.4.3 
Classification of an Adverse Event .......................................................................... 34 
8.4.3.1 
Severity of Event ................................................................................................... 35 
8.4.3.2 
Relationship to Study Intervention ....................................................................... 35 

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8.4.4 
Time Period and Frequency for Event Assessment and Follow-Up ...................... 35 
8.4.5 
Adverse Event Reporting .......................................................................................... 36 
8.4.5.1 
Investigators Reporting of AEs ............................................................................ 36 
8.4.5.2 
Special Reporting of Adverse Events ................................................................... 36 
8.4.6 
Serious Adverse Event Reporting ............................................................................. 36 
8.4.6.1 
Investigators Reporting of SAEs .......................................................................... 36 
8.4.6.2 
Regulatory Reporting of SAEs ............................................................................. 37 
8.4.7 
Reporting Events to Participants............................................................................... 38 
8.4.8 
Adverse Events of Special Interest (AESI) .............................................................. 38 
8.4.9 
Reporting of Pregnancy ............................................................................................. 38 
8.5 
Unanticipated Problems ..................................................................................................... 38 
8.5.1 
Definition of Unanticipated Problems (UP)............................................................. 38 
8.5.2 
Unanticipated Problem Reporting ............................................................................ 39 
8.5.3 
Reporting Unanticipated Problems to Participants .................................................. 39 
9. 
STATISTICAL CONSIDERATIONS ...................................................................................... 39 
9.1 
Statistical Hypotheses ........................................................................................................ 39 
9.2 
Sample Size Determination ............................................................................................... 40 
9.3 
Statistical Analyses ............................................................................................................ 42 
9.3.1 
General Methodology ................................................................................................ 42 
9.3.2 
Timing of Analyses ................................................................................................... 42 
9.3.2.1 
Interim Safety Analyses ........................................................................................ 42 
9.3.2.2 
Interim Immunogenicity Analyses ....................................................................... 42 
9.3.2.3 
Final Analyses........................................................................................................ 43 
9.3.3 
Populations for Analyses ........................................................................................... 43 
9.3.4 
Baseline Characteristics and Participant Disposition .............................................. 43 
9.3.5 
Immunogenicity Analyses ......................................................................................... 43 
9.3.6 
Safety Analyses.......................................................................................................... 44 
9.3.6.1 
Reactogenicity ....................................................................................................... 44 
9.3.6.2 
Other Adverse Events ............................................................................................ 44 
10. 
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS .... 44 
10.1 
Regulatory, Ethical, and Study Oversight Considerations .............................................. 44 
10.1.1 
Informed Consent Process......................................................................................... 45 
10.1.1.1 
Requirements for Permission by Parents/Guardians and Assent by Children 
(in case of a minor) ................................................................................................................ 46 
10.1.1.2 
Other Informed Consent Procedures ................................................................ 46 
10.1.2 
Study Termination and Closure ................................................................................ 47 
10.1.3 
Confidentiality and Privacy....................................................................................... 48 
10.1.4 
Secondary Use of Stored Specimens and Data ........................................................ 49 
10.1.4.1 
Samples for Secondary Research ..................................................................... 49 
10.1.4.2 
Data Sharing for Secondary Research ............................................................. 49 
10.1.5 
Key Roles and Study Governance ............................................................................ 50 
10.1.6 
Safety Oversight ........................................................................................................ 50 
10.1.7 
Clinical Monitoring ................................................................................................... 51 
10.1.8 
Quality Assurance and Quality Control ................................................................... 51 

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10.1.9 
Data Handling and Record Keeping ......................................................................... 52 
10.1.9.1 
Data Collection and Management Responsibilities ........................................ 52 
10.1.9.2 
Data Coordinating Center / Biostatistician Responsibilities .......................... 52 
10.1.9.3 
Data Capture Methods ...................................................................................... 52 
10.1.9.4 
Study Record Retention .................................................................................... 52 
10.1.9.5 
Source Records .................................................................................................. 53 
10.1.10 Protocol Deviations ................................................................................................... 53 
10.1.11 Publication and Data Sharing Policy ........................................................................ 53 
10.1.11.1 
Human Data Sharing Plan................................................................................. 53 
10.1.11.2 
Genomic Data Sharing Plan.............................................................................. 54 
10.1.11.3 
Publication ......................................................................................................... 54 
10.1.12 Conflict of Interest Policy ......................................................................................... 54 
10.2 
Additional Considerations ................................................................................................. 54 
10.2.1 
Research Related Injuries .......................................................................................... 54 
10.2.2 
PREP Act.................................................................................................................... 54 
10.3 
Abbreviations ..................................................................................................................... 56 
10.4 
Protocol Amendment History ............................................................................................ 57 
11. 
References............................................................................................................................... 57 
 
LIST OF TABLES 
Table 1. Schedule of Activities (SoA)................................................................................................. 9 
Table 2. Study Schema ....................................................................................................................... 10 
Table 3. Prior Subcutaneous Dosing Trials....................................................................................... 11 
Table 4. MVA-BN Compared to ACAM2000 ................................................................................. 12 
Table 5. Prior Intradermal Dosing Compared to Subcuteanous ...................................................... 12 
Table 6. Study Arms ........................................................................................................................... 23 
Table 7: Power calculations ............................................................................................................... 41 
Table 8: Standard deviation estimates ............................................................................................... 41 
Table 9: Standard deviation estimates ............................................................................................... 41 
 
 
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 an ad hoc sick visit. 
 
Primary Objectives 
• To determine if peak 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 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 
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 

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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. Please 
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 an 
ad hoc 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 deltoid region, 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 

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travelers returning from Nigeria. The first case involved transmission between the index patient 
and a healthcare 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 

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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 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).  
 
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 Subcuteanous 
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). 

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• 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 
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 

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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 
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 

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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  
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 

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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-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 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  
Vaccinia virus specific PRNT GMT at Day 43 
 
To determine if peak 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  
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 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 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 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: 
• at least 30% female participants, 
• at least 20% African American/Black participants, 

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• 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) 
2. Any history of monkeypox, cowpox, or vaccinia infection. 

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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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Not Applicable. This study will not enroll vulnerable participants including prisoners, 
cognitively 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 an ad hoc 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 

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site for potential participants who are interested in the study for further screening procedures and 
additional protocol-specific information.  
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 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.  
 

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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 (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 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 
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 

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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. 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.  
 

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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. 
 
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. 
  
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.  
 
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 

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• 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. 
 
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 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. 
7.2 
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.  

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7.3 
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. 
 
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: 
 
• 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 (HR, 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. 
 

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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 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, 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 

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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 
time of each vaccination through 14 days post each vaccination will include pain 
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 

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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. 
 
 

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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) 
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 

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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  
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)):  
• 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 

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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 
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.  
 
8.4.3.2 
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. 

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• 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. 
 
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) 

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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. 
Please 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. 
 
8.4.6.2 
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.  

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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.  
 
8.4.7 
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. 
 
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. 
 

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8.5.2 
Unanticipated Problem Reporting 
The investigator will report unanticipated problems (UPs) to the study sponsor, the reviewing 
Institutional Review Board (IRB) and to the Data and Statistical Coordinating Center (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. 
 
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.  
 

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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.] 
 
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 and 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.  
 
 
 

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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] 
 
 
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 
 
 
 

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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 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.  
 
9.3.2.2 
Interim Immunogenicity Analyses 
Interim data review of immunogenicity may be performed after all participants have completed 
Day 43 (i.e., 14 days after the second vaccine for the last participant). 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. 
 

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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. 
 
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. 
 
 

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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.  
  
Refer to the SAP for additional information. 
 
10. 
SUPPORTING DOCUMENTATION AND OPERATIONAL 
CONSIDERATIONS 
10.1 
Regulatory, Ethical, and Study Oversight Considerations 

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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. 
 
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, 

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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 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 

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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 
• Results of interim efficacy or futility analysis  
• Insufficient compliance to protocol requirements 

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• 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). 
 
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 

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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 

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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 
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 DSMB will review applicable data to include, but not limited to, study progress and 

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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:  
 
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.  

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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.  
 
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 

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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 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-

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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 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 

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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 (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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10.3 
Abbreviations 
AE 
Adverse Event 
ANCOVA 
Analysis of Covariance 
BLA 
Biologics License Application 
CAPA 
Corrective and Preventative Action Plan 
CFR 
Code of Federal Regulations 
CI 
Confidence Interval 
CIOMS 
Council for International Organizations of Medical Sciences 
CLIA 
Clinical Laboratory Improvement Amendments 
CMP 
Clinical Monitoring Plan 
CMS 
Clinical Material Services 
COC 
Certificate of Confidentiality 
CONSORT 
Consolidated Standards of Reporting Trials 
CQMP 
Clinical Quality Management Plan 
CRF 
Case Report Form 
CRO 
Contract Research Organization 
CSR  
Clinical Study Report 
SDCC 
Data and Statistical Coordinating Center 
DHHS 
Department of Health and Human Services 
DMID 
Division of Microbiology and Infectious Diseases 
DSMB 
Data and Safety Monitoring Board 
EC 
Ethics Committee 
eCRF 
Electronic Case Report Form 
FDA 
Food and Drug Administration 
FDAAA 
Food and Drug Administration Amendments Act of 2007 
FWA 
Federalwide Assurance 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practices 
GMP 
Good Manufacturing Practices 
GWAS 
Genome-Wide Association Studies 
HAART 
Highly Active Antiretroviral Therapy 
HIPAA 
Health Insurance Portability and Accountability Act 
IB 
Investigator’s Brochure 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
ICMJE 
International Committee of Medical Journal Editors 
IDE 
Investigational Device Exemption 
IEC 
Independent or Institutional Ethics Committee 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
ISO 
International Organization for Standardization 
ITT 
Intention-To-Treat 
MedDRA 
Medical Dictionary for Regulatory Activities 

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MOP 
Manual of Procedures 
MSDS 
Material Safety Data Sheet 
N 
Number (typically refers to participants) 
NDA 
New Drug Application 
NIAID 
National Institute of Allergy and Infectious Diseases 
NIH 
National Institutes of Health 
OHRP 
Office for Human Research Protections 
OHSR 
Office for Human Participants Research 
PHI 
Protected Health Information 
PI 
Principal Investigator 
PK 
Pharmacokinetics 
QA 
Quality Assurance 
QC 
Quality Control 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SDSP 
Study Data Standardization Plan 
SMC 
Safety Monitoring Committee 
SOA 
Schedule of Activities 
SOC 
System Organ Class 
SOP 
Standard Operating Procedure 
UP 
Unanticipated Problem 
US 
United States 
WHO 
World Health Organization 
 
10.4 
Protocol Amendment History 
 
Version 
Date 
Description of Change  
Brief Rationale 
 
 
 
 
 
 
 
 
11. 
REFERENCES 
1. 
McCollum AM, Damon IK. Human monkeypox. Clin Infect Dis 2014;58(2):260-7. DOI: 
10.1093/cid/cit703. 
2. 
Grant R, Nguyen LL, Breban R. Modelling human-to-human transmission of 
monkeypox. Bull World Health Organ 2020;98(9):638-640. DOI: 
10.2471/BLT.19.242347. 
3. 
Gong Q, Wang C, Chuai X, Chiu S. Monkeypox virus: a re-emergent threat to humans. 
Virol Sin 2022. DOI: 10.1016/j.virs.2022.07.006. 
4. 
Rimoin AW, Mulembakani PM, Johnston SC, et al. Major increase in human monkeypox 
incidence 30 years after smallpox vaccination campaigns cease in the Democratic 
Republic of Congo. Proceedings of the National Academy of Sciences of the United 
States of America 2010;107(37):16262-7. DOI: 10.1073/pnas.1005769107. 

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5. 
Emergence of monkeypox in West Africa and Central Africa, 1970-2017. Wkly 
Epidemiol Rec 2018;93(11):125-32. (https://www.ncbi.nlm.nih.gov/pubmed/29546750). 
6. 
Centers for Disease C, Prevention. Multistate outbreak of monkeypox--Illinois, Indiana, 
and Wisconsin, 2003. MMWR Morb Mortal Wkly Rep 2003;52(23):537-40. 
(https://www.ncbi.nlm.nih.gov/pubmed/12803191). 
7. 
Erez N, Achdout H, Milrot E, et al. Diagnosis of Imported Monkeypox, Israel, 2018. 
Emerging infectious diseases 2019;25(5):980-983. DOI: 10.3201/eid2505.190076. 
8. 
Yong SEF, Ng OT, Ho ZJM, et al. Imported Monkeypox, Singapore. Emerging infectious 
diseases 2020;26(8):1826-1830. DOI: 10.3201/eid2608.191387. 
9. 
Rao AK, Schulte J, Chen TH, et al. Monkeypox in a Traveler Returning from Nigeria - 
Dallas, Texas, July 2021. MMWR Morb Mortal Wkly Rep 2022;71(14):509-516. DOI: 
10.15585/mmwr.mm7114a1. 
10. 
Vaughan A, Aarons E, Astbury J, et al. Human-to-Human Transmission of Monkeypox 
Virus, United Kingdom, October 2018. Emerging infectious diseases 2020;26(4):782-
785. DOI: 10.3201/eid2604.191164. 
11. 
Hobson G, Adamson J, Adler H, et al. Family cluster of three cases of monkeypox 
imported from Nigeria to the United Kingdom, May 2021. Euro Surveill 2021;26(32). 
DOI: 10.2807/1560-7917.ES.2021.26.32.2100745. 
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