An Exploratory, Pilot Study of the Safety and Immunogenicity of Reduced Doses of the US Yellow Fever Vaccine
Phase: PHASE4
Conditions: Yellow Fever Vaccination Reaction
Sponsor: US Army Medical Research Institute of Infectious Diseases

Protocol Title: Pilot Study, US Yellow Fever Vaccine: Safety and Immunogenicity of Reduced Doses of YF-VAX® (FY19-26)  
Date:  14 March 2023 
 
 
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PROTOCOL TITLE:  An Exploratory, Pilot Study of the Safety and Immunogenicity of Reduced Doses of the 
US Yellow Fever Vaccine (FY19-26) 
 
SECTION A:  RESEARCH TEAM AND LOCATIONS 
 
A1.  RESEARCH TEAM 
 
Study Role 
Institution/Company and Contact Information 
Funder 
DHA-Immunization Healthcare Division (DHA-IHD)  
Office of the Principal Assistant for Acquisition 
US Army Medical Research and Development 
Command 
810 Schreider St., Ste. 204 
Ft. Detrick, MD 21701 
Phone: 301-619-4566 
DSN: 343-4566 
Fax: 301-619-9793 
 
Principal Investigator 
 
 
 
 
 
 
Phillip R. Pittman, M.D., MPH 
Chief, Clinical Research Department 
Division of Medicine, USAMRIID 
1425 Porter Street, Fort Detrick, MD 21702-5011 
Phone:  301-619-2997 
Email:  phillip.r.pittman.civ@health.mil 
 
 
Associate Investigator(s)  
 
Fernando B Guerena, M.D., M.P.H., COL 
Director Core Support, USAMRIID 
1425 Porter Street, Fort Detrick, MD 21702-5011 
Telephone: (301) 619-0010  
Email: fernando.b.guerena.mil@health.mil  
 
 
 
Study Coordinator/ 
Protocol Nurse 
Lawrence Korman, R.N., BSN, CCRP 
Division of Medicine, USAMRIID 
1425 Porter Street, Fort Detrick, MD 21702-5011 
Phone: 301-619-6008 
Email:  lawrence.korman2.civ@health.mil 
 
 
Recruiter 
 
 
Vincent Fulton B.S., CCRP 
Division of Medicine, USAMRIID 
1425 Porter Street, Fort Detrick, MD 21702-5011 
Phone:  301-619-6019 
Email: vincent.b.fulton2.ctr@health.mil 
 

Protocol Title: Pilot Study, US Yellow Fever Vaccine: Safety and Immunogenicity of Reduced Doses of YF-VAX® (FY19-26)  
Date:  14 March 2023 
 
 
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Other Individuals 
Supporting  
the Research  
 
 
 
 
 
 
Eric C. Mossel, PhD., MAJ 
Microbiologist 
Center for Disease Control (CDC) 
Ft. Collins Branch 
3156 Rampart Rd 
Fort Collins, CO 80521 
Phone:  970-494-6595 
Email:  eric.c.mossel.mil@health.mil 
 
Rafi Ahmed, PhD. 
Emory University 
Emory Vaccine Center 
1510 Clifton Road 
G211 Rollins Research Building 
Atlanta, Georgia 30322 
 
Rafick-Pierre Sekaly, Ph.D. 
Emory University 
Atlanta, Georgia 30322 
 
A2.  ROLES AND RESPONSIBILITIES 
      
       A2.1  Key Research Personnel   
 
            Name(s):  Phillip R. Pittman, M.D., MPH 
            Research Role:  Principal Investigator 
 Study Responsibilities:  Supervises research team, trains study staff, obtain informed consent, 
determine inclusion/exclusion criteria, conducts physical exams, provide medical care for adverse 
events, collecting data, analyzing data, administration of vaccine, and evaluation of adverse events. 
 
            Name(s):  Fernando B Guerena, M.D., MPH, COL 
            Research Role:  Associate Investigator 
Study Responsibilities:  Assists the PI in conduct of study and supervision of study staff, obtain 
informed consent, determine inclusion/exclusion criteria, conducts physical exams, provide medical 
care for adverse events, collecting data, administration of vaccine, and evaluation of adverse 
events. 
 
Name(s):  Lawrence Korman, R.N., BSN, CCRP 
            Research Role:  Protocol Nurse / Study Coordinator 
           Study Responsibilities:  obtain informed consent, review inclusion/exclusion criteria, collecting data, 
administration of vaccine, vaccine accountability, phlebotomy, recruitment, follow-up on adverse 
events, and trains research team on protocol/protocol changes. 
 
 
Name(s):  Vincent Fulton BS, CCRP 
            Research Role:  Recruiter 
            Study Responsibilities:  Recruitment and collect data. 
       A2.2. Others Involved in the Research, as applicable  
 
            Name(s):  Eric C. Mossel, PhD., MAJ, Rafi Ahmed, PhD., Rafick-Pierre Sekaly, Ph.D. 
            Research Role:  Microbiologist 

Protocol Title: Pilot Study, US Yellow Fever Vaccine: Safety and Immunogenicity of Reduced Doses of YF-VAX® (FY19-26)  
Date:  14 March 2023 
 
 
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           Study Responsibilities:  Performs laboratory testing of de-identified samples.  
 
      
       
A3.  RESEARCH LOCATIONS    
 
            Department of Clinical Research, Division of Medicine, USAMRIID will serve as the site where subjects 
will be recruited and enrolled into the study, where study interventions and data analysis will occur. 
CDC, Fort Collins Branch will perform PRNT and PCR evaluations. 
Emory University will perform peripheral blood mononuclear cell (PBMC) and culture evaluations. 
 
Lab Corp will perform hematology, chemistry, HIV and Hepatitis panel evaluations for all blood 
samples. 
 
A4.  MULTI-SITE RESEARCH 
 
N/A 
 
 
SECTION B:  RESEARCH METHODOLOGY 
 
B1.  ABSTRACT   
 
YF-VAX® shortages caused by vaccine manufacturing issues or disease outbreaks are major world-wide 
safety concern.  Outbreaks often occur in areas of the world where the DoD is at risk of deploying it forces and 
as such the DoD is compelled to examine alternative methods to expand vaccine capacity in order to ensure 
warfighter immune readiness.  The purpose of this open-label, randomized, exploratory, pilot study is to 
evaluate the human immune response to reduced subcutaneous (SQ) dosing of YF-VAX® compared to the 
standard FDA approved subcutaneous vaccination dose.  The current dose of the US FDA licensed YF-VAX® 
is approximately 55,000 PFU in 0.5 mL administered SQ.  Using the licensed dosage as standard, we propose 
to evaluate reduced doses of 1/5th and 1/10th or 0.10 mL and 0.05 mL YF-VAX®.  There will be a total of 90 
subjects divided into 3 Groups of 30 subjects each.  As many as 150 healthy volunteers age 18 – 50 years who 
have not previously received yellow fever vaccine or any flavivirus vaccine nor knowingly has suffered with 
yellow fever disease or other flavivirus disease may be screened to qualify 90 subjects as meeting 
inclusion/exclusion criteria.  On the day of vaccination, subjects will be randomized to one of 3 groups.  
Cohorts of approximately 15-20 will be vaccinated until enrollment is complete. Following vaccination, solicited 
adverse events (AEs) will be recorded on the case report forms, and unsolicited AEs on a diary card for 28 
days.  SAEs will be recorded through day 365.  Blood will be collected at designated time points for antibody 
titers and vaccine virus viremia. The study will assess the feasibility of launching a large pivotal non-inferiority 
study of the standard dose vs the optimal reduced dose as determined by this study.  
 
 
B2.  BACKGROUND AND SIGNIFICANCE   
 
Background: The African yellow fever epidemic coupled with vaccine production constraints has led to a 
worldwide shortage of yellow fever vaccine [1].  On 9 May 2016 DHA-Immunization Healthcare Division (DHA-
IHD) issued an information paper describing the yellow fever vaccine (YF-VAX®) shortage and revising US 
DOD vaccination and ordering procedures [2].  The DHA information paper explained that Sanofi Pasteur, the 
sole FDA-licensed manufacturer of yellow fever vaccine in the United States was unable to produce sufficient 
quantity of YF-VAX®.  The DHA information paper also outlined the potential impact as “Proof of yellow fever 
immunization is a requirement for entry into 18 countries within the AFRICOM AOR in addition to, endemic 
zones located within the SOUTHCOM AOR.  Entry into certain countries may be denied to Service members if 
they do not have a current (within 10 years) yellow fever immunization documented, possibly impacting their 
mission or resulting in quarantine/detainment [2].  DHA monitors the DOD YF-VAX® supply monthly [3].  To 

Protocol Title: Pilot Study, US Yellow Fever Vaccine: Safety and Immunogenicity of Reduced Doses of YF-VAX® (FY19-26)  
Date:  14 March 2023 
 
 
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address the shortage among US travelers, FDA allowed US travelers to receive the Sanofi Pasteur European 
Yellow Fever Vaccine (Stamaril) under pre-selected travel clinics throughout the country, under the auspices of 
CDC and Sanofi Pasteur [4].    
The current YF vaccine shortage has highlighted the need to pursue alternative solutions to extend existing 
vaccine supplies, the most rational solution being dose-sparing strategies.  The Stamaril vaccine is currently 
licensed only under an expedited access pathway (EAP) for use at a limited number of sites in the U.S.  FDA 
licensure for Stamaril would need to be initiated by Sanofi and would require funding as well as time to conduct 
the required clinical trials.  Although a new batch of YF-Vax became available in 2019, this does not address 
the underlying problem of how long it takes to manufacture and qualify new YF-Vax® lots.  While licensure of a 
fractionated dose would take time, data that fractionated dosing induces immunity above the WHO-defined 
protective threshold could form the basis for an FDA EAP approval in the event of an outbreak.  An EAP would 
also provide a vaccination alternative for U.S. Armed Forces deployed to endemic areas during any future 
vaccine shortages. 
The purpose of this study is to evaluate whether SQ dosing at 1/5th (0.1 mL) and 1/10th (0.05 mL) the current 
dose of YF –VAX® is similar to the FDA approved subcutaneous vaccination dose of 0.5 mL.  A number of 
recently published editorials have suggested that due to the recent epidemic and vaccine shortage, there 
should be a renewed emphasis on yellow fever vaccine dose reduction [1, 5-8].    Two recent clinical trials 
have reported favorable immunogenicity with reduced dosing of YF-VAX using alternative routes of 
administration.  Roukens et al. compared YF-VAX SQ at the standard dose to a reduced dose (1/5th of 
standard dose) administered ID. They observed that both groups met WHO standards of seroprotection, with 
PRNT80 titers > 1:16 in 77/77 (100%) ID and 78/78 (100%) SQ [9].”  While, Slifka et al. [10] used PRNT50 
titers and compared YF-VAX transcutaneous (TC) to SQ in subjects with and without atopic dermatitis and 
found that reduced dose TC yielded a conversion rate of 26/30 (87%) as compared to a conversion rate of 
37/38 (97%) with conventional SQ.  Similarly, Campi-Azevedo et al. found that with the Brazilian YF vaccine, a 
dose of 5000 PFU (1/10th routine dose) demonstrated similar immunological correlates and viral kinetics to the 
standard dose [11].  The latter point is emphasized as it conveys that immune-stimulating antigen exposure is 
essentially similar. Wu et al. assessed the approach of administering 1/5th dose of yellow fever vaccine with a 
mathematical model and concluded that it is an effective strategy for a reduction in the infection attack rate of 
yellow fever [12].  Visser and Roukens support further study of the reduced dose of vaccine with clinical trials 
[13].   
Recently, a study in the NEJM, conducted during a mass vaccination campaign in Kinshasa, examined a dose 
of 17DD YF vaccine (Bio-Manguinhos) at one fifth of the standard dose (0.1 ml) to 764 participants from one of 
six lots (14).  Of the 716 participants completing the study, 705 (98%; 95% confidence interval [CI], 97 to 99) 
were seropositive after vaccination and none of the participants who completed follow-up reported symptoms 
compatible with yellow fever after vaccination.  Unfortunately, this study did not collect data from a comparison 
arm of standard dose YF vaccine.  The authors of this study emphasized that follow-on studies should be done 
to confirm that other 17D-derived YF vaccines would perform in similar fashion (14).   
In addition, a publication from Bio-Manguinhos in Brazil describes a dose-response study with their 17DD YF 
vaccine, administering the vaccine in the usual mean dose of 27,476 IU (full dose, reference) and in tapered 
doses (10,447 IU, 3013 IU, 587 IU, 158 IU, and 31 IU) by the usual subcutaneous route and usual volume (0.5 
mL) (15a).  Doses down to 587 IU showed similar immunogenicity to the full dose, while the 158 IU and 31 IU 
doses displayed lower immunogenicity (15a).  Seropositivity was maintained at 10 months, except in the group 
that received the 31 IU dose (15a).  Overall, 85.2% of participants (95% CI 80.8; 88.9) remained seropositive 
to YF eight years after initial vaccination, with no significant differences between the fractional dose and full-
dose groups (15b).      
The Strategic Advisory Group of Experts (SAGE) on immunization of the World Health Organization (WHO) 
endorsed the use of reduced dose of yellow fever vaccine administration in order to quell the recent yellow 
fever epidemic in West Africa [16].  WHO had called for studying the immunogenicity and safety of fractional 
dosing of all 4 WHO prequalified yellow fever vaccines administered either subcutaneously or intramuscularly, 
as fractional dosing has been the mainstay in addressing current YF outbreaks.   

Protocol Title: Pilot Study, US Yellow Fever Vaccine: Safety and Immunogenicity of Reduced Doses of YF-VAX® (FY19-26)  
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In their review, Rouken and Visser wrote, “The global yellow fever vaccine supply is insufficient to provide full-
dose vaccination to millions threatened by outbreaks.  Given the excess of live-attenuated 17D yellow fever 
virus in the current single dose vials, dose sparing would increase available vaccine doses manifold (17).”  At 
this point, to our knowledge the only vaccine to have not been studied for feasibility of fractional dosing 
subcutaneously is the only U.S. FDA approved vaccine, YF-VAX®.  
It is critically important that the DOD address this gap in medical knowledge as future vaccine shortages for 
this disease, which is endemic to many areas of strategic military importance, are a very real possibility.  The 
most efficient and cost-effective path forward is to perform a pilot study to 1. Provide the DOD with an 
informative knowledge product regarding the performance of fractional YF-VAX and 2. Better position the DOD 
MRDC for follow-on studies should there be a future prolonged shortage of YF-VAX.  
 
B3.  MILITARY RELEVANCE    
 
The outcome of this work will provide a basis to support emergency use authorization of the current vaccine 
YF-VAX® at a reduced dose. Additionally, equivalency in this proof of concept study serves as a framework to 
conduct a larger non-inferiority study to meet the regulatory requirements for lowering the dose of the FDA 
approved vaccine, thereby helping to address the US shortage of YF-VAX®. 
 
YF-VAX® is currently in use by the DOD and is the only FDA approved vaccine against yellow fever disease. 
Thus, YF-VAX® is the only YF vaccine that can be routinely administered to DOD active duty personnel and 
dependents.  YF-VAX® is indicated for active immunization for the prevention of YF in persons 9 months of age 
and older in the following categories: Persons living in or traveling to endemic areas, persons travelling 
internationally through countries with YF, and laboratory personnel.  YF is endemic in Sub-Saharan Africa, 
South America, and the Caribbean. YF-VAX® is currently available only in very limited supplies.  There is 
currently no new production of YF-VAX® due to manufacturing issues.  Sanofi Pasteur, the vaccine 
manufacturer, has not determined definitively when YF-VAX® vaccine production will be restarted. 
 
YF disease is a viral hemorrhagic fever that is a re-emerging infectious disease and is likely to continue to be a 
threat to deploying military forces well into the future. Understanding the safety and biologic/immunologic 
responses to this vaccine is paramount to the warfighter's immune readiness and the readiness of the 
Department of Defense to perform its mission. It is essential that the war fighter is provided an effective 
method of protection from yellow fever virus infection when deployed in an endemic area. 
 
 
B4.  OBJECTIVES/SPECIFIC AIMS/RESEARCH QUESTIONS   
 
Hypothesis: Hypothesis: YF-VAX® administered by the SQ route with a fractional dose will demonstrate 
similar neutralizing antibody response and adverse events compared to YF-VAX® administered by standard 
dose SQ route. 
Primary Objective:  
• 
The primary objective of this study is to explore the safety and immunogenicity of two fractionated 
doses of YF-VAX (1/5th and 1/10th the standard dose) compared to the standard YF-VAX dose. 
Secondary Objectives:  
• 
To determine if YF vaccine viremia (as determined by viral plaque assays and/or RT-PCR), for the 14 
days following vaccination, is diminished by fractional dose vaccination vs standard dose vaccination.  
• 
To compare the neutralizing antibody response of SQ standard dose YF vaccine to SQ fractional dose 
YF vaccine up to one year following vaccination. 
Exploratory Objectives: 

Protocol Title: Pilot Study, US Yellow Fever Vaccine: Safety and Immunogenicity of Reduced Doses of YF-VAX® (FY19-26)  
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• 
To collect samples to characterize the impact of SQ fractional dose YF vaccine vs SQ standard dose 
YF vaccine in terms of immune profile. 
o These studies would be funded by follow-on proposals and not the current proposal 
 
Primary Endpoints 
• 
Immunogenicity 
o Proportion of subjects in each dose-group who develop protective antibody titers at day 28 post-
YF vaccination as defined by PRNT50 ≥1:10 or higher.  
o Geometric mean PRNT50 titers at day 28 post-YF vaccination for each dose group.  
o Proportion of subjects in each dose-group who develop a 4-fold increase in PRNT50 titers from 
day 0 to day 28. 
• 
Safety 
o Occurrence of adverse events, in each dose group. 
 
Occurrence of solicited adverse events in each dose group for the first 28 days following 
vaccination. 
 
Occurrence of unsolicited adverse events in each dose group for the first 28 days 
following vaccination. 
 
Occurrence of serious adverse events during the study period. 
 
Secondary Endpoints 
• 
Immunogenicity 
o Proportion of subjects in each dose-group who develop protective antibody titers up to a year 
(days 0, 3, 7, 10, 14, 90, 180, 365) post-YF vaccination as determined by PRNT50 and PRNT80 
of 1:10 or higher.  Days 0, 28 and 365 will be used for analyses addressing the secondary 
objectives.  Days 3, 7, 10, 14, 90 and 180 will be used for exploratory analyses only 
o Geometric mean PRNT50 and PRNT80 titers up to 1 year (days 0, 3, 7, 10, 14, 90, 180, 365) 
post-YF vaccination for each dose group. Days 0 and 365 will be used for analyses addressing 
the secondary objectives. Days 3, 7, 10, 14, 90 and 180 will be used for exploratory analyses 
only 
o Proportion of subjects in each dose-group who develop a 4-fold increase in titers up to a year 
(days 3, 7, 10, 14, 90, 180, 365) compared to day 0 as determined by PRNT50. Day 365 will be 
used for analyses addressing the secondary objectives. Days 3, 7, 10, 14, 90, and 180 will be 
used for exploratory analyses only.  All PRNT80 analyses, including 4-fold increase from 
baseline will be considered secondary. 
• 
Viremia 
o Mean viral load (copies / mL blood) at day 0, 2, 3, 4, 5 based on day of vaccination (blood draw 
will occur only once over the weekend—the missed day will not be considered a protocol 
violation or deviation), 6, 7, 10 and 14 post-vaccination in each dose group, as determined by 
PCR. 
Exploratory Endpoints 
• 
Immunogenicity 
o Frequency and phenotype of YF-specific T and B cells for each dose group up to 1 year post-
vaccination (days 0, 7, 14, 28, 90, 365) as determined via ELISPOT and / or ICS/flow cytometry 
(up to 40 members from the last 3 cohorts only - the exact number will be determined by the 
number of subjects in these cohorts who volunteer to participate in this part of the study). 

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o Cytokine profiling for YF-specific peripheral blood mononuclear cells via Mesoscale multiplex 
assay or comparable (up to 40 members from the last 3 cohorts only). 
o Microbiome—blood samples will be collected (days 0 (baseline), 2, 7, 14, 28, 3 months, 1 year) 
for determination of how vaccination with the live, attenuated YF-VAX effects the microbiome  
(up to 40 members from the last 3 cohorts only). 
 
 
B5.  RESEARCH PLAN    
 
       B5.1  Research Design   
 
This is an open label, randomized, exploratory pilot study to assess proof of concept for reduced 
subcutaneous doses of the FDA licensed YF vaccine, YF-VAX®.   
 
      B5.2  Research Subjects/Population(s) 
 
                B5.2.1  Subject Population(s)   
 
The study population will consist of males and non-pregnant or non-breastfeeding females 18 to 50 years 
of age who reside in the Washington-Baltimore-Frederick area to include active duty military personnel, 
government and non-government (including contractors) civilians.  
 
                B5.2.2  Number of Subjects, Records, and/or Specimens   
 
       Up to 150 individuals will be screened in order to randomize 90 eligible individuals to one of three groups: 
Group 1— YF-VAX® standard dose 0.5 mL SQ = 30 subjects; Group 2—0.10 mL (1/5th) SQ = 30 subjects; 
Group 3—0.05 mL (1/10th) SQ = 30 subjects. 
 
Group 
Number of Subjects 
YF-VAX Dose 
Volume (mL) 
Group 1 
30 
Standard dose 
0.5 mL 
Group 2 
30 
1/5th 
0.1 mL 
Group 3 
30 
1/10th 
0.05 mL  
 
               B5.2.3  Inclusion Criteria 
 
Subjects must meet all of the following criteria to be included in the study:                                                          
1. Males and Females 18 to 50 years of age. 
 
2. In good health, as determined by pertinent medical history, physical examination, vital signs, and 
clinical safety laboratory evaluations. 
3. Female of child bearing potential:  Has a negative pregnancy test and is willing to use a reliable 
form of contraception for the duration of the study after vaccination.  
4. Negative human immunodeficiency virus (HIV) antibody screen, seronegative for hepatitis B surface 
antigen (HBsAg) and hepatitis C antibody (following HIV and hepatitis testing, subjects will be 
provided with counseling and referral for health care if any test is positive). 
5. Ability to comprehend and a willingness to sign an informed consent, which includes the Health 
Insurance Portability and Accountability Act (HIPAA) Authorization, and a separate consent form for 
HIV testing. 

Protocol Title: Pilot Study, US Yellow Fever Vaccine: Safety and Immunogenicity of Reduced Doses of YF-VAX® (FY19-26)  
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6. Be willing to comply with all follow-up visits, testing, AE reporting, and completion of diary card. 
 
               B5.2.4  Exclusion Criteria 
 
Subjects meeting any of the following criteria will be excluded from the study: 
1. Receipt of any other investigational vaccine or investigational drug within 28 days prior to or after 
vaccination with YF-VAX® vaccine. 
2. Have had any known flavivirus disease or receipt of any flavivirus vaccine, licensed or investigational 
at any time; in addition to any yellow fever vaccine, these include; Japanese Encephalitis (JE), St. 
Louis Encephalitis, Tick Borne Encephalitis (TBE), West Nile, Dengue, Zika virus 
3. Anticipates receipt of any other vaccine within 28 days of YF-VAX®.  COVID-19 vaccination and 
Influenza vaccination will be permitted but not within 14 days of YF-VAX®. 
4. Acute or chronic medical conditions, or medications that, in the Principal Investigator’s (PI) opinion, 
would impair the subject’s ability to respond to vaccination. 
5. Hypersensitivity to any vaccine, eggs or egg products, or allergy to any component of the YF-VAX® 
(sorbitol, gelatin) or latex. 
6. Corticosteroids even ≥20 mg/day of prednisone for ≥ 2 weeks suppresses the immune system. Low-
dose corticosteroid topical products and nasal sprays used sporadically (i.e. prn--according to 
circumstances) are permissible. 
7. History of immunosuppression, by any cause--primary or acquired immunodeficiencies, 
transplantation, malignant neoplasm, lymphoma, leukemia, thymoma, mysthenia gravis, radiation, 
immunosuppressive drugs, including antimetabolites, TNF-alpha inhibitors (etanercept), IL-1 blocking 
agents and other monoclonal antibodies targeting immune cells (e.g., rituximab, alemtuzumab, etc),    
etc.  
8. Receipt of or anticipates receipt of/or donation of blood or blood products for 2 months after receipt of 
YF-VAX®.  (Note:  Blood banks require a minimum 2 week interval between the receipt of this FDA 
licensed vaccine and blood donations; however because of the blood collections in this study, an interval 
of 2 months is requested). 
9. Female:  Pregnant (or planning to become pregnant) or breastfeeding for the duration of the study 
after receipt of   YF-VAX®.  
10. Clinically significant abnormal laboratory tests (generally ≥2 times the upper limit of normal or as    
determined by the PI). 
 
      B5.3  Research Procedures   
 
After informed consent is obtained, prospective participants will be screened for study eligibility criteria to 
include medical history, physical examination including vital signs, review of concomitant medications including 
vaccination history, lab tests including complete blood count (CBC) with differential (4 mL), comprehensive 
metabolic panel (CMP) (8.5 mL), urinalysis, hepatitis panel (Hepatitis B surface antigen [HBsAg] and 
antibodies to Hepatitis C [8.5 mL]), human immunodeficiency virus (HIV) antibody screen (8.5 mL), pregnancy 
test (for all females to confirm non-pregnant status), and Yellow Fever PRNT 50/80 (8.5 mL). Maximum 
amount of blood drawn for screening tests is 38 mL. The results of all screening labs, vaccine titers and safety 
labs (CBC, CMP) will be reviewed with each subject and a copy of the results will be provided if requested by 
the subject. 
 
In the event of a screening failure secondary to mild or limited acute illness or abnormal laboratory values, the 
subject may be re-screened after resolution of the event. Re-screening may require only an additional blood 
draw or may require a full re-screening evaluation, depending on the circumstances of and the time interval 
from the initial screening failure. 
If a subject is screened and cannot be vaccinated because of a certain transient condition, (e.g. abnormal lab 
value due to an acute condition or a missing lab evaluation) then the subject can be re-screened on one further 
occasion only and the respective test(s) should be repeated as a "partial" re-screening rather than a “full” re-

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screening. The partial re-screening visit must be within the 60-day window started by the first Screening Visit 
and the window -60 to -1 day before the vaccination must not be exceeded.  
 
If a subject could not be vaccinated and the 60-day period is over, the subject is withdrawn from the study, a 
“full” re-screening assessment including re-consenting, physical examination, blood tests must be performed 
and the subject will be assigned a new study ID number. The clock then re-starts at the re-screening visit with 
Day -60 before 1st vaccination. 
 
The PI or Associate Investigator will review the eligibility criteria and the screening laboratory test results to 
determine a candidate’s eligibility to participate in this study.  Blood tests that show a subject is HIV, hepatitis 
B or C positive are required by law to be reported to the Maryland Health Department. Subjects will be 
notified of this reporting requirement. The test results reported to Maryland Health Department will contain 
the participant’s name, contact information, including address and telephone numbers, and the type of 
testing that was done. If the participant is in the military, study staff are required to report the same kind of 
information to military preventive medicine service. As a result, this information may end up in the 
subject’s military medical record and may be reported to their chain of command. The study doctors will 
discuss abnormal testing results face-to-face with the study participant (and notify their primary doctor at their 
request). Participants will be advised of this in the informed consent form. Civilian subjects who are positive for 
HIV, Hepatitis B surface antigen, or Hepatitis C will be referred to their private physician if they wish.  Military 
personnel who test positive for HIV, Hepatitis B surface antigen, or Hepatitis C will be referred to an Army 
Health Clinic.  Study personnel will also inform subjects if they do not qualify to participate in this study and 
why.  
 
On vaccination day prior to administration of the vaccine, review of current concomitant medications, 
pregnancy test (for all females to confirm non-pregnant status), eligibility criteria review and research lab tests 
to include, Yellow Fever PRNT 50/80, PBMC, and Yellow Fever Vaccine viremia.  
 
Cohorts of participants should be randomized for vaccination to one of three (3) groups with individuals 
assigned to each group so that a proportional of each sex is roughly equivalent between groups. For each 
cohort of subjects, a Randomization Worksheet with subject ID and sex for each subject will either be 
transmitted electronically or by hand to statistician for randomization once all subjects have been approved for 
study participation. YF-VAX® will be administered in the clinic area according to the assigned dosing regimen 
of one (1) subcutaneous (SQ) injection documented on the Randomization Worksheet supplied by the 
statistician on the day of vaccination.  
 
After the vaccination, subjects will remain in the clinic area for at least 30 minutes for vital signs, review of any 
post vaccination adverse events and will receive a diary card to document all adverse events that occur over 
the next 28 days.  
 
Post vaccination visit procedures to include vital signs, review of current concomitant medications, lab tests, 
focused physical exam directed at vaccination site and review of adverse events as documented in the Study 
Event Schedule. Follow-up visits will take approximately 15 to 30 minutes.  
 
If a female subject becomes pregnant during the study, she will be advised to contact the principal investigator.  
The Investigators will follow the subject until the baby’s birth regarding the outcome of her pregnancy. The 
following information will be requested from the subject concerning the pregnancy outcome:  term or early 
delivery; natural birth or C-section; child's birth weight and length; child’s physical examination (normal or any 
birth defects).  
 
Subjects who receive less than the full dose during study participation should receive, when appropriate, a full 
dose of YF-VAX® before either deploying or travelling as a tourist to an endemic area as documented in the 
YF-VAX® package insert. Data suggest that vaccination in the presence of neutralizing YFV antibodies does 
not increase the risk for adverse events—SAEs occur primarily after primary YF immunization (18).  The level 

Protocol Title: Pilot Study, US Yellow Fever Vaccine: Safety and Immunogenicity of Reduced Doses of YF-VAX® (FY19-26)  
Date:  14 March 2023 
 
 
Protocol v7 
 
Page 10 of 27 
 
of YFV-specific antibodies following booster vaccinations appear to be correlated inversely to the amount of 
pre-existing antibodies (19), however, no data suggest that there is a negative impact on sero-protection. 
 
Study Events Schedule 
 
 
c Targeted examination at principal investigator's discretion. 
 
d Blood pressure, pulse, respiration rate, and temperature; not to be done on weekends.  
e Pre vaccination and ≥ 30 minutes post-vaccination. 
f  Subjects will be observed in the clinic for AEs for at least 30 minutes following vaccination 
g  Diary Card Review 
      B5.4  Data Collection     
Study Event 
Screening 
 
Day of 
Vaccination 
 
Post-Vaccination Day 
 
Days -60 to -1 
0 
2 
3 
5 
6 
7 
 (+ 1)  
10 
 (± 1) 
14 
(± 2) 
28 
 (± 3) 
90 
 (± 7) 
180 
(± 14) 
365 
(± 28) 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion 
Criteria Review 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
X 
 
 
 
 
 
 
 
 
 
 
 
X c 
Concomitant 
Medication  
Review 
X 
X 
 
 
 
 
X 
 
X 
X 
 
X 
X 
Physical 
Examination 
X 
 
 
 
 
 
 
 
 
 
 
 
X c 
Vital Signs d 
X 
Xe 
X 
 
 
 
X 
 
 
X 
 
 
X 
CLIN LABS 
 
 
 
 
 
 
 
 
 
 
 
 
 
Complete Blood 
Count (CBC) with 
Differential 
X 
 
 
 
 
 
X 
 
X 
 
 
 
 
Comprehensive 
Metabolic Panel 
(CMP) 
X 
 
 
 
 
 
X 
 
X 
 
 
 
 
Urinalysis 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Hepatitis Panel 
X 
 
 
 
 
 
 
 
 
 
 
 
 
HIV Antibody 
Screen 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Serum/Urine 
Pregnancy Test for 
Females of 
Childbearing 
Potential 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
Research LABS 
 
 
 
 
 
 
 
 
 
 
 
 
 
PRNT 50/80 
X 
X 
 
X 
 
 
X 
X 
X 
X 
X 
X 
X 
YFV viremia 
 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
Amount of Blood 
(mL) 
38 
17 
9 
17 
9 
9 
30 
17 
30 
9 
9 
9 
9 
Additional Tests on Last 40 Subjects 
PBMC’s  
 
X 
 
 
 
 
X 
 
X 
X 
X 
 
X 
Microbiome 
 
X 
X 
 
 
 
X 
 
X 
X 
X 
 
X 
Amount of Blood 
(mL) 
 
42 
 
 
 
 
42 
 
42 
42 
42 
 
76 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Approx. Total Amt. 
of Blood (mL) 
38 
59 
9 
17 
9 
9 
72 
17 
72 
51 
51 
9 
85 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YF-VAX® 
Administration 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Injection Site 
Observation 
 
X 
X 
 
 
 
X 
 
 
X 
 
 
 
AE Review 
 
   Xf,g 
X 
 
 
 
Xg 
 
 
Xg 
 
 
 
SAE Review 
 
X 
X 
X 
X 
 
X 
 
 
X 
X 
X 
X 

Protocol Title: Pilot Study, US Yellow Fever Vaccine: Safety and Immunogenicity of Reduced Doses of YF-VAX® (FY19-26)  
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Protocol v7 
 
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Demographic information to include gender, race and date of birth along with the information/labs listed in the 
Schedule of Events table. 
      B5.5  Managing Data and/or Human Biological Specimens for this Research   
 
For this study, an EDC database system will be used for the collection of study data in an electronic format. 
The EDC database system will be designed based on protocol requirements, approved eCRF layouts and 
specifications, and IAW 21 CFR Part 11. The eCRF layouts, generated by the Data Manager, and source 
documents and specifications define and identify the applicable source data that will be collected and captured 
into the EDC database system. The applicable source data will be electronically transcribed by the site 
designee onto the eCRF (data entry screens) in the EDC database system. The investigator is ultimately 
responsible for the accuracy of data transcribed on the eCRF. Data monitoring and management will be 
performed in the EDC database system by the clinical monitor and the designated Data Management Group. 
The data management plan will describe data storage, security, database user access management. 
Subjects will be identified on eCRFs by a unique subject identification number. No personal identifier will be 
used in any publication or communication used to support this research study. The subject’s identification 
number will be used in the event it becomes necessary to identify data specific to a single subject. 
The electronic case report form (eCRF) data will be transcribed from source documentation. No source data 
will be recorded directly in the eCRF (ie, without prior written or electronic record of data). The transcribed data 
will be consistent with the source documents or the discrepancies will be explained 
 
Data generated by this study may be available for inspection upon request by representatives of the 
USAMRIID Office of Human Research Oversight (OHRO), HQ USAMRMC IRB, and other DoD offices charged 
with oversight of human subjects research. 
Blood specimens not designated for future use in the subject’s informed consent document (ICD) will be 
destroyed upon the completion of research in accordance with USAMRIID SOP MD-09-11. 
Clinical members of the team will be able to identify subjects because of the written consent process. HIPAA 
requires that researchers obtain the subject’s permission (authorization) to use health information about the 
subject that is either created by or used in connection with this research. For this study, PHI will include a 
subject’s research record, immunization record and, clinical/laboratory data obtained during the course of this 
study. This authorization has no expiration date.  
Data that are considered PHI under HIPAA legislation as described earlier are coded, linked to subjects only 
via a SIN, and acceptable under HIPAA as a limited data set. Identified data (signed consent documents and 
enrollment logs linking subject names and SINs) collected during the course of the study will be given to the PI 
(or designee) and maintained in a secure fashion in accordance with standard procedures at USAMRIID. 
The research team (Investigators, Study Coordinator) will have access to the data/specimens and to the link 
between the subjects and their data/specimens. The enrollment/withdrawal log linking the data/specimens to 
the subjects will be destroyed after the closure of the research study by the IRB.  
 
 
      B5.6  Managing Data and/or Human Biological Specimens for Future Research  
 
With written consent from the subject, unused serum specimens will be stored for future study use to 
further our understanding of the immune response to YF-VAX®. These samples will be stored indefinitely at 
USAMRIID.  
 
      B5.7  Devices, Drugs, Dietary Supplements, Nutritional Supplements, And Biologics   

Protocol Title: Pilot Study, US Yellow Fever Vaccine: Safety and Immunogenicity of Reduced Doses of YF-VAX® (FY19-26)  
Date:  14 March 2023 
 
 
Protocol v7 
 
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                B5.7.1  Devices 
 
                           5.7.1.1 FDA-approved device being used in this research according to the approved 
labeling 
 
N/A 
 
                           5.7.1.2 FDA-approved device being used in this research in a manner other than its 
approved labeling 
 
N/A 
 
                B5.7.2  Drugs 
 
                             B5.7.2.1 FDA-approved and used in accordance with the approved labeling 
 
N/A 
 
                             B5.7.2.2 FDA-approved and used in a manner not in accordance with its approved 
labeling 
 
Drug name:  YF-VAX.  Source: Sanofi Pasteur, Inc.  Per Package Insert, “YF-VAX®, Yellow Fever Vaccine, 
for subcutaneous use, is prepared by culturing the 17D-204 strain of yellow fever virus in living avian 
leucosis virus-free (ALV-free) chicken embryos.  The vaccine contains sorbitol and gelatin as a stabilizer, is 
lyophilized, and is hermetically sealed under nitrogen.  No preservative is added.  Each vial of vaccine is 
supplied with a separate vial of sterile diluent, which contains Sodium Chloride Injection USP—without a 
preservative.  YF-Vax is formulated to contain not less than 4.74 log 10 plaque forming units (PFU) per 0.5 
mL dose throughout the life of the product.  Before reconstitution, YF-VAX is a pinkish color.  After 
reconstitution, YF-VAX is a slight pink-brown suspension.  The vial stoppers for YF-VAX and diluent are not 
made with natural rubber latex.” 
 
Store lyophilized vaccine at 2° to 8° C (35° to 46° F).  DO NOT FREEZE!  
Cold Chain Precaution:  Half-life is reduced from approximately 14 days at 35° to 37° C to 3-4 days at 45° 
to 47° C.   
 
Vaccine Preparation 
 
Reconstitute the vaccine using only the diluent supplied (0.6 mL vial of Sodium Chloride injection USP for 
single dose vial of vaccine.  After removing the “flip-off” caps, cleanse the vaccine and diluent vial stoppers 
with a suitable germicide.  Do not remove the vial stoppers or metal seals holding them in place.  
Using aseptic technique, use a suitable sterile needle and syringe to withdraw the volume of supplied 
diluent shown on the diluent label and slowly inject the diluent into the vial containing the vaccine.  Allow 
the reconstituted vaccine to sit for one to two minutes and then carefully swirl mixture until a uniform 
suspension is achieved.  Avoid vigorous shaking as this tends to cause foaming of the suspension.  Do not 
dilute reconstituted vaccine.  Use aseptic technique and a separate sterile needle and syringe to withdraw 
each vaccine dose from the single dose vial of reconstituted vaccine. The proper dose of reconstituted 
vaccine will be withdrawn directly from each “single dose vial” and used to vaccinate a single subject, the 
remaining vaccine, if any will be disposed of as Medical Waste.   
 
Parental drug products should be inspected visually for particulate matter and discoloration prior to 
administration.  If either of these conditions exists, do not administer the vaccine.  
 
Use YF-VAX within 60 minutes of reconstituting the single dose or multi-dose vial.  

Protocol Title: Pilot Study, US Yellow Fever Vaccine: Safety and Immunogenicity of Reduced Doses of YF-VAX® (FY19-26)  
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Protocol v7 
 
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Properly dispose of all reconstituted vaccine and containers that remain unused after one hour according to 
locally approved guidelines (e, sterilized or disposed in red hazardous waste containers) (18).   
 
Dosing information: 
 
Syringes will be used with 25 gauge, 5/8 inch needle for fractional dosing.   
 
Group 1:  A single subcutaneous injection of 0.5 mL of reconstituted vaccine (standard dose) 
Group 2:  A single subcutaneous injection of 0.1 mL of reconstituted vaccine (1/5th dose) 
Group 3:  A single subcutaneous injection of 0.05 mL of reconstituted vaccine (1/10th dose) 
 
The vaccine preparation process is described in detail in the Package Insert (Appendix C).  The handling of 
reconstituted vaccine and its administration is described in a Study Specific Procedure (SSP). 
 
 
                             B5.7.2.3 Any drug not approved by the FDA 
 
N/A 
 
     B5.8  Statistical Analysis 
 
               B5.8.1  Sample Size Estimation 
 
The primary objective of this study is to explore the safety and immunogenicity of two fractionated doses of YF-
VAX (1/5th and 1/10th the standard dose) compared to the standard YF-VAX dose.  As this is a pilot study, no 
formal statistical hypothesis testing is planned.  A target enrollment of 30 participants per treatment group is 
planned and assuming a drop-out rate of 30%, the final sample size for analysis will be approximately 21 
participants per treatment group.  The primary objective will be evaluating proportions of subjects that 
seroconverted and the proportion of subjects experiencing each type of adverse event . Proportions will be 
presented with the 95% confidence interval using an exact binomial proportion.  The following table displays 
the width of the 95% confidence intervals under different sample sizes and expected proportions. 
 
Expected Proportion 
95% CI width (lower 
bound – higher bound) 
95% CI width (lower 
bound – higher bound) 
 
N=20/group 
N=30/group 
0.05 
0.247 (0.001 – 0.249) 
0.193 (0.004 – 0.197) 
0.10 
0.305 (0.012 – 0.317) 
0.244 (0.021 – 0.265) 
0.15 
0.347 (0.032 – 0.379) 
0.281 (0.047 – 0.327) 
0.25 
0.404 (0.087 – 0.491) 
0.330 (0.111 – 0.441) 
0.50 
0.456 (0.272 – 0.728) 
0.374 (0.313 – 0.687) 
0.95 
0.247 (0.751 – 0.999) 
0.193 (0.803 – 0.996) 
1.00 
0.168 (0.832 – 1.000) 
0.116 (0.884 – 1.000) 
 
With the sample sizes of between 20 and 30 per treatment group, if the expected seroconversion of the 
fractionated doses is 100% as seen in previous studies, there will be 95% confidence that the actual 
seroconversion rate will be above 83% and 88% respectively.  This is above the WHO recommendation of 
80% efficacy in yellow-fever vaccination sero-protection and would help justify a larger non-inferiority study of 
the fractionated doses to the standard dose. 
 
 

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               B5.8.2  Data analysis   
 
Detailed statistical procedures and proposed tables, listings, and figures will be provided in a separate 
statistical analysis plan (SAP) written shortly after protocol approval. The SAP will be finalized before study 
closeout and database lock. The following key statistical components will be considered, and a detailed 
description will be documented in the SAP: 
• 
Primary and secondary endpoints and how they will be measured, 
• 
Statistical methods and tests that will be used to analyze the endpoints, 
• 
Strategy that will be used if the statistical test assumptions are not satisfied, 
• 
Indication of whether the comparisons will be one-tailed or two-tailed (with justification of the 
choice) and the level of significance to be used, 
• 
Identification of whether any adjustments to the significance level or the overall P value will be 
made to account for any planned or unplanned subgroup analyses or multiple testing, 
• 
Specification of potential adjusted analyses and a statement of which covariates or factors will be 
included, 
• 
Planned exploratory analyses and justification of their importance, and 
• 
Any subgroup effects with biological justification and support from within and outside the study. 
 
An electronic data capture (EDC) database system will be used for the collection of clinical data in an 
electronic format. After the clinical database has been locked at the conclusion of the study, database 
management personnel will extract a data file in SAS® data format using data transfer programs specific to the 
EDC database and will provide the study data from the database to the statistician at USAMRIID. A statistician 
at USAMRIID will analyze these data. Data in this study will be assessed IAW USAMRIID SOPs relating to 
statistical analyses of data in a GCP environment. 
All analyses, including any hypotheses suggested by these data, will be tested using the statistical methods as 
specified in the SAP at the two-tailed 95% confidence level. Adjustments for multiple comparisons will be 
considered only in the context of sets of like variables (such as reactions) using either a bootstrap approach or 
other methods deemed appropriate. All computations will be completed using the SAS package of standard 
biostatistical tools or other validated statistical software (SAS Institute Inc., SAS System Version 9.4 [or later 
version], Cary, NC 27513, 2013). 
Safety endpoint measurements in this vaccine study will be evaluated for all vaccinated subjects regardless of 
adherence to the protocol. Immunogenicity endpoints will be evaluated for all per-protocol subjects. 
This study is designed to be an exploratory analysis comparing the standard of care SQ route at full dose to 
SQ administration that utilizes significantly decreased doses (1/5th or 1/10th).  The primary immunogenicity 
assessment will be based on the exact (Clopper-Pearson) 95% confidence interval of the observed sample 
rates of immune response (PRNT50/PRNT80 ≥ 1:10).  The emphasis of the study is on descriptive rather than 
analytical statistics in order to inform future non-inferiority studies.  A final sample size of no less than 20 per 
group produces a two-sided 95% confidence interval with a width equal to 0.168 when the observed 
immunogenicity response rate 1.00.   
The number of subjects enrolled, completed, or withdrawn will be summarized for each group and overall. 
Reasons for withdrawal, when known, will be provided. Subject demographics including gender, age, and race 
will be summarized by group and overall. Summary statistics will include mean, standard deviation, median, 

Protocol Title: Pilot Study, US Yellow Fever Vaccine: Safety and Immunogenicity of Reduced Doses of YF-VAX® (FY19-26)  
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Protocol v7 
 
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and range for continuous variables and number and percent for categorical variables. Descriptive tables of 
demographics, subject disposition, vaccinations administered, compliance with protocol, study deviations, any 
local injection site measurements or vitals taken will be compiled.  
Only subjects vaccinated in compliance with the protocol and having blood for titers drawn in compliance with 
the protocol will be included in the immunogenicity analyses. The primary analysis variable for assessing 
immunogenicity will be the proportion of subjects who develop PRNT50 and PRNT80 titers ≥ 1:10 at each 
scheduled time point for which blood samples are drawn and over the entire study period to study completion. 
Binomial proportions and 95% confidence intervals will be calculated for subjects who develop PRNT50 and 
PRNT80 titers ≥ 1:10 at each scheduled time point for which blood samples are drawn and over the entire 
study period to study completion and exact 95% confidence intervals of these rates will be calculated. The 
effect of demographic variables on immunogenicity rates may be tested by Fisher exact tests when permitted 
by data. Geometric means of PRNT80 titers and standard deviations of the geometric means will be calculated 
using log-transformed titers, replacing any titers below the limit of detection with a value equal to the lower limit 
of detection divided by the square root of 2 (LLOD/√2). 
Rates of adverse events (AEs) will be tabulated overall, by type (local or systemic), by system organ class, by 
severity, by relationship, and by sex. Binomial proportions of these rates and exact 95% confidence intervals 
will be calculated. If the same reaction occurs on multiple occasions after a given vaccination for a given 
subject, the highest severity will be assumed and will be counted only once. Thus, individuals receiving a 
vaccination and reporting a specific reaction, not reactions themselves, will be counted in the calculation of 
reaction rates for a specific reaction type. Duration of local and systemic reactions will be calculated. Mean, 
median, and range of duration of local and systemic reactions will be tabulated. Serious and/or unexpected 
AEs reported during the study period will be listed. All vaccinated subjects will be included in the safety 
analyses regardless of compliance with this protocol. The effect of demographic variables on AE rates may be 
tested by Fisher exact tests when permitted by data. 
 
 
 
SECTION C:  HUMAN RESEARCH PROTECTIONS 
 
C1.  RECRUITMENT AND CONSENT  . 
 
       C1.1  Identification and Selection of Subjects   
 
Potentially eligible individuals will be recruited using the institutional review board (IRB)–approved 
recruitment material/advertisement to include flyers and e-mail documenting subject eligibility criteria, number 
of study/blood draw visits and participant’s study duration time frame.  
 
       C1.2  Recruitment Process   
 
Potentially eligible individuals will be recruited using the institutional review board (IRB)–approved 
recruitment material/advertisement.  
 
Interested individuals will initiate contact involving either the study recruiter, investigators or study coordinator 
to discuss study participation requirements. All prospective study subjects will be briefed individually by study 
personnel on the nature of the study and will be provided the currently approved informed consent document 
describing all aspects of the research study and procedures (including, but not exclusive to, the timing of blood 
draws and the amount of blood to be drawn). Prospective subjects will be provided the opportunity to discuss 
the study with the study investigator(s), research nurse, or study coordinator and will have any/all questions 
answered.  
 

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For active military, Unit officers and senior NCOs in the chain of command will not be present at the time of 
research subject solicitation and consent during any research recruitment sessions in which members of units 
under their command are afforded the opportunity to participate as research subjects (DODI 3216.02). 
However, it is not the intent to recruit from assembled units. 
 
 
       C1.3  Eligibility   
 
Participation in this study will be determined by either the Principal Investigator, Associate Investigator or 
designee upon review of the eligibility criteria requirements, history and physical, and all screening lab tests. 
 
 
       C1.4  Consent Process   
 
A combined written informed consent and HIPAA Authorization document will be signed by each subject before 
any study-related procedures are initiated. This informed consent document will be retained by the investigator 
as part of the study records. The investigators or their designees will present the protocol in lay terms to 
individual subjects. Questions on the purpose of the protocol, protocol procedures, and risks to the subjects will 
then be solicited. Any question that cannot be answered will be referred to the PI. No subject should grant 
consent until questions have been answered to his or her satisfaction.  
Should the protocol be modified, the ICD must be revised to reflect the changes to the protocol. If the subject is 
directly affected by the change, the subject will receive a copy of the revised ICD for review. If the subject 
decides to continue participation, then the subject must sign and date the revised ICD. Each subject will 
receive a copy of the signed and dated ICD. 
 
 
                 C1.4.1  Research involving subjects with cognitive impairment or who lack capacity to 
provide informed consent 
 
N/A 
 
                 C1.4.2  Research involving non-English speaking subjects 
 
N/A 
 
                 C1.4.3  Research involving a waiver of the requirement to obtain informed consent OR 
alteration of the elements of informed consent 
 
N/A 
 
                 C1.4.4  Research involving a waiver of the requirement for investigator to obtain a signed 
consent form 
 
 
N/A 
                 C1.4.5  Waivers of assent or parental permission when the research involves children 
 
N/A 
 
                 C1.4.6  Research involving data collection for the USAMRDC Volunteer Registry Database 
 
N/A 
 

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Protocol v7 
 
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C2.  COMPENSATION FOR PARTICIPATION     
 
Subjects will be compensated for participation in this study. 
Utilizing a preloaded gift card, subjects will be compensated on the same day the blood sample is obtained 
with $50.00 for each blood draw. Study subjects who complete vaccination day activities will be compensated 
an additional $200.00 for a total of $850.00.  (This is in addition to the $50 study participant receives for the 
blood draw on the vaccination day). On vaccination days subjects may be required to be present at the facility 
for up to 1-2 hours. Post vaccination vital signs and clinical checks must be obtained no less than 30 minutes 
after receipt of the vaccination. These additional funds are to compensate for the additional time necessary on 
vaccination days. All military and federal/civilian employees will be off duty or on leave on the day of 
vaccination in order to receive the additional $200, day of vaccination compensation.  
 
 
C3.  WITHDRAWAL FROM RESEARCH PARTICIPATION   
 
Subjects may withdraw from this protocol at any time without penalty or loss of benefits to which they are 
otherwise entitled. Reasons for premature withdrawal from the study will be recorded on the appropriate 
source documents. 
 
Subjects may be withdrawn from the study by an investigator for any of the following reasons: 
• 
Failure to comply with study procedures, as outlined in the ICD, at the discretion of the principal 
investigator (PI). 
• 
Any problem wherein the safety or health of the subject may be compromised by further participation, 
as determined by the PI, or Headquarters US Army Medical Research and Development Command 
(HQ USMRDC) IRB.  
• 
Any problem that may preclude drawing blood. 
• 
Pregnancy. 
 
C4.  PRIVACY FOR SUBJECTS   
 
The PI, investigator or designee will present the protocol to the subject singly. Questions regarding the nature 
of the protocol, the means by which the study is to be conducted, and the risks to the participants will be 
solicited on an individual basis during the consent process and at each follow-up study visit.  
 
 
C5.  CONFIDENTIALITY PROCEDURES FOR RESEARCH RECORDS, DATA, HUMAN BIOLOGICAL 
SPECIMENS   
 
Each individual enrolled in the study will be assigned a subject identification number (SIN). Upon receipt of an 
individual’s signed and dated consent, the subject will be considered officially enrolled as a study subject. 
Subject information will be entered onto the current version of the study enrollment/withdrawal log. In addition, 
SINs will be used in the event that it becomes necessary to identify data specific to a single subject. All data 
and medical information obtained about subjects during the course of this research will be considered 
privileged and confidential. Subjects will not be identified by name in any published report, presentation of 
results, or provision of PHI to collaborating institutions (Privacy Act of 1974 [5 USC 552a] and AR 25-22). 
Completed study records will be stored in a secure fashion by the PI (or a designee) at USAMRIID. 

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Representatives of the USAMRIID OHRO, the HQ USAMRMC IRB and other DoD offices may review research 
records as a part of their responsibility to protect human subjects in research. 
Subjects will be identified in study documentation by a study identification number assigned according to 
USAMRIID SOPs.   
The enrollment/withdrawal log will be securely stored separately from the research data in the study specific 
regulatory file and will be destroyed once the IRB approves the final report. This will completely sever any links 
between the coded information in the subject study files and render the data anonymized. 
No personal identifier will be used in any publication or communication used to support this research study. 
The subject’s identification number will be used in the event it becomes necessary to identify data specific to a 
single subject. 
 
 
C6.  RISKS OF HARM, MEASURES TO REDUCE THE RISKS OF HARM, AND BENEFITS OF 
PARTICIPATION 
 
       C6.1 Risks of Harm     
 
The risks directly related to this study are those associated with the following: 
 
Vaccine Administration 
Common side effects after vaccination include: headache, tiredness or weakness, injection site reactions (pain, 
tenderness, redness, swelling), and muscle pains, fever, stomach problems, and joint pain.  
Other reported reactions include an abnormal sensation, typically tingling or pricking (“pins and needles”) and 
flu-like illness, injection site blisters and syncope. 
The most serious adverse reactions that may happen after vaccination with a yellow fever vaccine are the 
occurrence of Yellow Fever Vaccine-Associated Acute Viscerotropic Disease (YEL-AVD) affecting vital organs 
similarly to yellow fever infection, and Yellow Fever Vaccine-Associated Acute Neurotropic Disease (YEL-AND) 
affecting the brain and nerves.  These complications have occurred in individuals over the age of 60 years.  
This study limits the age range to 18-50 years of age. 
As with any vaccination, there is a possibility of an allergic reaction, such as rash, itching or hives, swelling of 
the lips or face, swelling of the throat, fast pulse, sweating, feeling of dread, difficulty breathing, sudden drop in 
blood pressure causing dizziness or lightheadedness, and inability to breathe without assistance. YF-VAX® will 
not be administered to anyone with a history of acute hypersensitivity to eggs or egg products due to a risk of 
anaphylaxis (a severe potentially life-threatening allergic reaction). 
 
Vaccine will be administered by trained professionals; emergency kits are located in vaccination area. 
 
Pregnancy and Breastfeeding Risks 
The vaccine may be dangerous to an embryo or fetus or to a breastfed infant. Vaccination with YF-VAX® is 
also contraindicated in lactating women who are providing breastmilk to infants less than 9 months of age due 
to the potential for transmission of vaccine virus in breastmilk. Pregnant and/or breastfeeding women are not 
eligible to participate in the study because of the potential risks. 
 
Phlebotomy Risk 
   
Subjects may experience local discomfort or bleeding under the skin from needle sticks, resulting in a localized 
hematoma that generally resolves within 1 to 2 weeks. A rare complication may be localized infection at the 

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phlebotomy site or thrombophlebitis. This would be treated as medically indicated. Some subjects may feel 
lightheaded, queasy, or nauseated; have chills; develop a fast heartbeat; and/or faint during blood collection. 
These symptoms can be resolved by having the subject lie down and/or by stopping the procedure. To 
minimize risks, only qualified personnel will draw blood. 
 
 
Confidentiality 
 
Each individual enrolled in the study will be assigned a SIN as noted in section C5. Subjects will not be 
identified by name in any published report, presentation of results, or provision of PHI. Completed study 
records will be stored in a secure fashion by the PI (or a designee) at USAMRIID. Representatives of the 
USAMRIID OHRO, the HQ USAMRDC IRB, and other DoD offices may review research records as a part of 
their responsibility to protect human subjects in research. 
 
Samples sent to CDC laboratory and Emory University will be stored in a secure manner. When sample testing 
is completed, all samples will be either destroyed at testing site or shipped back to USAMRIID for either 
destruction or for possible testing in future studies to further our understanding of the immune response to YF-
VAX®. 
 
Risks to Study Personnel and the Environment 
 
The principal risks to study personnel in the clinical setting are associated with needle sticks. Standard 
operating procedures (SOPs) and universal precautions will reduce the risk of exposure for these individuals. 
This study will have no known risks to the environment: all biohazardous wastes will be disposed of as 
stipulated by local, state, and federal regulations. 
 
 
      C6.2  Incidental or Unexpected Findings   
 
Unexpected or incidental findings will be duly evaluated for severity and relatedness and reported to the IRB 
and VAERS if greater qualified.  
 
      C6.3  Potential Benefits     
 
Subjects may benefit from participating in the study by learning about their health from the screening tests.  
Subjects who receive the full dose of YF-VAX® are considered protected from Yellow Fever disease per FDA.   
 
C7.  DATA AND SAFETY MONITORING   
 
       C7.1 Monitoring 
 
Safety monitoring will occur throughout the study; therefore safety concerns will be identified by continuous 
review of the data as represented by the Study Event Schedule table by the PI, research staff, and research 
monitor.  
 
A CRO will be contracted to perform data monitoring services. Monitoring will be conducted according to a 
monitoring plan approved by the PI. The monitoring plan will specify in detail the items for source data 
verification and other tasks to be performed during the clinical trial site visits. 
All documents in the context with this clinical trial will be handled confidentially at all times. 
The monitor will be given access to relevant clinical records to confirm their consistency with the CRF entries 
and to obtain an adequate overview of the course of the trial. The monitor will verify that the entries in the CRF 
are complete, accurate, correct and supported by source documents. In addition the monitor will verify that all 
required data documented in the source were transferred accurately in the CRF. This will be done under 
preservation of data protection. 

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The source data verification must be performed by direct inspection of the subject's source documents. If a 
subject refuses to consent to this procedure, he/she may not be enrolled in the trial. The clinical trial site will 
provide direct access to all trial related data for the purpose of monitoring and auditing by regulatory 
authorities. The PI (or a representative) has further agreed to support the monitor in solving any problems 
he/she discovers during his/her visits. 
 
 
 
C8.  REPORTABLE EVENTS    
 
       C8.1  Expected adverse events 
 
The most frequently reported reactions with YF-VAX® include: headache, tiredness or weakness, injection site 
reactions (pain, tenderness, redness, swelling), and muscle pains. 
Other common symptoms include: fever, stomach problems, and joint pain. These reactions usually occur 
within the first 3 days following vaccination (except fever, which is likely to occur between the 4th and the 14th 
day after vaccination), and usually last for not more than 3 days. 
Other reported reactions include an abnormal sensation, typically tingling or pricking (“pins and needles”) and 
flu-like illness, injection site blisters and syncope. 
The most serious adverse reactions that may happen after vaccination with a yellow fever vaccine are the 
occurrence of Yellow Fever Vaccine-Associated Acute Viscerotropic Disease (YEL-AVD) affecting vital organs 
similarly to yellow fever infection, and Yellow Fever Vaccine-Associated Acute Neurotropic Disease (YEL-AND) 
affecting the brain and nerves. 
As with any vaccination, there is a possibility of an allergic reaction, such as rash, itching or hives on the skin, 
swelling of the lips or face, swelling of the throat, fast pulse, sweating, feeling of dread, difficulty breathing, a 
sudden drop in blood pressure causing dizziness or lightheadedness, and inability to breathe without 
assistance. YF-VAX® will not be administered to anyone with a history of acute hypersensitivity to eggs or egg 
products due to a risk of anaphylaxis. 
Following vaccination, solicited adverse events (AEs) will be recorded on the case report forms, and 
unsolicited AEs on a diary card for 28 days. 
 
       C8.2  Unexpected adverse events and unanticipated problems 
 
All unanticipated problems involving risk to subjects or others and serious adverse events related to study 
participation will be promptly reported to the HQ USAMRDC IRB by phone (301-619-6240), by e-mail 
(usarmy.detrick.medcom-usamrmc.other.irb-office@health.mil), by facsimile (301-619-4165), or sent to the 
U.S. Army Medical Research and Development Command, ATTN: MCMR-RPI, 810 Schreider Street, Fort 
Detrick, Maryland 21702-5012. A complete written report will follow the initial notification. 
 
       C8.3  Adverse device effects 
 
N/A 
 
       C8.4  FDA-regulated research under IND and IDE 
 
N/A 
 
D. Assays 
 

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PRNTs:  The WHO sanctioned PRNT will be used to determine YF neutralizing antibodies in sera collected 
from subjects participating on this protocol.  This assay will be performed by the CDC’s Fort Collins’ laboratory, 
which is one of a few laboratories recognized by the WHO to perform this assay.  CDC-Ft. Collins is in the 
GYFLN at the level of Global Specialized Lab, along with Erasmus MC, Robert Koch Institute, and Institut 
Pasteur de Dakar.  The results from the CDC-Fort Collins’ lab will serve as the gold standard and will be the 
assay for which group responses will be compared.  Other laboratories, including USAMRIID labs have 
expressed interest in testing samples for comparison with their assays. Such assays will be considered 
experimental.   
 
RT-PCR:  The CDC-Fort Collins diagnostic lab does YF RT-PCRs using the Domingo primer set and protocol.  
 
YFV Viral Plaque Assay:  CDC-Fort Collins lab  
 
Assay procedure/protocol/SOPs will be obtained from CDC-Fort Collins as allowable. 
 
PBMCs and Microbiome: Emory University 
 
 
 
SECTION E:  REFERENCES 
 
 [1] Vasconcelos PFC and Monath TP. Yellow Fever Remains a Potential Threat to Public Health Vector-Borne 
and Zoonotic Diseases. 2016; 16 (8): 566- 567.  
[2] https://health.mil/Military-Health-Topics/Health-Readiness/Immunization-Healthcare/Vaccine-Preventable-
Diseases/Yellow-Fever?type=All#RefFeed, accessed July 10, 2017  
[3] Medical Material Quality Control Message MMQC-17-1727, 
http://www.usamma.amedd.army.mil/assets/apps/nala_qaweb/message.cfm?MSG=MMQC-17-1727 
[4] Gershman MD, Angelo KM, Ritchey J, et al. Addressing a Yellow Fever Vaccine Shortage — United States, 
2016–2017. MMWR Morb Mortal Wkly Rep 2017;66:457–459. DOI: 
http://dx.doi.org/10.15585/mmwr.mm6617e2.  
[5] Monath TP, Woodall JP, Gubler DJ. Yellow fever vaccine supply: a possible solution. Lancet 2016; 387: 
1600.  
[6] WHO Strategic Advisory Group of Experts on Immunization (SAGE), Fractional dose yellow fever vaccine 
as a dose-sparing option for outbreak response 
http://www.who.int/immunization/sage/meetings/2016/october/3_Fractional_dose_secretariat_report_full_versi
on.pdf?ua=1, accessed July 14, 2017.  
[7] CH Calisher and Woodall JP. Yellow Fever—More a Policy and Planning Problem than a Biological One. 
Emerging Infectious Diseases. 2016; 22 (10): 1859 – 1860. DOI: http://dx.doi.org/10.3201/eid2210.160875  
[8] Elachola H, Ditekemena J, Zhuo J et al., Yellow fever outbreaks, vaccine shortages and the Hajj and 
Olympics: call for global vigilance Lancet 2016; 388: 1155. http://dx.doi.org/10.1016/ S0140-6736(16)31546-X.  
 [9] Roukens AH, Vossen AC, Bredenbeek PJ, van Dissel JT, Visser LG. Intradermally administered yellow 
fever vaccine at reduced dose induces a protective immune response: a randomized controlled non-inferiority 
trial. PLoS ONE. 2008; 3:e1993. [PubMed: 18431480]  
[10] Slifka MK, Leung DYM, Hammarlund E, et al. Transcutaneous Yellow Fever Vaccination of Subjects with 
or without Atopic Dermatitis. J Allergy Clin Immunol. 2014 February ; 133(2): 439–447. 
doi:10.1016/j.jaci.2013.10.037.  
 [11] Campi-Azevedo AC, de Almeida Estevam P, Coelho-dos-Reis JG, et al. Subdoses of 17DD yellow fever 
vaccine elicit similar virological/immunological kinetics timeline. BMC Infectious Diseases. 2014;14:391. 
doi:10.1186/1471-2334-14-391.  
[12] Wu JT, Peak CM, Leung GM, Lipsitch M, Fractional dosing of yellow fever vaccine to extend supply: a 
modeling study, The Lancet, Volume 388, Issue 10062, 10–16 December 2016, Pages 2904-2911, 
http://dx.doi.org/10.1016/S0140-6736(16)31838-4.  
[13] Visser LG, Roukens AHE, Modeling a way out of yellow fever, The Lancet, Volume 388, Issue 10062, 10–
16 December 2016, Pages 2847-2848, http://dx.doi.org/10.1016/S0140-6736(16)31330-7.  

Protocol Title: Pilot Study, US Yellow Fever Vaccine: Safety and Immunogenicity of Reduced Doses of YF-VAX® (FY19-26)  
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[14] Casey RM, Harris JB, Ahuka-Mundeke S, Dixon MG, Nsele PM, Kizito GM, Umutesi G, Laven J, Paluku 
G, Gueye AS, Hyde TB, Sheria GKM, Muyembe-Tanfum JJ, Staples JE. Immunogenicity of Fractional-Dose 
Vaccine during a Yellow Fever Outbreak -Final Report. NEJM 2019; 381:444-54. 
[15a] Martins RM, Maia MLS, Farias RHG, et al. 17DD Yellow Fever vaccine: A double blind, randomized 
clinical trial of immunogenicity and safety on a dose-response study.  Hu Vac & Immunoth 9: 4, 879-888, 2013.  
[15b] Martins R, Maia MLS, de Lima SMB, de Noronha TG, Xavier JR, Camacho LAB, de Albuquerque EM, 
Farias RHG, da Matta de Castro T, Homma A; Collaborative Group for Studies on Duration of Immunity from 
Yellow Fever Vaccine. Duration of post-vaccination immunity to yellow fever in volunteers eight years after a 
dose-response study. Vaccine. 2018 Jun 27; 36(28):4112-4117. 
[16] Weekly Epidemiological Record, 23 June 2017, vol. 92, 25 (pp. 345–356) Yellow fever vaccine: WHO 
position on the use of fractional doses – June 2017 Global polio eradication: progress towards containment of 
poliovirus type 2, worldwide 2017. 
[17] Roukens AHE, LG Visser. Fractional-dose Yellow Fever vaccination: an expert review.  J Trav Med, 2019: 
26(6): 1-5.  
[18] Recommendations of the Advisory Committee on Immunization Practices (ACIP).  Yellow Fever Vaccine. 
MMWR 2010; 59(RR-7): 1-32.  
[19] Hepburn MJ, Kortepeter MG, Pittman PR, et al.  Neutralizing antibody response to booster vaccination 
with the 17D yellow fever vaccine.  Vaccine 2006; 24:2843-9.  
 
 
SECTION E:  ABBREVIATIONS AND ACRONY 
Abbreviation 
Explanation 
AE 
adverse event, adverse experience 
AFRICOM AOR 
US Africa Command Area of Responsibility 
C 
Celsius 
CDC 
US Centers for Disease Control and Prevention 
CFR 
Code of Federal Regulations 
Cm 
Centimeter(s) 
DHA-IHB 
Defense Health Agency Defense Health Agency-Immunization 
Healthcare Branch 
DoD 
Department of Defense 
eCRF 
electronic case report form 
EDC 
electronic data capture 
F 
Fahrenheit 
FDA 
US Food and Drug Administration 
FWA 
Federal Wide Assurance 
GCP 
Good Clinical Practice 
HbsAg 
Hepatitis B Surface Antigen 
Hg 
mercury 
HIPAA 
Health Insurance Portability and Accountability Act 
HIV 
human immunodeficiency virus 
HQ 
Headquarters 
IAW 
in accordance with 
IB 
investigator’s brochure 
ICD 
informed consent document 
ICH 
International Conference on Harmonisation 
ID 
Intradermal 
IRB 
Institutional Review Board 
mg 
milligram(s) 
mL 
milliliter(s) 
mm 
millimeter(s) 
OHRO 
Office of Human Research Oversight (USAMRIID) 

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Abbreviation 
Explanation 
PBMC 
peripheral blood mononuclear cell 
pfu 
plaque-forming unit(s) 
PI 
principal investigator 
PHI 
protected health information 
PRNT50 
plaque reduction neutralization 50% titer 
PRNT80 
plaque reduction neutralization 80% titer 
SAE 
serious adverse event 
SAGE 
Strategic Advisory Group of Experts 
SAP 
statistical analysis plan 
SIN 
subject identification number 
SOP 
standard operating procedure 
SOUTHCOM AOR 
US Southern Command Area of Responsibility 
SQ 
Subcutaneous 
TC 
Transcutaneous 
USAMRIID 
US Army Medical Research Institute of Infectious Diseases 
USAMRDC/ MRDC 
US Army Medical Research and Development Command 
WHO 
World Health Organization 
YF 
Yellow Fever 
YFV/ YF-VAX 
Yellow Fever vaccine 
 
 
 
 
SECTION F: DoD PRIVACY RULE AND PROTECTED HEALTH INFORMATION (HIPAA) 
   
 
 NA – institution is not a covered entity 
 
 NA – will not use or disclose protected health information 
 
 HIPAA authorization will be obtained  
 
 An application for waiver/alteration of HIPAA authorization will be submitted   
 
 
 
 
 

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APPENDIX A:  STUDY RELATED ROLES AND RESPONSIBILITIES 
 
Vaccination Room Team 
• 
May prepare vaccine for administration. 
• 
May administer YF-VAX® to study participants. 
Data Manager  
• 
Provides study database end-user training to users requiring access to the study database. 
• 
Oversees the data entry and data discrepancy management activities. 
• 
Ensures data consistency, quality, and integrity. 
• 
Performs Medical Dictionary for Regulatory Affairs (MedDRA) and World Health Organization 
(WHO) coding. 
• 
Manages and maintains the study database. 
 
 
 
 
 
 
 
 

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APPENDIX B: TOXICITY GRADING SCALE 
 
Criteria for Rating Local Adverse Events 
Local Reaction 
to Injectable 
Product 
Mild  
(Grade 1) 
Moderate 
(Grade 2) 
Severe  
(Grade 3) 
Potentially Life 
Threatening 
(Grade 4) 
Fatal 
(Grade 5)  
Pain 
Does not 
interfere with 
activity 
Interferes with 
activity or repeated 
use of non-narcotic 
pain reliever 
Prevents daily 
activity or repeated 
use of narcotic pain 
reliever 
Emergency room 
(ER) visit or 
hospitalization 
Death 
Tenderness 
Mild pain to 
touch 
Pain with movement 
Significant pain at 
rest 
ER visit or 
hospitalization 
Death 
Erythema/ 
Rednessa 
2.5-5 cm 
5.1-10 cm 
> 10 cm 
Necrosis or 
exfoliative 
dermatitis 
Death 
Swellingb 
2.5-5 cm and 
does not 
interfere with 
activity 
5.1-10 cm or 
interferes with 
activity 
> 10 cm or prevents 
daily activity 
Necrosis 
Death 
a In addition to grading the measured local reaction at the greatest single diameter, the measurement should be recorded as a 
continuous variable. 
b Swelling should be evaluated and graded using the functional scale as well as the actual measurement. 
Criteria for Rating Systemic Adverse Events (Vital Signs) 
Vital Signsa 
Mild  
(Grade 1) 
Moderate 
(Grade 2) 
Severe  
(Grade 3) 
Potentially Life  
Threatening  
(Grade 4) 
Fatal  
(Grade 5)  
Fever (°C)b 
 (°F) 
38.0-38.4 
100.4-101.1 
38.5-38.9 
101.2-102.0 
39.0-40 
102.1-104 
> 40 
> 104 
Death 
Tachycardia - beats 
per minute 
101-115 
116-130 
> 130 
ER visit or 
hospitalization for 
arrhythmia 
Death 
Bradycardia - beats 
per minute 
50-54 
45-49 
< 45 
Death 
Hypertension 
(systolic) - mm Hg 
141-150 
151-155 
> 155 
ER visit or 
hospitalization for 
malignant 
hypertension 
Death 
Hypertension 
(diastolic) - mm Hg 
91-95 
96-100 
> 100 
Death 
Hypotension (systolic) 
- mm Hg 
85-89 
80-84 
< 80 
ER visit or 
hospitalization for 
hypotensive shock 
Death 
Respiratory Rate - 
breaths per minute 
17-20 
21-25 
> 25 
Intubation 
Death 
a Subject should be at rest for all vital sign measurements. 
b  Oral temperature; no recent hot or cold beverages or smoking. 

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Criteria for Rating Systemic Adverse Events (Symptoms) 
Systemic (General) 
Mild  
(Grade 1) 
Moderate 
(Grade 2) 
Severe  
(Grade 3) 
Potentially Life  
Threatening  
(Grade 4) 
Fatal  
(Grade 5)  
Nausea/vomiting 
No 
interference 
with activity 
or 1-2 
episodes/ 
24 hours 
Some 
interference 
with activity or 
> 2 episodes/ 
24 hours 
Prevents 
daily activity, 
requires 
outpatient IV 
hydration 
ER visit or 
hospitalization for 
hypotensive shock 
Death 
Diarrhea 
2-3 loose 
stools or  
< 400 gms/ 
24 hours 
4-5 stools or 
400-800 gms/ 
24 hours 
6 or more 
watery stools 
or > 800 
gms/ 
24 hours or 
requires 
outpatient IV 
hydration 
ER visit or 
hospitalization for 
hypotensive shock 
Death 
Headache 
No 
interference 
with activity 
Some 
interference 
with activity or 
repeated use of 
non-narcotic 
pain reliever 
Significant, 
prevents 
daily activity 
or repeated 
use of 
narcotic pain 
reliever 
ER visit or 
hospitalization 
Death 
Fatigue 
No 
interference 
with activity 
Some 
interference 
with activity 
Significant, 
prevents 
daily activity 
ER visit or 
hospitalization 
Death 
Myalgia 
No 
interference 
with activity 
Some 
interference 
with activity 
Significant, 
prevents 
daily activity 
ER visit or 
hospitalization 
Death 
Illness or clinical 
adverse event (as 
defined according to 
applicable regulation) 
No 
interference 
with activity 
Some 
interference 
with activity 
not requiring 
medical 
intervention 
Prevents 
daily activity 
and requires 
medical 
intervention 
ER visit or 
hospitalization 
Death 
 
 
 
 
 
 
 
 

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Criteria for Rating Systemic Adverse Events (Chemistry) 
Lab Value 
Mild 
(Grade 1) 
Moderate 
(Grade 2) 
Severe 
(Grade 
3) 
Potentially Life 
Threatening 
(Grade 4) 
Sodium (mmol/L) 
Hyponatremia 
<LLN to 132 
130-131 
125-129 
<125 
Sodium (mmol/L) 
Hypernatremia 
>ULN to 149 
150-154 
155-159 
≥160 
Potassium (mmol/L) 
Hypokalemia 
<LLN to 3.1 
2.5-3.0 
2.0-2.4 
<2.0 
Potassium (mmol/L) 
Hyperkalemia 
>ULN to 5.9 
6.0-6.5 
6.6-7.0 
>7.0 
Calcium (mmol/L) 
Hypocalcaemia 
<LLN to 2.00 
1.76-2.00 
1.50-1.75 
<1.50 
 
Calcium (mmol/L) 
Hypercalcaemia 
>ULN to 2.89 
2.90-3.09 
3.10-3.30 
>3.30 
Serum creatinine (mg/dL) 
>ULN to <1.5x 
ULN 
≥1.5 to <3x ULN 
≥3 to 6x 
ULN 
>6x ULN 
Alkaline phosphatase 
(increase by factor) 
>1.25x to <2x ULN ≥2x to <3x ULN 
≥3x ULN >10x ULN 
Liver function tests 
(increase by factor) 
>1x to <2.5x ULN 
≥2.5x to <4x ULN 
≥4x ULN >10x ULN 
Total bilirubin (increase 
by factor) 
>ULN to 1.5x 
ULN 
>1.5x to 3x ULN 
>3x to 
10x ULN 
>10x ULN 
 
 (increase by factor) 
>ULN to <2xULN 
≥2x to <5x ULN 
≥5x ULN 
Total cholesterol (mg/dL) 
> ULN to 300 
>300 to 400 
>400 
 
Criteria for Rating Systemic Adverse Events (Hematology) 
Lab Value 
Mild 
(Grade 1) 
Moderate 
(Grade 2) 
Severe 
(Grade 
3) 
Potentially Life 
Threatening 
(Grade 4) 
Hemoglobin (g/dL) 
Female 
< LLN to ≥10.5 
<10.5 to ≥10.0 
< 10.0 
Hemoglobin (g/dL) 
Male 
<LLN to ≥12.5 
<12.5 to ≥11.0 
< 11.0 
WBC (cells/mm3) 
Decrease 
<LLN to ≥2,500 
<2,500 to ≥1,500 
<1,500 
WBC (cells/mm3) 
Increase 
>ULN to < 15,000 
≥15,000 to 
<20,000 
≥ 20,000 
Lymphocytes (cells/mm3) 
Decrease 
<LLN to ≥750 
<750 to ≥500 
<500 
Neutrophils (cells/mm3) 
Decrease 
<LLN to ≥1,500 
<1,500 to ≥1,000 
<1,000 
Platelets (cells/mm3) 
Decrease 
<LLN to ≥75,000 
<75,000 to ≥ 
50,000 
<50,000