A Phase 2, Randomized, Double-Blind, Multicenter, Safety and Immunogenicity Clinical Bridging Study to Compare V181 (Dengue Quadrivalent Vaccine rDENVΔ30 [Live, Attenuated]) to Butantan Dengue Vaccine (Butantan - DV) in Healthy Adults 18 to 50 Years of Age in Brazil
Phase: PHASE2
Conditions: Dengue
Sponsor: Butantan Institute

Official Protocol Title: 
NCT number: 
NCT05710224 
Document Date: 
23-Aug-2024
A Phase 2, Randomized, Double-Blind, Multicenter, Safety and
Immunogenicity Clinical Bridging Study to Compare V181 (Dengue 
Quadrivalent Vaccine rDENVΔ30 [live, attenuated]) to Butantan 
Dengue Vaccine (Butantan-DV) in Healthy Adults 18 to 50 Years 
of Age in Brazil

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Title Page
THIS PROTOCOL AMENDMENT AND ALL OF THE INFORMATION RELATING 
TO IT ARE CONFIDENTIAL AND PROPRIETARY PROPERTY OF MERCK 
SHARP & DOHME LLC, RAHWAY, NJ, USA (MSD).
Protocol Title: A Phase 2, Randomized, Double-Blind, Multicenter, Safety and 
Immunogenicity Clinical Bridging Study to Compare V181 (Dengue Quadrivalent Vaccine 
rDENVΔ30 [live, attenuated]) to Butantan Dengue Vaccine (Butantan-DV) in Healthy 
Adults 18 to 50 Years of Age in Brazil
Protocol Number: 002-04
Compound Number: V181
Sponsor Name:
Instituto Butantan
(hereafter called the Sponsor)
Legal Registered Address:
Sponsor Address
Av. Vital Brasil, 1500, Butantã
São Paulo – SP [São Paulo] 05503-900 – Brasil
Study Executor:
Merck Sharp & Dohme LLC
(hereafter called MSD)
126 East Lincoln Avenue
P.O. Box 200
Rahway, NJ 07065 USA
Regulatory Agency Identifying Number(s):
ANVISA
25351019896/2021-84
Approval Date: 23 August 2024
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Sponsor Signatory
Typed Name:
Title:
Date
MSD is executing the study. MSD contact information can be found in the Investigator 
Trial File Binder (or equivalent).
Investigator Signatory
I agree to conduct this clinical study in accordance with the design outlined in this protocol 
and to abide by all provisions of this protocol.
Typed Name:
Title:
Date
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DOCUMENT HISTORY
Document
Date of Issue
Overall Rationale
Amendment 04
23-AUG-2024
 
 
Amendment 03
23-AUG-2022
To extend the contraception requirements from 4 
weeks after administration of study intervention 
to 90 days after administration of study 
intervention.
Amendment 02
28-JUL-2021
To change the comparison of dengue virus-
neutralizing antibody seroconversion rates for 
V181 and Butantan-DV from a secondary study 
objective to a primary study objective.
Amendment 01
19-FEB-2021
Correction of errors in the Study Interventions 
table (Table 1).
Original Protocol
21-DEC-2020
Not applicable.
CCI
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PROTOCOL AMENDMENT SUMMARY OF CHANGES
Amendment: 04
Overall Rationale for the Amendment:
 
Summary of Changes Table
Section Number and 
Name
Description of Change
Brief Rationale
Primary Reason for Amendment
Section 3, Hypotheses, 
Objectives, and 
Endpoints
 
 
 
 
 
Section Number and 
Name
Description of Change
Brief Rationale
Additional Changes
Section 1.3.1, Study 
Procedures for All 
Participants
The note for visit windows was changed to a 
letter footnote.
To align with addition of new footnote for 
flaviviruses.
Added a footnote on collection of previous 
exposure to other flaviviruses and previous 
receipt of other flavivirus vaccines, for those 
participants remaining in the study
To ensure collection of additional medical 
history to explore the prior exposure to other 
flaviviruses circulating in Brazil and previous 
vaccination information to explore prior 
vaccination to other flaviviruses.
Section 4.2.1.3
Added brief rationale for new exploratory 
objective and endpoint.
Refer to Section 3 rationale.
Section 8.1.5, Medical 
History
Added text for collection of participant’s 
history of any other flavivirus infection(s) at 
any time prior to Day 1, for those 
participants remaining in the study 
Refer to Section 1.3.1 rationale.
Section 8.1.6.1, Prior 
Medications
Added text for collection of participant’s 
history of vaccination for any other 
flavivirus infection(s) at any time prior to
Day 1, for those participants remaining in 
the study 
Refer to Section 1.3.1 rationale.
Section 8.2.4, 
 
 
Refer to Section 3 rationale.
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Section Number and 
Name
Description of Change
Brief Rationale
Section 9.4.1, 
Immunogenicity and 
Viremia Endpoints
Added bullet point for new exploratory 
endpoint.
Refer to Section 3 rationale.
Throughout
Minor administrative, formatting, 
grammatical, and/or typographical changes 
were made throughout the document.
To ensure clarity and accurate interpretation 
of the intent of the protocol.
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Table of Contents
DOCUMENT HISTORY ........................................................................................................3
PROTOCOL AMENDMENT SUMMARY OF CHANGES...............................................4
1
PROTOCOL SUMMARY ............................................................................................13
1.1
Synopsis.................................................................................................................13
1.2
Schema ..................................................................................................................17
1.3
Schedule of Activities...........................................................................................18
1.3.1
Study Procedures for All Participants..........................................................18
1.3.2
Study Procedures for Participants With Suspected Dengue ........................22
2
INTRODUCTION..........................................................................................................24
2.1
Study Rationale....................................................................................................24
2.2
Background ..........................................................................................................24
2.2.1
Dengue Disease and V181 Development ....................................................25
2.2.2
Preclinical and Clinical Studies ...................................................................26
2.2.2.1
Preclinical Studies..............................................................................26
2.2.2.2
Clinical Studies..................................................................................26
2.2.2.2.1
MSD V181 Completed Clinical Studies..................................26
2.2.2.2.2
NIH Dengue LATV Clinical Studies.......................................26
2.2.2.2.3
Butantan-DV Clinical Studies..................................................27
2.3
Benefit/Risk Assessment......................................................................................27
3
HYPOTHESES, OBJECTIVES, AND ENDPOINTS................................................27
4
STUDY DESIGN............................................................................................................29
4.1
Overall Design......................................................................................................29
4.2
Scientific Rationale for Study Design.................................................................31
4.2.1
Rationale for Endpoints ...............................................................................32
4.2.1.1
Immunogenicity Endpoints................................................................32
4.2.1.2
Safety Endpoints................................................................................32
4.2.1.3
Other Exploratory Endpoints.............................................................33
4.2.1.4
Pharmacokinetic Endpoints ...............................................................33
4.2.1.5
Pharmacodynamic Endpoints.............................................................33
4.2.2
Rationale for the Use of Comparator...........................................................33
4.3
Justification for Dose...........................................................................................33
4.4
Beginning and End-of-Study Definition ............................................................34
4.4.1
Clinical Criteria for Early Study Termination .............................................34
5
STUDY POPULATION ................................................................................................34
5.1
Inclusion Criteria.................................................................................................34
5.2
Exclusion Criteria................................................................................................36
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5.3
Lifestyle Considerations......................................................................................38
5.4
Screen Failures.....................................................................................................38
5.5
Participant Replacement Strategy......................................................................38
6
STUDY INTERVENTION............................................................................................38
6.1
Study Intervention(s) Administered...................................................................39
6.2
Preparation/Handling/Storage/Accountability .................................................41
6.2.1
Dose Preparation..........................................................................................41
6.2.2
Handling, Storage, and Accountability........................................................41
6.3
Measures to Minimize Bias: Randomization and Blinding..............................42
6.3.1
Intervention Assignment..............................................................................42
6.3.2
Stratification.................................................................................................42
6.3.3
Blinding........................................................................................................42
6.4
Study Intervention Compliance..........................................................................43
6.5
Management of GMO..........................................................................................43
6.6
Concomitant Therapy..........................................................................................43
6.6.1
Rescue Medications and Supportive Care ...................................................44
6.7
Dose Modification (Escalation/Titration/Other)...............................................44
6.7.1
Stopping Rules.............................................................................................44
6.8
Intervention After the End of the Study............................................................44
6.9
Clinical Supplies Disclosure................................................................................44
7
DISCONTINUATION OF STUDY INTERVENTION AND PARTICIPANT 
WITHDRAWAL............................................................................................................44
7.1
Discontinuation of Study Intervention...............................................................44
7.2
Participant Withdrawal From the Study...........................................................44
7.3
Lost to Follow-up .................................................................................................45
8
STUDY ASSESSMENTS AND PROCEDURES........................................................45
8.1
Administrative and General Procedures ...........................................................46
8.1.1
Informed Consent.........................................................................................46
8.1.1.1
General Informed Consent.................................................................46
8.1.2
Assignment of Screening Number...............................................................47
8.1.3
Participant Identification Card.....................................................................47
8.1.4
Inclusion/Exclusion Criteria ........................................................................47
8.1.5
Medical History ...........................................................................................47
8.1.6
Prior and Concomitant Medications Review...............................................48
8.1.6.1
Prior Medications...............................................................................48
8.1.6.2
Concomitant Medications..................................................................48
8.1.7
Pregnancy Testing........................................................................................48
8.1.8
Baseline Dengue Serostatus POC Screening Assay ....................................48
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8.1.9
Assignment of Treatment/Randomization Number.....................................49
8.1.10
Study Intervention Administration ..............................................................49
8.1.10.1
Timing of Dose Administration.........................................................49
8.1.11
Electronic Vaccination Report Card (eVRC) ..............................................50
8.1.12
Discontinuation and Withdrawal .................................................................50
8.1.13
Participant Blinding/Unblinding..................................................................50
8.1.14
Calibration of Equipment.............................................................................51
8.2
Immunogenicity and Other Laboratory Assessments......................................51
8.2.1
DENV-Reduction Neutralization Test (VRNT) ..........................................51
8.2.2
Dengue Viremia RT-PCR Assay (Dengue Vaccine and/or Dengue Wild 
Type)............................................................................................................52
8.2.3
Dengue NS1 ELISA.....................................................................................52
8.2.4
Exploratory Immunogenicity Testing..........................................................53
8.3
Safety Assessments...............................................................................................53
8.3.1
Physical Examinations Including Height and Weight .................................53
8.3.2
Vital Signs....................................................................................................54
8.3.3
Postvaccination Safety Observation Period.................................................54
8.3.4
Clinical Safety Laboratory Assessments .....................................................54
8.3.5
Assessment of Rash .....................................................................................55
8.3.6
Assessment of Suspected Dengue Disease ..................................................55
8.4
Adverse Events, Serious Adverse Events, and Other Reportable Safety 
Events....................................................................................................................58
8.4.1
Time Period and Frequency for Collecting AE, SAE, and Other 
Reportable Safety Event Information ..........................................................58
8.4.2
Method of Detecting AEs, SAEs, and Other Reportable Safety Events......60
8.4.3
Follow-up of AE, SAE, and Other Reportable Safety Event Information...60
8.4.4
Regulatory Reporting Requirements for SAE .............................................60
8.4.5
Pregnancy and Exposure During Breastfeeding ..........................................60
8.4.6
Disease-related Events and/or Disease-related Outcomes Not Qualifying 
as AEs or SAEs............................................................................................61
8.4.7
Adverse Events Reported on the eVRC.......................................................61
8.4.7.1
Solicited Adverse Events ...................................................................61
8.4.7.2
Unsolicited Adverse Events...............................................................62
8.4.8
Events of Clinical Interest............................................................................62
8.5
Treatment of Overdose........................................................................................62
8.6
Pharmacokinetics.................................................................................................62
8.7
Pharmacodynamics..............................................................................................62
8.8
Visit Requirements...............................................................................................62
8.8.1
Screening......................................................................................................63
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8.8.2
Treatment Period/Vaccination Visit ............................................................63
9
STATISTICAL ANALYSIS PLAN .............................................................................63
9.1
Statistical Analysis Plan Summary.....................................................................63
9.2
Responsibility for Analyses/In-house Blinding .................................................64
9.3
Hypotheses/Estimation ........................................................................................65
9.4
Analysis Endpoints...............................................................................................65
9.4.1
Immunogenicity and Viremia Endpoints.....................................................65
9.4.2
Safety Endpoints..........................................................................................66
9.5
Analysis Populations............................................................................................67
9.5.1
Immunogenicity Analysis Populations ........................................................67
9.5.2
Safety Analysis Populations ........................................................................67
9.6
Statistical Methods...............................................................................................67
9.6.1
Statistical Methods for Immunogenicity Analyses......................................68
9.6.2
Statistical Methods for Safety Analyses ......................................................69
9.6.2.1
Overall Safety Assessment ................................................................69
9.6.2.2
Assessment of Safety Topics of Special Interest ...............................70
9.6.3
Summaries of Baseline Characteristics, Demographics, and Other 
Analyses.......................................................................................................71
9.7
Interim Analyses ..................................................................................................71
9.8
Multiplicity ...........................................................................................................72
9.9
Sample Size and Power Calculations .................................................................72
9.9.1
Sample Size and Power for Immunogenicity Analyses...............................72
9.9.2
Sample Size and Power for Safety Analyses ...............................................72
9.10
Subgroup Analyses...............................................................................................73
9.11
Compliance (Medication Adherence).................................................................73
9.12
Extent of Exposure...............................................................................................74
10
SUPPORTING DOCUMENTATION AND OPERATIONAL 
CONSIDERATIONS.....................................................................................................75
10.1
Appendix 1: Regulatory, Ethical, and Study Oversight Considerations........75
10.1.1
Code of Conduct for Clinical Trials.............................................................75
10.1.2
Financial Disclosure.....................................................................................77
10.1.3
Data Protection.............................................................................................77
10.1.3.1
Confidentiality of Data ......................................................................78
10.1.3.2
Confidentiality of Participant Records...............................................78
10.1.3.3
Confidentiality of IRB/IEC Information............................................78
10.1.4
Committees Structure...................................................................................79
10.1.4.1
Executive Oversight Committee........................................................79
10.1.4.2
External Data Monitoring Committee ...............................................79
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10.1.5
Publication Policy........................................................................................79
10.1.6
Compliance with Study Registration and Results Posting Requirements ...79
10.1.7
Compliance with Law, Audit, and Debarment ............................................80
10.1.8
Data Quality Assurance ...............................................................................81
10.1.9
Source Documents .......................................................................................82
10.1.10
Study and Site Closure.................................................................................82
10.2
Appendix 2: Clinical Laboratory Tests..............................................................83
10.3
Appendix 3: Adverse Events: Definitions and Procedures for Recording, 
Evaluating, Follow-up, and Reporting...............................................................84
10.3.1
Definitions of Medication Error, Misuse, and Abuse..................................84
10.3.2
Definition of AE ..........................................................................................84
10.3.3
Definition of SAE ........................................................................................86
10.3.4
Additional Events Reported.........................................................................87
10.3.5
Recording AE and SAE ...............................................................................87
10.3.6
Reporting of AEs, SAEs, and Other Reportable Safety Events to MSD.....93
10.3.7
2009 WHO Dengue Guidelines for Diagnosis, Treatment, Prevention 
and Control...................................................................................................94
10.4
Appendix 4: Device Events, Adverse Device Events, and Medical Device 
Incidents: Definitions, Collection, and Documentation....................................95
10.5
Appendix 5: Contraceptive Guidance................................................................96
10.5.1
Definitions....................................................................................................96
10.5.2
Contraception Requirements........................................................................97
10.6
Appendix 6: Collection and Management of Specimens for Future 
Biomedical Research............................................................................................98
10.7
Appendix 7: Country-specific Requirements....................................................99
10.8
Appendix 8: Abbreviations ...............................................................................100
11
REFERENCES.............................................................................................................102
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LIST OF TABLES
Table 1
Study Interventions..........................................................................................40
Table 2
Evaluation and Outcomes for Febrile Event Assessments ..............................56
Table 3
Reporting Time Periods and Time Frames for Adverse Events and Other 
Reportable Safety Events.................................................................................59
Table 4
Solicited Adverse Events for V181-002 ..........................................................61
Table 5
Analysis Strategy for Primary Immunogenicity Variables..............................69
Table 6
Analysis Strategy for Safety Parameters..........................................................71
Table 7
Differences in Incidence of Adverse Event Rates Between the 2 
Vaccination Groups That Can be Detected With an ~80% Probability 
(Assuming a 2-Sided 5% Alpha Level With 620 Participants in the V181 
Group and 620 Participants in the Butantan-DV Group).................................73
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LIST OF FIGURES
Figure 1
V181-002 Study Design...................................................................................17
Figure 2
V181-002 Assessment of Febrile Events for Suspected Dengue Disease.......57
Figure 3
Suggested Dengue Case Classification and Levels of Severity.......................94
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1
PROTOCOL SUMMARY
1.1
Synopsis
Protocol Title: A Phase 2, Randomized, Double-Blind, Multicenter, Safety and 
Immunogenicity Clinical Bridging Study to Compare V181 (Dengue Quadrivalent Vaccine 
rDENVΔ30 [live, attenuated]) to Butantan Dengue Vaccine (Butantan-DV) in Healthy 
Adults 18 to 50 Years of Age in Brazil
Short Title: Phase 2 Bridging Study of V181 to Butantan Dengue Vaccine in Healthy Adults
Acronym: V181-002
Hypotheses, Objectives, and Endpoints:
Hypotheses are aligned with objectives in the Objectives and Endpoints table.
The following objectives and endpoints will be evaluated in healthy participants 18 to 
50 years of age (inclusive) in low dengue-endemic areas in Brazil.
Primary Objectives
Primary Endpoints
- To compare the dengue virus-neutralizing 
antibody geometric mean titers (GMTs) for 
each of the 4 dengue serotypes at Day 28 
postvaccination for participants 
administered V181 versus Butantan-DV 
Hypothesis (H1): V181 is non-inferior to 
Butantan-DV for each of the 4 dengue 
serotypes based on GMTs at Day 28 
postvaccination.
(The statistical criterion for non-inferiority 
requires the lower bound of the 2-sided 95% 
CI of the GMT ratio [V181 versus 
Butantan-DV] to be greater than 0.67 for 
each dengue serotype).
- Dengue virus-neutralizing antibody titers 
for each of the 4 dengue serotypes as 
measured by virus reduction neutralization 
test (VRNT) 
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- To compare the dengue virus-neutralizing 
antibody seroconversion rates for each of 
the 4 dengue serotypes at Day 28 
postvaccination for participants 
administered V181 versus Butantan-DV 
Hypothesis (H2): V181 is non-inferior to 
Butantan-DV for each of the 4 dengue 
serotypes based on seroconversion rates at 
Day 28 postvaccination.
(The statistical criterion for non-inferiority 
requires the lower bound of the 2-sided 95% 
CI of the difference in the seroconversion 
rates [V181 minus Butantan-DV] to be 
greater than -0.1 for each dengue serotype).
- Dengue virus-neutralizing antibody titers 
for each of the 4 dengue serotypes as 
measured by VRNT
- To evaluate the safety and tolerability of 
V181 and Butantan-DV with respect to the 
proportion of participants experiencing 
vaccine-related serious adverse events 
(SAEs)
- Vaccine-related SAEs from Day 1 through 
Day 28 postvaccination
Secondary Objective
Secondary Endpoint
- To evaluate the safety and tolerability of 
V181 and Butantan-DV with respect to the 
proportion of participants experiencing 
solicited AEs
- Solicited injection-site AEs from Day 1 
through Day 5 postvaccination
- Solicited systemic AEs from Day 1 
through Day 28 postvaccination
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Overall Design:
Study Phase
Phase 2
Primary Purpose
Prevention
Indication
Prevention of dengue disease in toddlers, children, and 
adults in endemic areas, as well as travelers to endemic 
areas
Population
Healthy adults 18 to 50 years of age
Study Type
Interventional
Intervention Model
Parallel
This is a multisite study
Type of Control
Active Control Without Placebo
Study Blinding
Double-blind with in-house blinding
Blinding Roles
Sponsor
MSD
Investigator
Participants
Estimated Duration of Study
MSD estimates that the study will require approximately 
22 months from the time the first participant (or their 
legally acceptable representative) provides documented 
informed consent until the last participant’s last study-
related contact.
For purposes of analysis and reporting, the overall study 
ends when MSD receives the last laboratory result or at the 
time of final contact with the last participant, whichever 
comes last.
Number of Participants:
Approximately 1240 participants will be randomized in this study.
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Intervention Groups and Duration:
Intervention 
Groups
Arm Name
Intervention 
Name
Dosage Level/
Unit Dose 
Strength
Vaccine 
Regimen
Route 
of 
Admin.
Use
V181
Group
V181
 
 
Single 
dose at 
Visit 1 
SC
Test Product
Butantan-
DV
Group
Butantan-DV
 
 
Single 
dose at 
Visit 1 
SC
Test Product
Admin=administration; DV=dengue vaccine; PFU=plaque forming unit; SC=subcutaneous
Total Number
of Intervention 
Groups/ Arms
2
Duration of 
Participation
Each participant will participate in the study for approximately 
12 months from the time the participant provides documented informed 
consent through the final contact.
Study Governance Committees:
Steering Committee
No  
Executive Oversight Committee
Yes
Data Monitoring Committee
Yes
Clinical Adjudication Committee
No
Study governance considerations are outlined in Appendix 1.
Study Accepts Healthy Volunteers: Yes
A list of abbreviations used in this document can be found in Appendix 8.
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1.2
Schema
The study design is depicted in Figure 1.
Figure 1
V181-002 Study Design
eVRC=electronic Vaccination Report Card; MAAE=medically attended adverse event; N=number of participants; 
n=number of participants in vaccination group; SAE=serious adverse event.
a
Participants who report rash onset from Day 1 through Day 28 postvaccination should contact the site promptly to 
ensure that the rash is assessed by the investigator within 72 hours of onset. If rash assessment cannot occur at a 
planned visit (Visit 2, 3, or 4) within 72 hours of the participant’s rash onset, then the rash should be assessed by the 
investigator at an unscheduled visit.
b
Participants who experience protocol-specified fever (axillary temperature of ≥37.8°C) for ≥2 consecutive days 
postvaccination at any time during the study should schedule an initial evaluation for suspected dengue as soon as 
possible and no later than 8 days after the second day of protocol-specified fever. 
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1.3
Schedule of Activities
1.3.1
Study Procedures for All Participants
Study Period
Screening/
Randomization/
Intervention
Follow-up
(through Month 12 postvaccination)
Notes
Visit Number:
1
2
3
4
5
6
7
8
Scheduled 
Day/Month
Day 1
Day 7 
Day 12
Day 28
Month 3
Month 6 
Phone Call
Month 9
Phone Call
Month 12 
Visit Window 
Permitted a
Pre-
Dose
Dose
Post-
Dose
±2 days
D5-D9
±2 days
D10-D14
+14 days
D28-D42
±14 days
D76-D104
±14 days
D166-D194
±14 days
D256-D284
±14 days
D346-D374
Screening Procedures
Informed Consent
X
Consent must be 
obtained PRIOR to 
any study procedures, 
including screening.
Assignment of 
Screening Number
X
Participant 
Identification Card
X
Inclusion/
Exclusion Criteria 
X
Medical History b
X
Prior b/Concomitant 
Medications/ 
Vaccines Review
X
X
X
X
X
X
X
X
After V4, report only 
concomitant 
medications 
associated with SAEs
or dengue events, or 
receipt of any 
investigational or 
approved dengue 
vaccine (Section 6.6).
Urine Pregnancy 
Test (WOCBP only)
X
Performed by 
site/local laboratory. 
WOCBP must have 
negative result prior to 
vaccination.
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Study Period
Screening/
Randomization/
Intervention
Follow-up
(through Month 12 postvaccination)
Notes
Visit Number:
1
2
3
4
5
6
7
8
Scheduled 
Day/Month
Day 1
Day 7 
Day 12
Day 28
Month 3
Month 6 
Phone Call
Month 9
Phone Call
Month 12 
Visit Window 
Permitted a
Pre-
Dose
Dose
Post-
Dose
±2 days
D5-D9
±2 days
D10-D14
+14 days
D28-D42
±14 days
D76-D104
±14 days
D166-D194
±14 days
D256-D284
±14 days
D346-D374
Serum hCG 
(WOCBP only)
X
Serum hCG is tested 
only if the urine 
pregnancy test is 
inconclusive.
Baseline Dengue 
Serostatus POC
Screening Assay
X
Result must be dengue 
seronegative to
proceed with 
randomization.
See Section 8.1.8.
Randomization/Vaccination
Assignment of 
Randomization 
Number
X
Study Vaccine 
Administration
X
Provide Electronic 
Device or Configure 
Participant’s Own 
Electronic Device 
for eVRC Data 
Collection
X
Study-site personnel 
will train participant 
on use of eVRC.
Immunogenicity Procedures
Serum Samples for 
Dengue Antibody 
Titers (VRNT)
X
X
X
X
Day 1 blood sample 
must be collected 
prior to vaccination. 
Safety Procedures
Full Physical 
Examination 
Including Height 
and Weight
X
See Section 8.3.1.
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Study Period
Screening/
Randomization/
Intervention
Follow-up
(through Month 12 postvaccination)
Notes
Visit Number:
1
2
3
4
5
6
7
8
Scheduled 
Day/Month
Day 1
Day 7 
Day 12
Day 28
Month 3
Month 6 
Phone Call
Month 9
Phone Call
Month 12 
Visit Window 
Permitted a
Pre-
Dose
Dose
Post-
Dose
±2 days
D5-D9
±2 days
D10-D14
+14 days
D28-D42
±14 days
D76-D104
±14 days
D166-D194
±14 days
D256-D284
±14 days
D346-D374
Vital Signs
X
See Section 8.3.2.
Postvaccination 
Safety Observation
X
Observe participant 
for at least 30 minutes 
following vaccination 
for any immediate 
reactions.
See Section 8.3.3.
AE/SAE Review
X
X
X
X
X
X
X
X
After V4, report
only MAAEs, SAEs, 
deaths, and dengue-
related events.
Rashes with onset 
D1 through D28 
postvaccination 
should be evaluated 
by the investigator 
within 72 hours of 
onset (Section 8.3.5).
Review eVRC Data 
with Participant
X
X
X
Collect Electronic 
Device From 
Participant
X
For participants who 
were provided an 
electronic device.
Viremia
Blood for Viremia 
Testing (RT-PCR)
X
X
There must be at least 
2 days between V2 
and V3.
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AE=adverse event; D=day; eVRC=electronic Vaccination Report Card; hCG=human chorionic gonadotropin; MAAE=medically attended adverse event; POC=point of care;
RT-PCR=reverse transcription polymerase chain reaction; SAE=serious adverse event; V=visit; VRNT=virus reduction neutralization test; WOCBP=women of childbearing 
potential.
a
To calculate subsequent visit windows, assume that 1 month equals to 30 days.
b
For those participants remaining in the study at the time of Amendment 04, the investigator will also inquire about the participant’s history of any other flavivirus infection(s) 
and any other flavivirus vaccination, at any time prior to Vist 1 (Day 1) (see Section 8.1.5 and Section 8.1.6.1).
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1.3.2
Study Procedures for Participants With Suspected Dengue
Procedures at Unscheduled 
Visits 
(Full Duration of Study)
Acute Initial Evaluation Visit
Convalescent Follow-up Visit
14 to 28 Days After 
Acute Initial Evaluation Visit
Notes
Participants who experience protocol-specified 
fever (axillary temperature of ≥37.8°C) for ≥2 
consecutive days postvaccination at any time 
during the study should schedule an acute visit
as soon as possible and no later than 8 days 
after the second day of protocol-specified fever.
If the investigator assesses a case as 
dengue or possible/probable dengue, a 
convalescent follow-up visit is to occur 
14 to 28 days after the acute visit to 
collect information about the severity 
and recovery from the febrile illness.
Study Procedures
Clinical evaluation for dengue
X
X
Investigators will conduct a clinical 
evaluation using the 2009 WHO 
Dengue Guidelines. See Section 10.3.6.
Directed physical examination 
X
X
See Section 8.3.1.
Vital signs
X
X
See Section 8.3.2.
Concomitant 
medications/vaccines review
X
X
After Day 28 postvaccination (V4), 
report only concomitant medications 
associated with SAEs or dengue events, 
or receipt of any investigational or 
approved dengue vaccine. See Section 
6.6.
Safety Evaluations
AEs/SAEs review
X
X
After Day 28 postvaccination (V4), 
report MAAEs and SAEs (regardless of 
causality), deaths (due to any cause), 
and dengue-related events (regardless of 
seriousness).
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Procedures at Unscheduled 
Visits 
(Full Duration of Study)
Acute Initial Evaluation Visit
Convalescent Follow-up Visit
14 to 28 Days After 
Acute Initial Evaluation Visit
Notes
Participants who experience protocol-specified 
fever (axillary temperature of ≥37.8°C) for ≥2 
consecutive days postvaccination at any time 
during the study should schedule an acute visit
as soon as possible and no later than 8 days 
after the second day of protocol-specified fever.
If the investigator assesses a case as 
dengue or possible/probable dengue, a 
convalescent follow-up visit is to occur 
14 to 28 days after the acute visit to 
collect information about the severity 
and recovery from the febrile illness.
Specimen Collection
Serum sample for DENV
detection by quantitative 
serotype-specific RT-PCR
X
A participant may have an acute visit on 
the first day of protocol-specified fever
if they choose; however, if the fever 
persists on the second consecutive day, 
the participant must return for a second 
serum sample collection no later than 8 
days after the second day of protocol-
specified fever. See Section 8.3.6.
Serum sample for DENV
antigen detection by NS1 
ELISA
X
AE=adverse event; DENV=dengue virus; ELISA=enzyme-linked immunosorbent assay; MAAE=medically attended adverse event; NS=non-structural protein; RT-
PCR=reverse transcription polymerase chain reaction; SAE=serious adverse event; V=visit; WHO=World Health Organization
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2
INTRODUCTION
The dengue quadrivalent vaccine rDENVΔ30 (live, attenuated), hereafter referred to as 
V181, is a dengue vaccine that is being developed by Merck Sharp & Dohme LLC (hereafter 
referred to as MSD) in collaboration with Instituto Butantan (hereafter referred to as Sponsor
or Butantan) for the prevention of dengue disease in individuals at risk of exposure by living 
in or traveling to dengue-endemic areas. V181 is also known as dengue Live-Attenuated 
Tetravalent Vaccine (LATV) in some preclinical and Phase 1 studies.
Similarly to V181, the parental viruses for the Butantan-DV were initially developed by NIH. 
V181, Butantan-DV, and the NIH dengue LATV TV003 are analogous quadrivalent
formulations as they all have the same parental strains, similar amounts of each attenuated 
virus strains per dose, are produced using similar methods, and have the same antigenic 
composition.
The Sponsor of the study is Butantan, and the study will be conducted by MSD in 
collaboration with the Sponsor in a manner consistent with the MSD Code of Conduct for 
Clinical Trials (Section 10.1.1).
2.1
Study Rationale
The purpose of this study is to demonstrate that V181 and Butantan-DV have a comparable 
safety and immunogenicity profile in healthy participants 18 to 50 years of age in Brazil. The 
age range of 18 to 50 years was selected in order to include healthy adults with intact 
immune systems capable of optimal immune responses in this study that includes hypothesis-
driven primary immunogenicity objectives. Differences are not expected in immunogenicity 
by age subgroup within this study population. To avoid the impact of pre-existing immunity 
on the immune responses induced postvaccination, participants must be seronegative to all 4 
dengue serotypes at baseline. Because the DENVs share common epitopes, having a prior 
exposure to 1 serotype influences the response to the other serotypes, which may confound 
the primary immunogenicity hypotheses.
The 2 vaccines originate from the same viral lineage (the same NIH live-attenuated viruses), 
thus contain the same antigenic composition and are produced by similar manufacturing 
processes utilizing adherent Vero cell cultures. However, V181 and Butantan-DV products 
were developed independently from each other, are produced from independently derived 
viral seeds, and while the processes are similar, there are some minor differences in the 
process itself, in the facilities/equipment used to manufacture the products, and in the 
composition and concentration of the excipients in the drug product formulation. Despite 
these minor differences, the safety and immunogenicity profiles of V181 are expected to be 
similar to those of Butantan-DV.
2.2
Background
Refer to the IB for detailed background information on V181, NIH dengue LATV, and 
Butantan-DV.
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2.2.1
Dengue Disease and V181 Development 
Dengue is among the most important arthropod-borne viral diseases in terms of human 
morbidity and mortality in the world [World Health Organization 2009] [Guzman, M. G., et 
al 2002] [Anderson, K. B., et al 2007] [Torres, J. R. and Castro, J. 2007] [Guzman, M. G., et 
al 2010] [Whitehorn, J. and Farrar, J. 2010] [Halstead, S. B. 2007] [Tapia-Conyer, R., et al 
2009] [Suaya, J. A., et al 2009]. Dengue is endemic in many tropical and subtropical
countries in Africa, the Americas, the Eastern Mediterranean, Asia, and the Pacific islands.
Approximately 3 to 4 billion people live in these countries and are therefore at risk for 
dengue infection [Gubler, D. J. 2002] [Brady, O. J., et al 2012]. Furthermore, approximately 
120 million people travel to dengue-endemic regions annually [Suaya, J. A., et al 2009].
Dengue disease is caused by any one of 4 virus serotypes (DENV1, DENV2, DENV3, and 
DENV4). Each serotype is widely distributed and capable of causing the full spectrum of 
dengue disease ranging from an inapparent or mild febrile illness, to classic DF characterized 
by high fever, headache, joint and muscle pain, rash, lymphadenopathy, and leukopenia, to 
life-threatening DHF and DSS. Primary dengue infection results in the induction of virus-
neutralizing antibodies that are broadly cross-reactive early after infection and become more 
type-specific over time. Primary dengue infection confers long-lasting immunity against the 
infecting serotype, but only short-term protection against the other dengue serotypes. There is 
a strong association between a later second infection with a different viral serotype and the 
more severe disease forms (ie, DHF and DSS). It has been hypothesized that the increase in 
severity with secondary infection may be immune mediated through a mechanism termed 
antibody-dependent enhancement [Halstead, S. B. 2007] [Halstead, S. B. 2014] [Guzman, M. 
G., et al 2013]. According to this theory, non-neutralizing, cross-reactive, heterotypic 
antibodies bind to a heterologous infecting serotype and facilitate uptake of the virus into Fc 
receptor-bearing target cells (such as monocytes and macrophages), leading to increased viral
replication, higher viral and viral antigen NS1 loads and cytokine release, which 
cumulatively manifests in the plasma leakage syndrome observed in DHF. Therefore, the 
major approach for developing an effective dengue vaccine and mitigating the risk of 
vaccine-induced sensitivity for more severe disease is a quadrivalent vaccine that will 
simultaneously and durably protect against disease caused by all 4 dengue serotypes 
[Halstead, S. B. and Deen, J. 2002]. 
Each year, approximately 390 million people are infected with dengue globally, causing an 
estimated 96 million symptomatic cases, with 2.1 million of those cases being classified as 
severe, resulting in approximately 21,000 deaths [Bhatt, S., et al 2013] [Thomas, S. J. and 
Endy, T. P. 2011]. Brazil is considered hyper-endemic for dengue with more than 12 million 
cases reported between 1990 and 2017 (with approximately 9 million reported between 2008 
and 2017) [Andrioli, D. C., et al 2020]. Dengue disease in Brazil affects primarily 
adolescents and adults, with adults (18 to 59 years of age) contributing 60% to 70% of
reported dengue cases. While the majority of dengue illness in Brazil is currently 
concentrated among adolescents and adults, data from the countrywide surveillance systems 
observed that, between 1998 and 2006, most cases of DHF were among adults 20 to 40 years 
of age, while in 2007, more than 53% of DHF cases occurred in children less than 15 years of 
age, with more than 40% of dengue hospitalizations among children less than 10 years of age 
indicating a possible increase in disease burden in children [Teixeira, M. G., et al 2013]. 
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V181 is comprised of the attenuated viral strains rDENV1Δ30, rDENV2/4Δ30(ME), 
rDENV3Δ30/31, and rDENV4Δ30 and is intended to prevent disease caused by each of the 
4 dengue serotypes (DENV1, DENV2, DENV3, and DENV4). The parental viruses for V181 
were initially developed by the US NIH. 
Attenuation of all 4 viral components in NIH dengue LATV was achieved by genetic 
modification, eg, deletion of 30 nucleotides in the 3’ non-coding region (∆30) of the dengue 
genome. DENV2 is the only serotype that is not a full-length homotypic genome, but is 
instead a chimeric virus with the prM and E protein from DENV2 inserted into an attenuated 
DENV4 backbone. In addition, DENV3 also has an additional 31-nucleotide deletion in the 3 
non-coding region (∆30/31). The vaccine viral strains are referred to as rDENV1∆30, 
rDENV2/4∆30(ME), rDENV3∆30/31, and rDENV4∆30 for DENV1, 2, 3, and 4 
respectively. 
All of the final vaccine strains have been fully characterized and their attenuation confirmed 
through in vitro and in vivo testing.
The overall goal of the V181 program is to demonstrate that a single SC dose of V181 is 
effective in preventing disease from all 4 dengue serotypes in both dengue-naïve and 
dengue-experienced individuals.
2.2.2
Preclinical and Clinical Studies
2.2.2.1
Preclinical Studies
Nonclinical studies have been performed on the components of the NIH dengue LATV 
formulation, which supports the V181 clinical program given that the vaccines are similar in 
design. Preclinical data for V181 and the NIH dengue LATV are provided in the V181 IB.
2.2.2.2
Clinical Studies
A brief summary of completed clinical studies is provided below, and details are provided in 
the V181 and Butantan-DV IBs.
2.2.2.2.1
MSD V181 Completed Clinical Studies
Results from the V181-001 Phase 1 study indicated V181 is highly immunogenic through 
6 months Postdose 1, with a second dose in 6 months resulting in minimal or no additional 
boosting. The vaccine was generally safe and well tolerated in flavivirus-naïve and 
flavivirus-experienced participants though 1 year Postdose 2. AEs were generally assessed as 
mild to moderate in intensity by the participants.
2.2.2.2.2
NIH Dengue LATV Clinical Studies
The NIH has administered the dengue LATV monovalent components or tetravalent 
formulations comprising the same parental strains as V181 to more than 1000 participants to 
date, with studies in the US, Bangladesh, and Thailand. The NIH monovalent and tetravalent 
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vaccines were generally well tolerated in both nonclinical and clinical studies conducted by 
the NIH. 
2.2.2.2.3
Butantan-DV Clinical Studies
Butantan-DV was administered in a Phase 2 study of 300 participants (of which 210 received 
Butantan-DV) in Brazil and was found to be immunogenic and generally safe and well 
tolerated in both dengue-naïve and dengue-experienced participants [Kallas, E. G., et al 
2020]. It is currently being investigated in a Phase 3 safety and efficacy study with about 
17,000 participants 2 to 59 years of age in Brazil. The Butantan-DV that will be used in this 
study will be manufactured in the same facility and with the same manufacturing process that 
produced the Butantan-DV used in the Phase 3 efficacy study.
2.3
Benefit/Risk Assessment
It cannot be guaranteed that participants will directly benefit from study vaccination during 
participation, since this clinical study is being conducted to evaluate the safety and 
immunogenicity of an investigational dengue vaccine.
Data generated to date in V181, NIH dengue LATV, and Butantan-DV clinical studies 
demonstrate that these vaccines are generally safe, well tolerated, and highly immunogenic. 
The frequency, severity, and magnitude of the AEs identified in these studies support a 
favorable benefit-risk analysis for the dengue vaccine in the study population.
Additional details regarding specific benefits and risks for the participants in this clinical 
study may be found in the accompanying IB and informed consent documents.
3
HYPOTHESES, OBJECTIVES, AND ENDPOINTS
Hypotheses are aligned with objectives in the Objectives and Endpoints table.
The following objectives and endpoints will be evaluated in healthy participants 18 to 
50 years of age (inclusive) in low dengue-endemic areas in Brazil.
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Objectives
Endpoints
Primary

To compare the dengue virus-
neutralizing antibody geometric mean 
titers (GMTs) for each of the 4 dengue 
serotypes at Day 28 postvaccination for 
participants administered V181 versus 
Butantan-DV
Hypothesis (H1): V181 is non-inferior 
to Butantan-DV for each of the 4 dengue 
serotypes based on GMTs at Day 28 
postvaccination.
(The statistical criterion for non-
inferiority requires the lower bound of 
the 2-sided 95% CI of the GMT ratio 
[V181 versus Butantan-DV] to be 
greater than 0.67 for each dengue 
serotype).

Dengue virus-neutralizing antibody 
titers for each of the 4 dengue serotypes 
as measured by virus reduction 
neutralization test (VRNT) 

To compare the dengue virus-
neutralizing antibody seroconversion 
rates for each of the 4 dengue serotypes 
at Day 28 postvaccination for 
participants administered V181 versus 
Butantan-DV
Hypothesis (H2): V181 is non-inferior 
to Butantan-DV for each of the 4 dengue 
serotypes based on seroconversion rates 
at Day 28 postvaccination.
(The statistical criterion for non-
inferiority requires the lower bound of 
the 2-sided 95% CI of the difference in 
the seroconversion rates [V181 minus 
Butantan-DV] to be greater than -0.1 for 
each dengue serotype).

Dengue virus-neutralizing antibody 
titers for each of the 4 dengue serotypes 
as measured by VRNT

To evaluate the safety and tolerability of 
V181 and Butantan-DV with respect to
the proportion of participants 
experiencing vaccine-related serious 
adverse events (SAEs)

Vaccine-related SAEs from Day 1 
through Day 28 postvaccination
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Objectives
Endpoints
Secondary

To evaluate the safety and tolerability of 
V181 and Butantan-DV with respect to 
the proportion of participants 
experiencing solicited AEs

Solicited injection-site AEs from Day 1 
through Day 5 postvaccination

Solicited systemic AEs from Day 1 
through Day 28 postvaccination
Tertiary/Exploratory
4
STUDY DESIGN
4.1
Overall Design
This is a randomized, double-blind, active comparator-controlled, parallel-group, multisite, 
study to evaluate the safety and immunogenicity of V181 compared with Butantan-DV in 
healthy adults 18 to 50 years of age in Brazil.
Approximately 1240 participants will be randomized in a 1:1 ratio to receive a single dose of 
V181 or Butantan-DV. The duration of the study for each participant will be approximately 
CCI
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12 months from the time the participant provides documented informed consent through the 
final contact.
Butantan has extensive experience evaluating Butantan-DV in Brazil and has active 
regulatory activities in Brazil including an ongoing Phase 3 efficacy trial. Therefore, in order 
to leverage that experience, this study will be conducted at investigator sites within Brazil. 
Given the high rate of dengue transmission across many regions in Brazil, a two-stage 
strategy will be implemented to maximize recruitment of dengue-seronegative individuals. 
First, data generated previously from the dengue surveillance system in Brazil (SINAN) as 
well as seroepidemiologic data collected from Brazilian populations will be reviewed to 
identify study sites with historically lower rates of dengue illness. Second, a POC serologic 
screening assay will be conducted at screening to determine a participant’s eligibility based 
on dengue serostatus.
An unblinded pharmacist or unblinded qualified study-site personnel will be required at each 
site to manage clinical supplies and prepare the study vaccines in order to maintain the 
blinding of the clinical material and the study. The unblinded pharmacist or unblinded 
qualified study-site personnel will mask each syringe to conceal the contents before
dispensing a vaccine dose to a blinded member of the study team for administration to the 
participant. The participant, investigator, and study-site personnel directly involved in the 
clinical evaluation of the participants, as well as MSD field personnel or delegate(s) and 
Sponsor and MSD Headquarters personnel involved with the conduct of this study will be
blinded to the participant-level intervention assignments. 
Prior to randomization and administration of study vaccine, participants will be screened to 
document general good health on Day 1. All participants will be provided an electronic 
device or have their own electronic device configured, if compatible, to complete the eVRC
on a daily basis from the day of vaccination (Day 1) through Day 28 postvaccination in order 
to collect the following data:

Solicited injection-site AEs of injection-site pain, injection-site erythema, and 
injection-site swelling from Day 1 through Day 5 postvaccination 

Solicited systemic AEs of rash, headache, fatigue (tiredness), myalgia (muscle pain), 
and arthralgia (joint pain) from Day 1 through Day 28 postvaccination

Unsolicited AEs from Day 1 through Day 28 postvaccination

Axillary temperatures from Day 1 through Day 28 postvaccination

Concomitant medications and nonstudy vaccines from Day 1 through Day 28 
postvaccination.
Following Day 28 postvaccination, MAAEs and SAEs (regardless of causality), deaths (due 
to any cause), and dengue-related events (regardless of seriousness) defined as laboratory-
confirmed DF, DHF, and/or DSS will be reported through Month 12 postvaccination. 
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Participants who report protocol-specified fever, defined as axillary temperature ≥37.8°C, for 
at least 2 consecutive days postvaccination at any time during the study, will be instructed to 
schedule an acute visit for clinical evaluation and serum collection to test for dengue disease.
The acute visit should occur as soon as possible and no later than 8 days after the second 
consecutive day of protocol-specified fever. Alternately, a participant may have an acute visit
on the first day of protocol-specified fever if they choose, but if the fever persists on the 
second consecutive day, the participant must return for collection of a second serum sample 
within the aforementioned time period (see Figure 2 in Section 8.3.6). Investigators will 
conduct the clinical evaluation using the 2009 WHO Dengue Guidelines [World Health 
Organization 2009] (Section 10.3.6) to assess for dengue disease symptoms and clinical 
severity. 
Virologically confirmed dengue is defined as 2 or more consecutive days of axillary 
temperature ≥37.8°C with positive results for quantitative serotype-specific RT-PCR assay 
and/or NS1 ELISA. 
Participant safety will be monitored by an eDMC that will perform periodic reviews of safety 
data throughout the study (Appendix 1). Details will be provided in the eDMC charter.
Details on the safety endpoints evaluated in this study, including the endpoints reported on 
the eVRC, are provided in Section 8.3 and Section 9.4.2. Details on AEs, including 
definitions and reporting requirements, are provided in Appendix 3.
Blood samples for the assessment of immune responses will be collected from all participants 
prior to vaccination on Day 1 and at the Day 28, Month 3, and Month 12 postvaccination 
time points. As this study will be conducted in low dengue-endemic areas of Brazil and 
screening POC dengue serologic testing will be performed, it is expected that the baseline 
serostatus for the majority of randomized participants will be dengue seronegative. The final 
determination of baseline serostatus for the purposes of the primary analysis will be 
determined by VRNT. All participants with a prevaccination VRNT result that is seropositive 
for any 1 of the 4 dengue serotypes by VRNT will be excluded from the primary PP 
immunogenicity analysis population, as described in Section 9.5.1. Seropositivity is defined 
as having a serotype-specific VRNT titer at or above the LLOQ of the assay.
In addition to safety and immunogenicity assessments, blood samples for viremia testing will 
be obtained at the Day 7 and Day 12 postvaccination time points.
Specific procedures to be performed during the study, including prescribed times and 
associated visit windows, are outlined in Section 1.3. Details of each procedure are provided 
in Section 8.
4.2
Scientific Rationale for Study Design
The purpose of this study is to demonstrate that V181 is safe and well tolerated and elicits an 
immune response that is non-inferior to that of Butantan-DV at Day 28 postvaccination in 
adults 18 to 50 years of age in Brazil. 
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For the primary safety endpoint, the incidence of vaccine-related SAEs reported from Day 1 
through Day 28 postvaccination will be evaluated to demonstrate that V181 and Butantan-
DV have a similar safety profile. For the primary immunogenicity endpoints, geometric mean
antibody titers and seroconversion rates at Day 28 postvaccination will be assessed to 
determine that the elicited immune response is comparable between V181 and Butantan-DV. 
The primary safety and immunogenicity analyses will be conducted at the Day 28 
postvaccination time point to support clinical bridging between V181 and Butantan-DV. A 
CSR will be produced to present the study results from Day 1 through Day 28 
postvaccination. Safety and immunogenicity results from Day 28 through Month 12 
postvaccination will be summarized in a final, separate study report.
4.2.1
Rationale for Endpoints
4.2.1.1
Immunogenicity Endpoints
The ability of V181 and Butantan-DV to induce neutralizing antibodies to the 4 vaccine virus 
serotypes through Day 28 postvaccination will be compared in this study using GMTs and 
seroconversion rates measured with the validated VRNT assay. GMTs and seroconversion 
rates are complementary ways of assessing vaccine immunogenicity. Seroconversion is 
defined as achieving a serotype-specific VRNT titer ≥LLOQ at Day 28 postvaccination in 
participants who are seronegative at baseline. The LLOQ is a measurable level of 
seroconversion in this baseline seronegative population.
The time point of Day 28 was chosen as the primary endpoint based on the immunogenicity 
results observed in the V181-001 Phase 1 study. Among flavivirus-naïve participants, the 
observed seropositivity rates ranged from 70.6% to 97.1% for each of the 4 dengue 
serotypes. The percentage of these flavivirus-naïve participants who achieved quadrivalent or 
trivalent responses was 86.5%. Additionally, antibody responses will be evaluated as 
presented below:
1. Visit 1 (baseline), Day 1, prevaccination
2. Visit 4, Day 28 postvaccination
3. Visit 5, Month 3 postvaccination
4. Visit 8, Month 12 postvaccination
The VRNT is a high-throughput virus-neutralization assay, specific for each of the 4 dengue 
serotypes (Section 8.2.1). While no correlate of protection has been established for dengue, 
the measurement of virus-neutralizing antibody responses provides a mechanism to assess 
the immunogenicity of the vaccine using a functional assay that may predict the potential for 
protection.
4.2.1.2
Safety Endpoints
The primary safety evaluation period for this study will be Day 1 through Day 28 
postvaccination. The 28-day primary safety follow-up period was chosen based on safety 
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data from the V181-001 Phase 1 clinical study and the clinical studies for the NIH LATV.
During this time period, active safety surveillance will be conducted using a validated eVRC, 
as was previously done in the V181-001 study.
Following Day 28 postvaccination, SAEs will be collected through Month 12 postvaccination 
for a comprehensive evaluation of safety for the duration of the trial.
4.2.1.3
Other Exploratory Endpoints
4.2.1.4
Pharmacokinetic Endpoints
Not applicable.
4.2.1.5
Pharmacodynamic Endpoints
Not applicable.
4.2.2
Rationale for the Use of Comparator
This study will compare the safety and immunogenicity of V181 to Butantan-DV, which 
serves as an active comparator. There is no placebo control group because the purpose of the 
study is to compare the safety and immunogenicity of V181 and Butantan-DV.
4.3
Justification for Dose
Results of the V181 Phase 1 study (V181-001) confirmed the acceptable safety, tolerability, 
and immunogenicity profiles of V181 at the proposed dose. Also, Butantan-DV was shown 
to be safe and induced robust balanced neutralizing antibody responses against the 4 DENV 
serotypes at the proposed dose in a Phase 2 trial and the same dose is being used in the 
ongoing Butantan-DV Phase 3 efficacy trial.
CCI
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4.4
Beginning and End-of-Study Definition
The overall study begins when the first participant (or their legally acceptable representative) 
provides documented informed consent. The overall study ends when the last participant 
completes the last study-related contact, withdraws consent, or is lost to follow-up (ie, the 
participant is unable to be contacted by the investigator).
For purposes of analysis and reporting, the overall study ends when MSD receives the last 
laboratory result or at the time of final contact with the last participant, whichever comes last.
4.4.1
Clinical Criteria for Early Study Termination
The clinical study may be terminated early if the extent (incidence and/or severity) of 
emerging effects/clinical endpoints is such that the risk/benefit ratio to the study population 
as a whole is unacceptable. In addition, further recruitment in the study or at (a) particular 
study site(s) may be stopped due to insufficient compliance with the protocol, GCP, and/or 
other applicable regulatory requirements, procedure-related problems or the number of 
discontinuations for administrative reasons is too high.
5
STUDY POPULATION
As stated in the Code of Conduct for Clinical Trials (Appendix 1.1) this study includes 
participants of varying age (as applicable), race, ethnicity, and sex (as applicable). The 
collection and use of these demographic data will follow all local laws and participant 
confidentiality guidelines while supporting the study of the disease, its related factors, and 
the IMP under investigation.
Healthy male and female participants between the ages of 18 and 50 years (inclusive) will be 
enrolled in this study.
Prospective approval of protocol deviations to recruitment and enrollment criteria, also 
known as protocol waivers or exemptions, is not permitted.
5.1
Inclusion Criteria
A participant is eligible for inclusion in the study if the participant meets all of the following 
criteria:
Type of Participant and Disease Characteristics
1.
Is healthy based on medical history and physical examination, according to the 
clinical judgment of the investigator.
Demographics
2.
Is male or female, from 18 years to 50 years of age inclusive, at the time of signing 
the informed consent.
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Male Participants
3.
Male participants are eligible to participate if they agree to the following for at least 
90 days after administration of study intervention:
•
Be abstinent from heterosexual intercourse as their preferred and usual lifestyle (abstinent 
on a long term and persistent basis) and agree to remain abstinent
OR
•
Must agree to use contraception unless confirmed to be azoospermic (vasectomized or 
secondary to medical cause [Appendix 5]) as detailed below:
-
Agree to use a male condom plus partner use of an additional contraceptive method 
when having penile-vaginal intercourse with a WOCBP who is not currently 
pregnant. Note: Men with a pregnant or breastfeeding partner must agree to remain 
abstinent from penile-vaginal intercourse or use a male condom during each episode 
of penile-vaginal penetration.
•
Contraceptive use by men should be consistent with local regulations regarding the 
methods of contraception for those participating in clinical studies.
Female Participants
4.
A female participant is eligible to participate if she is not pregnant or breastfeeding, 
and at least one of the following conditions applies: 
•
Is not a WOCBP
OR
•
Is a WOCBP and using a contraceptive method that is highly effective (with a failure rate 
of <1% per year), or be abstinent from heterosexual intercourse as their preferred and 
usual lifestyle (abstinent on a long term and persistent basis), as described in Appendix 5 
for at least 90 days after administration of study intervention. The investigator should 
evaluate the potential for contraceptive method failure (ie, noncompliance, recently 
initiated) in relationship to the first dose of study intervention.
•
A WOCBP must have a negative highly sensitive pregnancy test (urine or serum, as 
required by local regulations) before administration of study intervention.
•
If a urine test cannot be confirmed as negative (eg, an ambiguous result), a serum 
pregnancy test is required. In such cases, the participant must be excluded from 
participation if the serum pregnancy result is positive.
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•
The investigator is responsible for review of medical history, menstrual history, and 
recent sexual activity to decrease the risk for inclusion of a woman with an early 
undetected pregnancy.
•
Contraceptive use by women should be consistent with local regulations regarding the 
methods of contraception for those participating in clinical studies.
Informed Consent
5.
The participant (or legally acceptable representative) has provided documented
informed consent for the study. 
Additional Categories
6.
Is dengue seronegative based on a prevaccination POC dengue test.
5.2
Exclusion Criteria
The participant must be excluded from the study if the participant meets any of the following 
criteria:
(If a participant meets any of the exclusion criteria marked with an asterisk [*], the Day 1 
visit may be rescheduled for a time when these criteria are no longer met as long as the study 
is still open to enrollment.)
Medical Conditions
1.
Has a known history of dengue or Zika natural infection.
2.
* Has an acute febrile illness (axillary temperature ≥37.8°C) occurring within 
72 hours prior to receipt of study vaccine.
3.
Has a known hypersensitivity or history of severe allergic reaction (eg, swelling of 
the mouth and throat, difficulty breathing, hypotension or shock) to any component of 
the dengue vaccine, that required medical intervention.  
4.
Has a serious or progressive disease according to the investigator, including, but not 
limited to cancer, uncontrolled diabetes, severe cardiac, renal or hepatic insufficiency, 
systemic autoimmune, or neurologic disorder.
5.
Has known or suspected impairment of immunological function, including, but not 
limited to congenital or acquired immunodeficiency, HIV infection, hematologic 
malignancy, or treatment for autoimmune diseases.
6.
Has a condition in which repeated venipuncture or injections pose more than minimal 
risk for the participant, such as hemophilia, thrombocytopenia, other severe 
coagulation disorders, or significantly impaired venous access.
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Prior/Concomitant Therapy
7.
Has received a dose of any dengue vaccine (investigational or approved) prior to 
study entry, or plans to receive any dengue vaccine (investigational or approved) for
the duration of the trial.
8.
* Has received a licensed non-live vaccine within 14 days before receipt of study 
vaccine or is scheduled to receive any licensed non-live vaccine within 28 days 
following receipt of study vaccine. Exception: Inactivated influenza vaccine may be 
administered, but must be given at least 7 days before receipt of study vaccine or at 
least 28 days after receipt of study vaccine.
9.
* Has received a licensed live vaccine within 28 days prior to receipt of study vaccine 
or is scheduled to receive any live vaccine within 28 days following receipt of study 
vaccine.
10.
Has received systemic corticosteroids (equivalent of ≥2 mg/kg/day of prednisone or 
≥20 mg/day for persons weighing >10 kg) for ≥14 consecutive days and has not 
completed treatment at least 30 days before study entry or is expected to receive 
systemic corticosteroids at aforementioned dose and duration within 28 days 
following receipt of study vaccine. (Note: topical and inhaled/nebulized steroids are 
permitted.)
11.
Has received systemic corticosteroids exceeding physiologic replacement doses 
(approximately 5 mg/day prednisone equivalent) within 14 days before vaccination.
12.
Has received immunosuppressive therapies, including chemotherapeutic agents used 
to treat cancer or other conditions, treatments associated with organ or bone marrow 
transplantation, or autoimmune disease, within 6 months prior to receipt of study 
vaccine, or plans to receive immunosuppressive therapies within 28 days following 
receipt of study vaccine.
13.
Has received a blood transfusion or blood products (including immunoglobulins) 
within 6 months prior to receipt of study vaccine or plans to receive a blood 
transfusion or blood products (including immunoglobulins) within 28 days following 
receipt of study vaccine.
Prior/Concurrent Clinical Study Experience
14.
Has participated in another interventional clinical study within 6 months prior to 
signing the informed consent, or plans to participate in another interventional clinical 
study at any time during the duration of the current clinical study. Participants 
enrolled in observational studies may be included; these will be reviewed on a case-
by-case basis for approval by MSD.
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Diagnostic Assessments
Not applicable.
Other Exclusions
15.
Has any other reason that, in the opinion of the investigator, may interfere with the 
evaluations required by the study. Reasons may include, but are not limited to, being 
unable to complete the eVRC, being unable to complete visits including non-office 
visit contacts (eg, telephone), or being unable to comply with study procedures.
16.
Has planned donation of blood, eggs, or sperm at any time from signing the informed 
consent through 90 days postvaccination.
17.
Is or has an immediate family member (eg, spouse, parent/legal guardian, sibling, or 
child) who is investigational site, Sponsor, or MSD staff directly involved with this 
study. 
5.3
Lifestyle Considerations
No special restrictions on diet apply.
Since the study will evaluate immunogenicity of the vaccines at Day 28 postvaccination, it is 
suggested that participants who enroll in the study actively limit their exposure to mosquitoes
to the extent possible until the Day 28 immunogenicity assessment, so as to avoid WT
dengue infection. 
5.4
Screen Failures
Screen failures are defined as participants who consent to participate in the clinical study, but 
are not subsequently randomized in the study. A minimal set of screen failure information is 
required to ensure transparent reporting of screen failure participants to meet the CONSORT 
publishing requirements and to respond to queries from regulatory authorities. Minimal 
information includes demography, screen failure details, eligibility criteria, and any AEs or 
SAEs meeting reporting requirements as outlined in the data entry guidelines. 
5.5
Participant Replacement Strategy
A participant who withdraws from the study will not be replaced.
6
STUDY INTERVENTION
Study intervention is defined as any investigational intervention(s), marketed product(s), 
placebo, or medical device(s) intended to be administered to a study participant according to 
the study protocol.
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Clinical supplies provided by the Sponsor and MSD will be packaged to support enrollment. 
Clinical supplies will be affixed with a clinical label in accordance with regulatory 
requirements.
Open-label, single-dose vials (V181) or multi-dose vials (Butantan-DV) will be supplied to 
the unblinded individual(s) at the clinical site. An unblinded pharmacist or unblinded 
qualified study-site personnel will prepare the study vaccines and will mask each syringe to 
conceal the contents prior to dispensing a vaccine dose to a blinded member of the study
team for administration to the participant. Preparation and administration of the vaccine will 
occur as per the instructions in the Pharmacy Manual supplied by MSD.
6.1
Study Intervention(s) Administered
The study interventions to be used in this study are outlined in Table 1.
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Table 1
Study Interventions
Arm 
Name
Arm 
Type
Intervention 
Name
Intervention 
Type
Dose 
Formulation
Unit Dose 
Strength(s)
Dosage 
Level(s)
Route of 
Administration
Regimen/Treatment 
Period/Vaccination 
Regimen
Use
IMP or
NIMP/AxMP
Sourcing
V181 
Group
Experi-
mental
V181
Biological/
Vaccine
Sterile 
Suspension
10^2.8 –
10^3.8 PFU 
of each 
vaccine virus
0.5 mL
SC
Single dose at Visit 1
Test 
Product
IMP
Provided 
centrally by 
MSD
Butantan-
DV 
Group
Experi-
mental
Butantan-DV
Biological/
Vaccine
Sterile 
Suspension
10^3.4 –
10^4.1 PFU 
of each 
vaccine virus
0.5 mL
SC
Single dose at Visit 1
Test 
Product
IMP
Provided by 
Sponsor 
through 
local depot
DV=dengue vaccine; EEA=European Economic Area; IMP=investigational medicinal product; MSD=Merck Sharp & Dohme LLC; NIMP/AxMP=noninvestigational/auxiliary medicinal product; 
PFU=plaque forming unit; SC=subcutaneous.
The classification of IMP and NIMP/AxMP in this table is based on guidance issued by the European Commission and applies to countries in the EEA. Country differences with respect to the 
definition/classification of IMP and NIMP/AxMP may exist. In these circumstances, local legislation is followed.
The Sponsor of this study is Instituto Butantan. MSD is executing the study.
The instructions for preparation of V181 and Butantan-DV are provided in the Pharmacy Manual supplied by MSD.
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All supplies indicated in Table 1 will be provided per the "Sourcing" column depending upon 
local country operational requirements. If local sourcing, every attempt should be made to 
source these supplies from a single lot/batch number where possible (eg, not applicable in the 
case where multiple lots or batches may be required due to the length of the study, etc.).
Refer to Section 8.1.10 for details regarding administration of the study intervention.
6.2
Preparation/Handling/Storage/Accountability
6.2.1
Dose Preparation
There are no specific calculations or evaluations required to be performed in order to 
administer the proper dose to each participant. The rationale for selection of doses to be used 
in this study is provided in Section 4.3.
The study vaccine will be reconstituted by the unblinded pharmacist or unblinded qualified 
study-site personnel, as described in Section 6.3.3 and in the Pharmacy Manual. 
6.2.2
Handling, Storage, and Accountability
The investigator or designee must confirm appropriate temperature conditions have been 
maintained during transit for all study intervention received, and any discrepancies are 
reported and resolved before use of the study intervention.
Only participants enrolled in the study may receive study intervention, and only authorized 
site staff may supply or administer study intervention. All study interventions must be stored 
in a secure, environmentally controlled, and monitored (manual or automated) area in 
accordance with the labeled storage conditions with access limited to the investigator and 
authorized site staff.
The investigator, institution, or the head of the medical institution (where applicable) is 
responsible for study intervention accountability, reconciliation, and record maintenance (ie, 
receipt, reconciliation, and final disposition records).
For all study sites, the local country MSD personnel or designee will provide appropriate 
documentation that must be completed for drug accountability and return, or local discard 
and destruction if appropriate. Where local discard and destruction is appropriate, the 
investigator is responsible for ensuring that a local discard/destruction procedure is 
documented.
The study site is responsible for recording the lot number, manufacturer, and expiry date for 
any locally purchased product (if applicable) as per local guidelines unless otherwise 
instructed by MSD.
The investigator shall take responsibility for and shall take all steps to maintain appropriate 
records and ensure appropriate supply, storage, handling, distribution, and usage of study 
interventions in accordance with the protocol and any applicable laws and regulations.
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6.3
Measures to Minimize Bias: Randomization and Blinding
6.3.1
Intervention Assignment
Intervention randomization will occur centrally using an IRT system. There are 2 study 
intervention arms. Participants will be assigned randomly in a 1:1 ratio to V181 or
Butantan-DV.
6.3.2
Stratification
No stratification based on age, sex, or other characteristics will be used in this study.
6.3.3
Blinding
A double-blinding technique with in-house blinding will be used. Both V181 and 
Butantan-DV will be provided open-label. Therefore, an unblinded pharmacist or unblinded 
qualified study-site personnel will be responsible for receiving, maintaining, preparing, and 
dispensing the study vaccines in accordance with a Pharmacy Manual provided by MSD. An 
unblinded Clinical Research Associate will monitor vaccine accountability at the study site. 
A formal study of the visual appearances of the V181 and Butantan-DV cannot be performed 
prior to the study. Therefore, the unblinded pharmacist or unblinded study-site personnel will 
mask each syringe to conceal the contents prior to dispensing a vaccine dose to a blinded 
member of the study team for administration to the participant.
The participant, investigator, and study-site personnel directly involved in the clinical 
evaluation of the participants, as well as MSD field personnel or delegate(s) and Sponsor and 
MSD Headquarters personnel involved with the conduct of this study will be blinded to the 
participant-level intervention assignments. 
To avoid bias, contact between the unblinded study-site personnel and participants is strictly 
prohibited throughout the study. Additionally, blinded study-site personnel will not be 
present when the study vaccine is prepared. Blinded study-site personnel will be responsible 
for all safety follow-up and immunogenicity specimen collection after study vaccine 
administration. Laboratory personnel responsible for conducting the assays will remain 
blinded to vaccination group assignments throughout the duration of the study.
An external unblinded statistician and statistical programmer not directly involved in the 
conduct of the study will be responsible for providing unblinded report deliverables to the 
eDMC. Details will be provided in the eDMC charter.
The primary safety and immunogenicity analyses will be performed, and a CSR will be 
prepared to present the results from Day 1 through the Day 28 postvaccination time point. 
After the database lock for the primary analysis, Sponsor and MSD Headquarters personnel 
involved in the conduct of the trial will be unblinded to vaccination group assignments. A 
blinded MSD Headquarters medical monitoring team will monitor the study after Day 28 
through Month 12 postvaccination. Participants, investigators, study-site personnel, and 
MSD field personnel or delegates (eg, blinded Clinical Research Associate) will remain 
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blinded to the individual vaccination group assignments until the final study analyses are
completed following the Month 12 (final) database lock.
See Section 8.1.13 for a description of the method of unblinding a participant during the 
study should such action be warranted.
6.4
Study Intervention Compliance
Participant study intervention compliance is defined in this study as a participant who 
receives the protocol-specified single dose of V181 or Butantan-DV. Any changes in the 
protocol-specified vaccination plan require consultation between the investigator and MSD
Clinical Director and written documentation of the collaborative decision on participant 
management.
6.5
Management of GMO
V181 and Butantan-DV are GMOs. Standard precautions should be followed for vaccine 
preparation and administration. Needles and syringes that have been in contact with the study 
vaccines, as well as all other potentially contaminated materials, will be collected in 
dedicated containers and will be destroyed in a safe manner. This study will be conducted 
under local country regulations for use of a GMO.
6.6
Concomitant Therapy
Medications or vaccinations specifically prohibited within 28 days following receipt of study 
vaccine are described in Section 5.2. Receipt of any investigational or approved dengue 
vaccine (other than study vaccines) is prohibited during the duration of the study. If there is a 
clinical indication for any medications or vaccinations specifically prohibited, the 
investigator should discuss this with the MSD Clinical Director. The final decision on any 
supportive therapy or vaccination rests with the investigator and/or the participant’s primary 
physician.
Any medication or nonstudy vaccine (including over-the-counter or prescription medicines, 
vitamins, and/or herbal supplements or other specific categories of interest) that the 
participant is receiving at the time of enrollment or receives from the time of vaccination 
through Day 28 postvaccination must be recorded along with:
•
Reason for use
•
Dates of administration including start and end dates
•
Dosage information including dose and frequency
After Day 28 postvaccination, report only concomitant medications related to SAEs or
dengue events, or receipt of any dengue vaccine (investigational or approved) other than 
study vaccines. The MSD Clinical Director should be contacted if there are any questions 
regarding concomitant or prior therapy.
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6.6.1
Rescue Medications and Supportive Care 
No rescue or supportive medications are specified for use in this study.
6.7
Dose Modification (Escalation/Titration/Other)
No dose modification is specified to be used in this study.
6.7.1
Stopping Rules
There are no prespecified stopping rules for this study.
6.8
Intervention After the End of the Study
There is no study-specified intervention after the end of the study.
6.9
Clinical Supplies Disclosure
This study is blinded but supplies are provided as open label; therefore, an unblinded 
pharmacist or qualified study-site personnel will be used to blind supplies. Study intervention 
identity (name, strength, or potency) is included in the label text; random code/disclosure 
envelopes or lists are not provided.
The emergency unblinding call center will use the intervention/randomization schedule for 
the study to unblind participants and to unmask study intervention identity. The emergency 
unblinding call center should only be used in cases of emergency (see Section 8.1.13). If the 
emergency unblinding call center is not available for a given site in this study, the central 
electronic intervention randomization system (IRT) should be used to unblind participants 
and to unmask study intervention identity. MSD will not provide random code/disclosure 
envelopes or lists with the clinical supplies.
7
DISCONTINUATION OF STUDY INTERVENTION AND PARTICIPANT 
WITHDRAWAL
7.1
Discontinuation of Study Intervention
In clinical studies with a single intervention, discontinuation of study intervention can only 
occur prior to the intervention and generally represents withdrawal from the study.
Participants who receive a single-dose intervention cannot discontinue study intervention.
7.2
Participant Withdrawal From the Study
A participant must be withdrawn from the study if the participant or participant’s legally 
acceptable representative withdraws consent from the study.
If a participant withdraws from the study, they will no longer be followed at scheduled
protocol visits. 
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Specific details regarding procedures to be performed at the time of withdrawal from the 
study, are outlined in Section 8.1.12. The procedures to be performed should a participant 
repeatedly fail to return for scheduled visits and/or if the study site is unable to contact the 
participant are outlined in Section 7.3.
7.3
Lost to Follow-up
If a participant fails to return to the clinic for a required study visit and/or if the site is unable 
to contact the participant, the following procedures are to be performed:
•
The site must attempt to contact the participant and reschedule the missed visit. If the 
participant is contacted, the participant should be counseled on the importance of 
maintaining the protocol-specified visit schedule.
•
The investigator or designee must make every effort to regain contact with the participant 
at each missed visit (eg, telephone calls and/or a certified letter to the participant’s last 
known mailing address or locally equivalent methods). These contact attempts should be 
documented in the participant’s medical record.
•
Note: A participant is not considered lost to follow-up until the last scheduled visit for the 
individual participant. The missing data for the participant will be managed via the 
prespecified statistical data handling and analysis guidelines.
8
STUDY ASSESSMENTS AND PROCEDURES
•
Study procedures and their timing are summarized in the SoA. 
•
Adherence to the study design requirements, including those specified in the SoA, is 
essential and required for study conduct.
•
The investigator is responsible for ensuring that procedures are conducted by 
appropriately qualified (by education, training, and experience) staff. Delegation of 
study-site personnel responsibilities will be documented in the Investigator Trial File 
Binder (or equivalent).
•
All study-related medical decisions must be made by an investigator who is a qualified 
physician.
•
All screening evaluations must be completed and reviewed to confirm that potential 
participants meet all eligibility criteria. The investigator will maintain a screening log to 
record details of all participants screened and to confirm eligibility or record reasons for 
screening failure, as applicable.
•
Procedures conducted as part of the participant’s routine clinical management (eg, blood 
count) and obtained before signing of ICF may be used for screening or baseline purposes 
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provided the procedure met the protocol-specified criteria and were performed within the 
time frame defined in the SoA.
•
Additional evaluations/testing may be deemed necessary by MSD, as well as the 
investigator or the Sponsor, for reasons related to participant safety. In some cases, such 
evaluation/testing may be potentially sensitive in nature (eg, HIV, hepatitis C), and thus 
local regulations may require that additional informed consent be obtained from the 
participant. In these cases, such evaluations/testing will be performed in accordance with 
those regulations.
The total maximum amount of blood volume drawn from each participant over the duration 
of the study is approximately 50 mL, as detailed in the Laboratory Manual.
Repeat or unscheduled samples may be taken for safety reasons or for technical issues with 
the samples.
8.1
Administrative and General Procedures
8.1.1
Informed Consent
The investigator or medically qualified designee (consistent with local requirements) must 
obtain documented informed consent from each potential participant (or their legally 
acceptable representative) prior to participating in this clinical study. If there are changes to 
the participant’s status during the study (eg, health or age of majority requirements), the 
investigator or medically qualified designee must ensure the appropriate documented 
informed consent is in place.
8.1.1.1
General Informed Consent
Informed consent given by the participant or their legally acceptable representative must be 
documented on a consent form. The form must include the study protocol number, study 
protocol title, dated signature, and agreement of the participant (or his/her legally acceptable 
representative) and of the person conducting the consent discussion.
A copy of the signed and dated ICF should be given to the participant (or their legally 
acceptable representative) before participation in the study.
The initial ICF, any subsequent revised ICF, and any written information provided to the 
participant must receive the IRB/IEC’s approval/favorable opinion in advance of use. The 
participant or his/her legally acceptable representative should be informed in a timely manner 
if new information becomes available that may be relevant to the participant’s willingness to 
continue participation in the study. The communication of this information will be provided 
and documented via a revised consent form or addendum to the original consent form that 
captures the participant’s or the participant’s legally acceptable representative’s dated 
signature.
Specifics about the study and the study population are to be included in the study ICF.
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Informed consent will adhere to IRB/IEC requirements, applicable laws and regulations, and
Sponsor requirements.
8.1.2
Assignment of Screening Number
All consented participants will be given a unique screening number that will be used to 
identify the participant for all procedures that occur prior to randomization. Each participant 
will be assigned only 1 screening number. Screening numbers must not be reused for 
different participants.
Any participant who is screened multiple times will retain the original screening number 
assigned at the initial screening. Specific details on the screening/rescreening visit 
requirements are in Section 8.8.1.
8.1.3
Participant Identification Card
All participants will be given a participant identification card identifying them as participants 
in a research study. The card will contain study-site contact information (including direct 
telephone numbers) to be used in the event of an emergency. The investigator or qualified 
designee will provide the participant with a participant identification card immediately after 
the participant provides documented informed consent. At the time of intervention
randomization, site personnel will add the treatment/randomization number to the participant 
identification card.
The participant identification card also contains contact information for the emergency 
unblinding call center so that a health care provider can obtain information about study 
intervention in emergency situations where the investigator is not available. 
8.1.4
Inclusion/Exclusion Criteria
Prior to randomization, all inclusion and exclusion criteria will be reviewed by the 
investigator, who is a qualified physician, to ensure that the participant qualifies for the 
study.
8.1.5
Medical History
A medical history will be obtained by the investigator or qualified designee prior to 
vaccination at Visit 1 (Day 1). The participant’s relevant medical history for the 5 years prior 
to Visit 1 (Day 1) will be obtained to ensure that the participant satisfies the inclusion and 
exclusion criteria of the study. In addition, the investigator will inquire about the 
participant’s history of dengue or Zika natural infection at any time prior to Visit 1 (Day 1).
For those participants remaining in the study at the time of Amendment 04, the investigator 
will also inquire about the participant’s history of any other flavivirus infection(s) (west nile, 
yellow fever, etc) at any time prior to Visit 1 (Day 1).
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8.1.6
Prior and Concomitant Medications Review
8.1.6.1
Prior Medications
The investigator or qualified designee will review prior medication/vaccination use and 
record prior medications/vaccines taken by the participant within 30 days before enrolling in
the study in order to assess the study inclusion and exclusion criteria, including time 
windows for medication/vaccination use. In addition, the investigator will inquire about the 
receipt of any investigational or approved dengue vaccine at any time prior to Visit 1 
(Day 1).
For those participants remaining in the study at the time of Amendment 04, the investigator 
will also inquire about the receipt of any other investigational or approved flavivirus vaccine
(west nile, yellow fever, etc) at any time prior to Vist 1 (Day 1).
8.1.6.2
Concomitant Medications
At Visit 1 (Day 1) and at Visits 2, 3, and 4 postvaccination, the investigator or qualified 
designee will record medications and nonstudy vaccines, if any, taken by the participant 
through Day 28 postvaccination.
In addition, the participant will use the eVRC (Section 8.1.11) to record new and/or 
concomitant medications and nonstudy vaccines received from Day 1 through Day 28 
postvaccination.
After Day 28 postvaccination, report only concomitant medications related to SAEs or 
dengue events, or receipt of any dengue vaccine (investigational or approved) other than 
study vaccines.  
8.1.7
Pregnancy Testing
Pregnancy testing requirements for study inclusion are described in Section 5.1.
A pregnancy test consistent with local requirements (which must be sensitive to detect hCG 
at concentrations of 25 IU/L) must be performed in WOCBP at screening as shown in 
Section 1.3 or within 24 hours before study vaccine is administered. Urine or serum tests 
may be used, and results must be negative prior to vaccination. If a urine pregnancy test 
cannot be confirmed as negative (eg, an ambiguous result), a serum pregnancy test is 
required. A detailed definition of WOCBP is provided in Appendix 5. 
Additional serum or urine pregnancy tests may be performed, as determined necessary by the 
investigator or required by local regulation, at any time during the study.
8.1.8
Baseline Dengue Serostatus POC Screening Assay
A point of care (POC) serologic assay will be conducted at screening to determine a 
participant’s eligibility based on dengue serostatus as the participant must be dengue 
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seronegative to proceed with randomization. The POC assay must be conducted within 
24 hours prior to vaccination. 
The dengue POC assay is a lateral flow immunoassay for the simultaneous detection and 
differentiation of IgG and IgM anti-DENV (DENV1, 2, 3, and 4) in human serum, plasma, or 
whole blood. It is intended to be used by clinicians as a screening test and provides a 
preliminary test result to aid in the diagnosis of infection or prior infection with DENVs.
8.1.9
Assignment of Treatment/Randomization Number
All eligible participants will be randomly allocated and will receive a 
treatment/randomization number. The treatment/randomization number identifies the 
participant for all procedures occurring after treatment randomization. Once a 
treatment/randomization number is assigned to a participant, it can never be reassigned to 
another participant.
A single participant cannot be assigned more than 1 treatment/randomization number.
8.1.10
Study Intervention Administration
Study vaccines should be prepared and administered by appropriately qualified members of 
the study-site personnel (eg, physician, nurse, physician’s assistant, nurse practitioner, 
pharmacist, or medical assistant) as allowed by local/state, country, and institutional 
guidance.
Study intervention is given on the day of treatment allocation/randomization or as close as 
possible to the date on which the participant is allocated/assigned.
Once the study vaccine has been prepared by the unblinded pharmacist or unblinded 
qualified study-site personnel, the study vaccine will be provided to a blinded member of the 
study team for administration to the participant. A blinded study-site person should 
administer the study vaccine subcutaneously using the syringe that was prepared and masked 
by the unblinded pharmacist or unblinded qualified study-site personnel.
Details of the vaccination should be documented on the appropriate eCRF as specified in the 
data entry guidelines. 
Procedures for handling, preparing, dispensing, disposing, and returning the unblinded 
vaccines are provided in the Investigator Trial File Binder, which includes the Pharmacy 
Manual.
8.1.10.1
Timing of Dose Administration
In this study, V181 or Butantan-DV will be administered as a 0.5-mL SC injection at Visit 1 
(Day 1). The day of the study vaccination is considered Day 1 of the study. Study 
participants will be observed by blinded study-site personnel for at least 30 minutes 
following vaccination for any immediate AEs; the time period may be extended if clinically 
indicated.
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8.1.11
Electronic Vaccination Report Card (eVRC)
The eVRC was developed to be administered electronically via a hand-held device and is 
used to record AEs during the postvaccination period, as defined in Section 8.4.7. The eVRC 
is structured as recommended in the final US FDA Patient-Reported Outcome Guidance 
[U.S. Department of Health and Human Services 2009]. 
Participants will be provided an electronic device or have their own electronic device 
configured, if compatible, to complete the eVRC. The participant will be trained by the 
investigator or delegate in the use of the eVRC as indicated in Section 1.3.1. Noncompliance 
with the eVRC will require retraining by the site as soon as possible to ensure accurate and 
complete data capture. 
Daily body temperatures, injection-site reactions, other complaints or illnesses, and 
concomitant medications/nonstudy vaccines will be recorded on the eVRC from Day 1 
through Day 28 postvaccination (see Section 4.1). Participants will be required to measure 
their temperature using a digital thermometer provided by MSD and the size of injection-site 
reactions of swelling and redness using a ruler provided by MSD. Refer to Section 8.4.7 for 
safety assessments using the eVRC.
For the specific AEs collected via the eVRC, the investigator or delegate will discuss 
information entered into the eVRC with the participant at Day 7, Day 12, and Day 28 
postvaccination (V2, V3, and V4) and apply the appropriate assessment of overall intensity 
grade as described in Appendix 3.
Any differences between eVRC data and the clinical database must be documented in the 
participant’s source record.
8.1.12
Discontinuation and Withdrawal
Participants in this study will receive a single dose of study vaccine on Day 1 and cannot 
discontinue study intervention.
Participants who withdraw from the study should be encouraged to complete all applicable 
activities scheduled for the final study visit at the time of withdrawal. Any AEs that are 
present at the time of withdrawal should be followed in accordance with the safety 
requirements outlined in Section 8.4.
8.1.13
Participant Blinding/Unblinding
STUDY INTERVENTION IDENTIFICATION INFORMATION IS TO BE UNMASKED 
ONLY IF NECESSARY FOR THE WELFARE OF THE PARTICIPANT. EVERY 
EFFORT SHOULD BE MADE NOT TO UNBLIND.
For emergency situations where the investigator or medically qualified designee (consistent 
with local requirements) needs to identify the intervention used by a participant and/or the 
dosage administered, he/she will contact the emergency unblinding call center by telephone 
and make a request for emergency unblinding. As requested by the investigator or medically 
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qualified designee, the emergency unblinding call center will provide the information to 
him/her promptly and report unblinding to MSD. Prior to contacting the emergency 
unblinding call center to request unblinding of a participant’s intervention assignment, the 
investigator who is a qualified physician should make reasonable attempts to enter the 
intensity grade of the AEs observed, the relation to study intervention, the reason thereof, 
etc., in the medical chart. If it is not possible to record this assessment in the medical record
prior to the unblinding, the unblinding should not be delayed.
If unblinding has occurred, the circumstances around the unblinding (eg, date, reason, and 
person performing the unblinding) must be documented promptly, and the MSD Clinical 
Director notified as soon as possible.
Once an emergency unblinding has taken place, the investigator, site personnel, and MSD
personnel may be unblinded so that the appropriate follow-up medical care can be provided 
to the participant.
Participants whose treatment assignment has been unblinded by the investigator or medically 
qualified designee and/or nonstudy treating physician should continue to be monitored in the 
study.
Additionally, the investigator or medically qualified designee must go into the IRT system 
and perform the unblind in the IRT system to update drug disposition. In the event that the 
emergency unblinding call center is not available for a given site in this study, the IRT 
system should be used for emergency unblinding in the event that this is required for 
participant safety.
8.1.14
Calibration of Equipment
The investigator or qualified designee has the responsibility to ensure that any device or 
instrument used for a clinical evaluation/test during a clinical study that provides information 
about inclusion/exclusion criteria and/or safety or efficacy parameters shall be suitably 
calibrated and/or maintained to ensure that the data obtained are reliable and/or reproducible. 
Documentation of equipment calibration must be retained as source documentation at the 
study site.
8.2
Immunogenicity and Other Laboratory Assessments
All serum samples for immunogenicity and other laboratory assessments will be exported 
from Brazil to the US for testing.
8.2.1
DENV-Reduction Neutralization Test (VRNT)
The VRNT will be conducted to assess neutralizing antibodies for each of the 4 dengue 
vaccine serotypes (DENV1, DENV2, DENV3, DENV4) in specimens collected from 
vaccinated participants prior to vaccination on Day 1 (baseline) and at the Day 28, Month 3, 
and Month 12 postvaccination time points. 
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The VRNT for all 4 dengue serotypes was validated at Q2 Solutions contract research 
organization (US). The VRNT is performed by a two-fold serial dilution of serum samples 
and positive controls, and addition of an equal volume of diluted DENV (DENV1, DENV2, 
DENV3, or DENV4) containing a consistent target amount of virus for each given serotype.
Virus control containing diluted virus without serum is also tested. After an incubation period 
to allow for virus-neutralization, each serum/virus mixture and virus control is transferred to 
a tissue culture plate containing confluent Vero cells and incubated to allow for non-
neutralized virus adsorption. Following adsorption, the infected cells are incubated for a 
specified period of time to allow for replication of the virus. Plates are fixed, and infection is 
detected by immunostaining using a specific anti-dengue rabbit antibody and a secondary 
antibody labeled with Alexa Fluor 488. The titer of a sample is determined by counting and 
comparing the number of infected cells in the presence of the test serum to the virus control. 
The results are reported as a neutralization titer, which is the reciprocal of the dilution that 
reduced the number of infected cells by a defined percentage compared to the virus control. 
Calculations are performed using a 4-parameter nonlinear logistic equation. Dengue 
serostatus will be determined based on the VRNT60 LLOQ (titer results <LLOQ are 
considered negative), corresponding to each dengue serotype and established during assay 
validation.
8.2.2
Dengue Viremia RT-PCR Assay (Dengue Vaccine and/or Dengue Wild Type) 
8.2.3
Dengue NS1 ELISA
The FDA-approved InBios DENV Detect™NS1 Antigen ELISA in Human Serum assay is 
being validated at Q2 Solutions contract research organization (US). The DENV Detect™
NS1 antigen ELISA is an enzymatically amplified "two-step" sandwich-type immunoassay to 
detect low levels of NS1 in serum. In this assay, controls and unknown serum samples are 
CCI
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diluted in sample dilution buffer, containing secondary antibody, and incubated in 
microtitration wells. These wells have been coated with a highly effective NS1 antibody and 
then blocked. NS1 antigens present in the samples are then “sandwiched” between the 
capture and secondary antibodies. The presence of NS1 antigen is confirmed by the 
colorimetric response obtained using an antibody-HRP conjugate and liquid 3, 3’, 5, 5’-
tetramethylbenzidine (TMB) substrate. Once the reaction is stopped, using an acidic solution, 
the enzymatic turnover of the substrate is determined by absorbance measurement at 
450 nanometers.
8.2.4
Exploratory Immunogenicity Testing
8.3
Safety Assessments
Details regarding specific safety procedures/assessments to be performed in this study are 
provided. The maximum amount of blood collected per participant can be found in Section 8.
Planned time points for all safety assessments are provided in the SoA.
8.3.1
Physical Examinations Including Height and Weight
As part of the screening procedures, a complete physical examination will be conducted by 
an investigator or medically qualified designee (consistent with local requirements) per 
institutional standard at Visit (Day 1). 
A complete physical examination includes, but is not limited to, the assessment of vital signs
(heart rate, respiratory rate, seated BP, and body temperature); assessment of head, eyes, 
ears, nose and throat (HEENT); auscultation of the heart and lung; and examination of the 
abdomen, skin, lymph nodes, neurological system, and musculoskeletal system. Height and 
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weight will also be measured and recorded. Investigators should pay special attention to 
clinical signs related to previous serious illnesses.
For participants with suspected dengue (participants who experience protocol-specified fever 
[axillary temperature of ≥37.8°C] for at least 2 consecutive days postvaccination at any time 
during the study), a brief directed physical examination will be conducted by an investigator 
or medically qualified designee (consistent with local requirements) per institutional standard 
during the acute and convalescent follow-up visits.
In the source documents, investigators should document physical examination data and the 
status of all active medical conditions. Any clinically significant abnormality should be 
recorded on the appropriate eCRF.
8.3.2
Vital Signs
Vital signs are part of the physical examination at Visit 1 (Day 1) and include axillary body 
temperature, heart rate, respiratory rate, and seated BP.
BP and heart rate measurements will be assessed after the participant has at least 5 minutes of 
rest in a quiet setting without distractions, and from a sitting position, with a completely 
automated device. Manual techniques will be used only if an automated device is not 
available.
Abnormal vital signs must be confirmed by repeat testing after 15 minutes. Findings related 
to the vital signs should be documented in the participant source documentation. Any 
clinically significant abnormality will be recorded on the appropriate eCRF.
Axillary temperatures will be recorded by participants on the eVRC from Day 1 through 
Day 28 postvaccination. For this study, protocol-specified fever is defined as axillary 
temperature ≥37.8°C.
For participants with a febrile illness that is assessed as dengue or possible/probable dengue,
vital signs will be collected during the acute and convalescent follow-up visits
(Section 8.3.6).
8.3.3
Postvaccination Safety Observation Period
All participants will be observed, by blinded study-site personnel only, for at least 30 minutes 
postvaccination for any immediate reactions. If any immediate AEs are observed during this 
period, the time at which the event occurred within this timeframe, as well as the event itself, 
any concomitant medications that were administered, any medical intervention provided, and 
resolution of the event, must be recorded on the appropriate eCRFs.
8.3.4
Clinical Safety Laboratory Assessments
No clinical safety laboratory assessments are planned for this study.
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8.3.5
Assessment of Rash
Rash is a solicited systemic AE, and participants who experience rash during the primary 
postvaccination safety period (Day 1 through Day 28 postvaccination) will be asked to record 
rash events on the eVRC. In addition, participants should be instructed to contact the site 
promptly to ensure that the rash is assessed by the investigator within 72 hours of onset, 
when reported Day 1 through Day 28 postvaccination. If rash assessment cannot occur at a 
planned visit (Visit 2, Visit 3, or Visit 4) within 72 hours of the participant’s rash onset, then 
the rash should be assessed by the investigator at an unscheduled visit. Details of the rash
assessment should be documented on the appropriate eCRF as specified in the data entry 
guidelines. 
8.3.6
Assessment of Suspected Dengue Disease
The rationale for reporting all dengue-related events throughout the study is to collect data on 
dengue cases and severity because of previously reported increased dengue hospitalizations 
after vaccination with Dengvaxia® in baseline dengue-seronegative participants.
For the first 28 days after vaccination, participants should measure and record their 
temperature daily on the eVRC. After the 28-day period following vaccination through 
Month 12, participants should be advised to measure and record their temperature daily only 
when they feel febrile. Temperature should be documented on the appropriate eCRF as 
specified in the data entry guidelines.
Participants who experience protocol-specified fever (axillary temperature of ≥37.8°C) for 
≥2 consecutive days postvaccination at any time during the study should schedule an acute 
visit as soon as possible and no later than 8 days after the second day of protocol-specified 
fever.
At the acute visit, the investigator will perform a clinical evaluation to assess the participant 
for dengue disease symptoms and severity using 2009 WHO Dengue Guidelines [World 
Health Organization 2009] (Section 10.3.6). Serum samples will be obtained from the 
participant at the acute visit to determine the presence of DENV for the purpose of 
confirming dengue infection in the context of the trial (Table 2); investigators will not 
receive the results of the tests performed during these visits and should evaluate and treat the 
participant according to their clinical judgment outside the scope of the trial. 
Details of the febrile event assessment should be documented on the appropriate eCRF as 
specified in the data entry guidelines. A rash associated with an acute visit for suspected 
dengue should be documented on the appropriate eCRF.  
Alternatively, a participant may choose to have an acute visit on the first day of protocol-
specified fever and the investigator will follow the process outlined above; however, if the 
fever persists on the second consecutive day, then the participant must return for collection of 
a second serum sample, no later than 8 days after the second consecutive day of protocol-
specified fever. The clinical evaluation must be conducted at the first acute visit, but may be 
repeated during the second visit at the investigator’s discretion.
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Based on the duration of the participant-reported fever and the serum sample test results, 
there are 3 possible outcomes, as outlined in Table 2.  
Table 2
Evaluation and Outcomes for Febrile Event Assessments
Participant-reported 
Protocol-specified Fever a
Laboratory Result
Outcome
≥2 consecutive days
Positive for RT-PCR and/or NS1 ELISA
Virologically confirmed dengue
case, per the protocol-specified 
definition
1 day or multiple 
nonconsecutive days
Positive for RT-PCR and/or NS1 ELISA
Dengue case
≥1 day 
Negative for RT-PCR and/or NS1 ELISA
Not a dengue case
ELISA=enzyme-linked immunosorbent assay; NS=non-structural protein; RT-PCR=reverse transcription polymerase 
chain reaction.
a
Protocol-specified fever is defined as axillary temperature of ≥37.8°C.
Figure 2 outlines possible scenarios for participants who experience protocol-specified fever 
(axillary temperature of ≥37.8°C) and present at the clinic for an acute visit.
If, based on clinical and/or local laboratory evaluation, the investigator assesses a case as 
dengue or possible/probable dengue, a convalescent follow-up visit to collect information 
about the severity and recovery from the febrile illness is to occur 14 to 28 days after the 
acute visit clinical evaluation. During the convalescent follow-up visit, the investigator will 
conduct a clinical evaluation. Guidelines for the investigator’s clinical assessment of 
suspected dengue are in Section 10.3.6.
During extended follow-up visits (V5 and V8) and telephone contacts (V6 and V7), all 
participants will be reminded to schedule an acute visit in the event of at least 2 consecutive 
days of protocol-specified fever. 
Febrile events evaluated by the investigator at an acute visit will be reported as MAAEs. 
Febrile events evaluated from Day 1 through Day 28 will also be reported as an NSAE. At 
any time during the study, report febrile events that meet serious criteria as an SAE.
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Figure 2
V181-002 Assessment of Febrile Events for Suspected Dengue Disease
ELISA=enzyme-linked immunosorbent assay; MAAE=medically attended adverse event; NS=non-structural protein; RT-PCR=reverse transcription polymerase chain reaction 
a
Protocol-specified fever is defined as axillary temperature of ≥37.8°C. All febrile events evaluated at the site (acute visit) will be reported as MAAEs.
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8.4
Adverse Events, Serious Adverse Events, and Other Reportable Safety Events
The definitions of an AE or SAE, as well as the method of recording, evaluating, and 
assessing causality of AE and SAE and the procedures for completing and transmitting AE, 
SAE, and other reportable safety event reports can be found in Appendix 3.
Adverse events, SAEs, and other reportable safety events will be reported by the participant 
(or, when appropriate, by a caregiver, surrogate, or the participant's legally authorized 
representative).
The investigator and any designees are responsible for detecting, documenting, and reporting 
events that meet the definition of an AE or SAE as well as other reportable safety events. 
Investigators need to document if an SAE was associated with a medication error, misuse, or 
abuse. Investigators remain responsible for following up AEs, SAEs, and other reportable 
safety events for outcome according to Section 8.4.3.
The investigator, who is a qualified physician, will assess events that meet the definition of 
an AE or SAE as well as other reportable safety events with respect to seriousness, overall 
intensity grade, and causality.
8.4.1
Time Period and Frequency for Collecting AE, SAE, and Other Reportable 
Safety Event Information
All AEs, SAEs, and other reportable safety events that occur after the participant provides 
documented informed consent, but before randomization, must be reported by the 
investigator if they cause the participant to be excluded from the study, or are the result of a 
protocol-specified intervention, including, but not limited to washout or discontinuation of 
usual therapy, diet, placebo, or a procedure.
From the time of randomization through Day 28 postvaccination (primary safety follow-up 
period), all AEs, SAEs, and other reportable safety events must be reported by the 
investigator.
All MAAEs, SAEs, and deaths that occur from the time of randomization through Month 12 
postvaccination must be reported by the investigator, regardless of whether the events are 
considered to be vaccine-related by the investigator.
Investigators are not obligated to actively seek AEs or SAEs or other reportable safety events 
in former study participants. However, if the investigator learns of any SAE, including a 
death, at any time after a participant has been discharged from the study, and he/she 
considers the event to be reasonably related to the study intervention or study participation, 
the investigator must promptly notify MSD.
All initial and follow-up AEs, SAEs, and other reportable safety events will be recorded and 
reported to MSD or designee within the time frames as indicated in Table 3.
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Table 3
Reporting Time Periods and Time Frames for Adverse Events and Other 
Reportable Safety Events
Type of Event
Reporting Time 
Period:
Consent to 
Randomization/ 
Allocation
Reporting Time 
Period:
Randomization/ 
Allocation 
through Protocol-
specified Follow-
up Period
Reporting Time Period:
After the Protocol-
specified Follow-up 
Period
Time Frame to 
Report Event 
and Follow-up 
Information to 
MSD:
NSAE
Report if:
- due to protocol-
specified intervention
- causes exclusion
- participant is 
receiving placebo 
run-in or other run-in 
treatment
Report all
Not required
Per data entry 
guidelines
SAE
Report if:
- due to protocol-
specified intervention
- causes exclusion
- participant is 
receiving placebo 
run-in or other run-in 
treatment
Report all
Report if:
- drug/vaccine related.
- any death until 
participant completion of 
study
(Follow ongoing to 
outcome)
Within 24 hours 
of learning of 
event
Pregnancy/
Lactation Exposure
Report if:
- participant has been 
exposed to any 
protocol-specified 
intervention (eg, 
procedure, washout 
or run-in treatment 
including placebo 
run-in)
Exception: A 
positive pregnancy 
test at the time of 
initial screening is 
not a reportable 
event.
Report all
Previously reported –
Follow to 
completion/termination; 
report outcome
Within 24 hours 
of learning of 
event
Cancer
Report if:
- due to intervention
- causes exclusion
Report all
Not required
Within 5 
calendar days of 
learning of event
(unless serious)
Overdose
Report if:
- receiving placebo 
run-in or other run-in 
medication 
Report all
Not required
Within 5 
calendar days of 
learning of event
NSAE=nonserious adverse event; SAE=serious adverse event.
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8.4.2
Method of Detecting AEs, SAEs, and Other Reportable Safety Events
Care will be taken not to introduce bias when detecting AEs and/or SAEs and other 
reportable safety events. Open-ended and nonleading verbal questioning of the participant is 
the preferred method to inquire about AE occurrence.
8.4.3
Follow-up of AE, SAE, and Other Reportable Safety Event Information
After the initial AE/SAE report, the investigator is required to proactively follow each 
participant at subsequent visits/contacts. All AEs, SAEs, and other reportable safety events,
including pregnancy and exposure during breastfeeding, cancer, and overdose will be 
followed until resolution, stabilization, until the event is otherwise explained, or the 
participant is lost to follow-up (as defined in Section 7.3). In addition, the investigator will 
make every attempt to follow all nonserious AEs that occur in randomized participants for 
outcome. Further information on follow-up procedures is given in Appendix 3.
8.4.4
Regulatory Reporting Requirements for SAE
Prompt notification (within 24 hours) by the investigator to MSD of SAE is essential so that 
legal obligations and ethical responsibilities towards the safety of participants and the safety 
of a study intervention under clinical investigation are met.
The Sponsor and MSD have a legal responsibility to notify both the local regulatory authority 
and other regulatory agencies about the safety of a study intervention under clinical 
investigation. The Sponsor and MSD will comply with country-specific regulatory 
requirements and global laws and regulations relating to safety reporting to regulatory 
authorities, IRB/IECs, and investigators.
Investigator safety reports must be prepared for SUSARs according to local regulatory 
requirements and Sponsor and MSD policy and forwarded to investigators as necessary.
An investigator who receives an investigator safety report describing an SAE or other 
specific safety information (eg, summary or listing of SAE) from the Sponsor or MSD will 
file it along with the IB and will notify the IRB/IEC, if appropriate according to local 
requirements.
8.4.5
Pregnancy and Exposure During Breastfeeding
Although pregnancy and infant exposure during breastfeeding are not considered AEs, any 
pregnancy or infant exposure during breastfeeding in a participant (spontaneously reported to 
the investigator or their designee) that occurs during the study are reportable to MSD.
All reported pregnancies must be followed to the completion/termination of the pregnancy.
Any pregnancy complication will be reported as an AE or SAE.
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The medical reason (example: maternal health or fetal disease) for an elective termination of 
a pregnancy will be reported as an AE or SAE. Prenatal testing showing fetus will be born 
with severe abnormalities/congenital anomalies that leads to an elective termination of a 
pregnancy will be reported as an SAE for the fetus.
Pregnancy outcomes of ectopic pregnancy, spontaneous abortion, missed abortion, benign 
hydatidiform mole, blighted ovum, fetal death, intrauterine death, miscarriage, and stillbirth 
must be reported as serious events (Important Medical Events). If the pregnancy continues to 
term, the outcome (health of infant) must also be reported.
8.4.6
Disease-related Events and/or Disease-related Outcomes Not Qualifying as 
AEs or SAEs
Not applicable for this study.
8.4.7
Adverse Events Reported on the eVRC
Participants will use an eVRC to report solicited and unsolicited AEs (Section 8.1.11). 
The definitions of solicited and unsolicited AEs are provided in Appendix 3.
8.4.7.1
Solicited Adverse Events
Solicited AEs for this study are summarized in Table 4.
Table 4
Solicited Adverse Events for V181-002
Type of Solicited 
Adverse Event
Predefined Solicited Adverse Events
Solicited Time 
Period
Injection site
•
Injection-site pain/tenderness
•
Injection-site erythema/redness
•
Injection-site swelling 
Day 1 through
Day 5
postvaccination
Systemic
•
Rash 
•
Headache
•
Fatigue (tiredness)
•
Myalgia (muscle pain)
•
Arthralgia (joint pain)
Day 1 through
Day 28 
postvaccination
All solicited injection-site AEs will be considered related to study intervention. The 
investigator will assess all solicited injection-site AEs for overall intensity grade, and all 
systemic AEs for both overall intensity grade and causality (Appendix 3).
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In addition, the investigator will review all solicited AEs for the following:
•
Is the event a symptom of another diagnosis?
•
Is the event ongoing at the end of the solicited period?
•
Does the event meet serious criteria?
Investigators are responsible for reviewing, assessing, and reporting data entered in the 
eVRC on the appropriate eCRF(s) as specified in the data entry guidelines. In addition, 
solicited injection-site AEs and solicited systemic AEs reported by the participant using the 
eVRC will be transferred directly to MSD’s database.
8.4.7.2
Unsolicited Adverse Events
Unsolicited AEs for this study are events that are 1) not predefined in Table 4, or 
2) predefined in Table 4, but reported at any time outside the solicited time period. 
Unsolicited AEs reported by the participant will be entered by study-site personnel on the 
appropriate eCRF. 
As described in Section 8.4, the investigator will assess unsolicited events that meet the 
definition of an AE or SAE with respect to seriousness, overall intensity grade, and causality.
8.4.8
Events of Clinical Interest
No specific ECIs will be collected for this study.
8.5
Treatment of Overdose
In this study, an overdose is any dose higher than 1 dose of the investigational V181 or 
Butantan-DV.
No specific information is available on the treatment of overdose. 
8.6
Pharmacokinetics
PK parameters will not be evaluated in this study.
8.7
Pharmacodynamics
Pharmacodynamic parameters will not be evaluated in this study.
8.8
Visit Requirements
Visit requirements are outlined in Section 1.3. Specific procedure-related details are provided 
in Section 8.
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8.8.1
Screening
Prior to randomization, potential participants will be evaluated to determine that they fulfill 
the entry requirements as set forth in Section 5. Screening procedures will be conducted at 
Visit 1 (Day 1) and may be repeated after consultation with MSD.
8.8.2
Treatment Period/Vaccination Visit
Requirements during the treatment period are outlined in Section 1.3.
9
STATISTICAL ANALYSIS PLAN
This section outlines the statistical analysis strategy and procedures for the study. If, after the
study has begun, but prior to any unblinding, changes are made to primary and/or key
secondary hypotheses, or the statistical methods related to those hypotheses, then the
protocol will be amended (consistent with ICH Guideline E-9). Changes to exploratory or the 
nonconfirmatory analyses made after the protocol has been finalized, but prior to unblinding, 
will be documented in an sSAP and referenced in the CSR for the study. Post hoc exploratory 
analyses will be clearly identified in the CSR.
9.1
Statistical Analysis Plan Summary 
Key elements of the SAP are summarized below; the comprehensive plan is provided in 
Sections 9.2 to 9.12.
Study Design Overview
A Phase 2, Randomized, Double-Blind, Multicenter, Safety and 
Immunogenicity Clinical Bridging Study to Compare V181 (Dengue 
Quadrivalent Vaccine rDENVΔ30 [live, attenuated]) to Butantan Dengue 
Vaccine (Butantan-DV) in Healthy Adults 18 to 50 Years of Age in Brazil
Treatment Assignment
There are 2 vaccination arms. Participants will be assigned randomly in a 1:1 
ratio to receive V181 or Butantan-DV using an IRT. A double-blind/masking 
technique will be used.
Analysis Populations
Immunogenicity: PP Population
Safety: APaT
Primary Endpoint(s)
Immunogenicity (Primary):
DENV-neutralizing antibody GMTs for each of the 4 dengue serotypes at 
Day 28 postvaccination as measured by VRNT
DENV-neutralizing antibody seroconversion rates for each of the 4 dengue 
serotypes at Day 28 postvaccination as measured by the VRNT. 
Seroconversion is defined as achieving a serotype-specific VRNT titer 
≥LLOQ at Day 28 postvaccination in participants who are seronegative at 
baseline.
Safety (Primary):
Vaccine-related SAEs from Day 1 through Day 28 postvaccination
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Key Secondary Endpoints
Safety (Secondary):
Solicited injection-site AEs of pain, erythema, and swelling from Day 1 
through Day 5 postvaccination
Solicited systemic AEs of rash, headache, fatigue (tiredness), myalgia (muscle 
pain) and arthralgia (joint pain), from Day 1 through Day 28 postvaccination
Statistical Methods for Key 
Immunogenicity Analyses
To address the primary immunogenicity non-inferiority objective in terms of 
GMTs (H1), the comparison between groups will be made based on serotype-
specific antibody GMTs for the 4 dengue serotypes at Day 28 postvaccination. 
The estimation of the GMT ratios and the corresponding 95% CIs will be 
calculated using a linear model with the log-transformed antibody titer as the 
response and a single term for vaccination group.  
To address the primary immunogenicity non-inferiority objective in terms of 
seroconversion rates (H2), the comparison between groups will be made based 
on serotype-specific antibody seroconversion rates for the 4 dengue serotypes 
at Day 28 postvaccination. The between-treatment difference (V181 minus 
Butantan-DV) and its 95% CI will be calculated using M&N method 
[Miettinen, O. and Nurminen, M. 1985].
Statistical Methods for Key 
Safety Analyses
For overall safety endpoints and specific AEs point estimates and 95% CIs for 
the differences between treatment groups in the percentages of participants 
with events will be provided using the M&N method [Miettinen, O. and 
Nurminen, M. 1985].
Interim Analyses
There are no planned interim analyses for this study.
Multiplicity
The study will be considered to have met its primary objectives for 
immunogenicity if, at Day 28 postvaccination, V181 is demonstrated non-
inferior to Butantan-DV for the 4 dengue serotypes for both primary endpoints 
(virus-neutralizing antibody GMTs and virus-neutralizing antibody 
seroconversion rates). All hypotheses will be tested individually for each 
serotype at a 1-sided 0.025 alpha level. This approach controls the 1 sided 
type-I error rate at 0.025, thus no multiplicity adjustment is required.
Sample Size and Power 
Immunogenicity: This study will randomize participants in a 1:1 ratio into the 
2 vaccination groups (V181 vs Butantan-DV). The overall sample size will be 
approximately 1240 with 620 participants in each vaccination group. This 
sample size ensures sufficient power (approximately 90%) to assess the 
endpoints for both primary hypotheses. All statistical tests will be conducted at 
a 1-sided 2.5% alpha level. Details are provided in Section 9.9.1
Safety: If no vaccine-related SAEs are observed among the 620 participants in 
each vaccination group, this study will provide 97.5% confidence that the 
underlying percentage of participants with vaccine-related SAEs is <0.6% in 
each vaccination group.
9.2
Responsibility for Analyses/In-house Blinding 
The statistical analysis of the data obtained from this study will be the responsibility of the 
Clinical Biostatistics department of MSD. This study will be conducted as a double-blind 
study under in-house blinding procedures. 
The Clinical Biostatistics department will generate the randomized allocation schedule(s) for 
study vaccination assignment. Randomization will be implemented in an IRT.
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The primary safety and immunogenicity evaluation period for this study is defined as the 
period from Day 1 through Day 28 postvaccination. A CSR will be produced to present the 
results for this time period. The official, final database for the Day 28 analysis will not be 
unblinded until medical/scientific review has been performed, protocol deviations have been 
identified, and data have been declared final and complete. After the Day 28 postvaccination 
visit, participants will be followed for safety (MAAEs, SAEs, deaths, and dengue-related 
events only) and immunogenicity through Month 12 postvaccination. Results for the Month 3 
immunogenicity endpoints may be analyzed separately after Month 3 VRNT results become 
available and protocol deviations have been identified. Results for the remainder of the study
through Month 12 postvaccination time period will be presented in a final, separate study 
report.  
After the database lock for the primary analysis, most Sponsor and MSD Headquarters 
personnel involved in the conduct of the trial will be unblinded to vaccination group 
assignments. A blinded MSD Headquarters medical monitoring team will monitor the study 
after Day 28 through Month 12 postvaccination. Participants, investigators, study-site 
personnel, and MSD field personnel or delegates (eg, blinded Clinical Research Associate)
will remain blinded to vaccination group assignments until the final study analyses are 
completed following the Month 12 (final) database lock.
9.3
Hypotheses/Estimation 
Objectives and hypotheses of the study are stated in Section 3.
9.4
Analysis Endpoints 
Immunogenicity and safety endpoints that will be evaluated are listed below.
9.4.1
Immunogenicity and Viremia Endpoints
Primary Immunogenicity Endpoints

DENV-neutralizing antibody GMTs for each of the 4 dengue serotypes at Day 28 
postvaccination as measured by VRNT.

DENV-neutralizing antibody seroconversion rates for each of the 4 dengue serotypes at 
Day 28 postvaccination as measured by VRNT. Seroconversion is defined as achieving a 
serotype-specific VRNT titer ≥LLOQ at Day 28 postvaccination in participants who are 
seronegative at baseline. For participants who are seropositive at baseline (included in the 
FAS population) seroconversion is defined as achieving a 4-fold rise in serotype-specific 
VRNT titer at Day 28 postvaccination. Further information on the LLOQ will be 
documented in the sSAP.
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Additional Immunogenicity and Viremia Endpoints
9.4.2
Safety Endpoints
An initial description of safety measures is provided in Section 4.2.1.2. The overall safety 
and tolerability profile for each vaccine will be assessed by clinical review of all safety data 
collected. Solicited and unsolicited injection-site and systemic AEs will be summarized 
overall, and by maximum reported intensity. The primary safety evaluation period for this 
study will be Day 1 through Day 28 postvaccination.
Primary Safety Endpoints

Vaccine-related SAEs from Day 1 through Day 28 postvaccination
Secondary Safety Endpoints

Solicited injection-site AEs of injection-site pain, injection-site erythema, and injection-
site swelling from Day 1 through Day 5 postvaccination

Solicited systemic AEs of rash, headache, fatigue (tiredness), myalgia (muscle pain), and 
arthralgia (joint pain) from Day 1 through Day 28 postvaccination
Additional Safety Endpoints

Unsolicited AEs from Day 1 through Day 28 postvaccination 

Elevated temperature (≥37.8°C axillary) from Day 1 through Day 28 postvaccination 

MAAEs, SAEs, deaths, and dengue-related events from Day 1 through Month 12 
postvaccination
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9.5
Analysis Populations 
9.5.1
Immunogenicity Analysis Populations
The PP population will serve as the primary population for the analysis of the 
immunogenicity data in this study. The PP population excludes participants due to deviations 
from the protocol that may substantially affect the results of the primary immunogenicity 
endpoint. Potential deviations that may result in the exclusion of a participant from the PP 
population for all immunogenicity analyses include: 

Prevaccination baseline blood sample test result is seropositive for any of the 4 dengue 
serotypes by VRNT. Seropositivity is defined as having a serotype-specific VRNT titer at 
or above the LLOQ of the assay.

Failure to receive correct clinical material as per randomization schedule.

Receipt of prohibited medication or prohibited vaccine prior to study vaccination or 
through Day 28 postvaccination. 

Collection of a blood sample at the time point for the analysis outside the prespecified 
window (as described in Section 1.3.1).

Any virologically confirmed dengue case that occurs prior to the immunogenicity time 
point (Day 28, Month 3, Month 12 postvaccination) being evaluated.
The final determination on protocol violations, and thereby the composition of the PP
population, will be made prior to the unblinding of the database and will be documented in a 
separate memo. The key immunogenicity analyses will also be performed using the FAS 
population, which consists of all randomized participants who receive study vaccination and 
have at least 1 valid serology result. Participants will be included in the vaccination group to
which they are randomized for the analysis of immunogenicity data using the FAS 
population. No adjustment will be made for missing data.
If more than 10% of the participants have seropositive results at baseline, immunogenicity 
summaries of seropositive participants will also be generated.
9.5.2
Safety Analysis Populations
The APaT population will be used for the analysis of safety data in this study. The APaT
population consists of all randomized participants who received at least 1 dose of study 
vaccine. Participants will be included in the vaccination group corresponding to the study 
vaccine they actually received for the analysis of safety data using the APaT population. For 
most participants this will be the vaccination group to which they are randomized.
9.6
Statistical Methods 
This section describes the statistical methods that address the primary and secondary 
objectives. Statistical methods related to exploratory objectives will be further described in 
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the sSAP. The key immunogenicity analyses to be performed are summarized in Table 5
(Section 9.6.1). The safety analyses are summarized in Section 9.6.2. Unless otherwise 
stated, all statistical tests will be conducted at the α=0.05 (2-sided) level.  
9.6.1
Statistical Methods for Immunogenicity Analyses
Primary Endpoints/Hypothesis (H1)
The primary hypothesis of non-inferiority of antibody GMTs for each dengue serotype 
(DENV1, DENV2, DENV3, and DENV4) will be addressed by 4 one-sided tests of non-
inferiority (1 corresponding to each dengue serotype) conducted at α=0.025 level (1-sided).
For each dengue serotype, the hypotheses to be tested are: 
H0: GMT1/GMT2 ≤0.67
Versus 
H1: GMT1/GMT2 >0.67
where GMT1 represents the GMT at Day 28 postvaccination in the V181 group and GMT2
represents the GMT at Day 28 postvaccination in the Butantan-DV group. Estimation of the 
GMT ratios and computation of the corresponding 95% CIs will be calculated using 
t-distribution with the variance estimate from a linear model utilizing the log-transformed 
antibody titer as the response and a single term for vaccination group. The point estimates 
will be calculated by exponentiating the estimates of the mean of the natural log values and 
the CIs will be derived by exponentiating the CIs of the mean of the natural log values based 
on the model. The statistical criterion for non-inferiority requires that the lower bound of 
2-sided 95% CI of GMT ratio (V181 vs Butantan-DV) being greater than 0.67.
Primary Endpoints/Hypothesis (H2)
The primary hypothesis of non-inferiority of seroconversion rates for each dengue serotype 
(DENV1, DENV2, DENV3, and DENV4) will be addressed by 4 one-sided tests of non-
inferiority (1 corresponding to each dengue serotype) conducted at α=0.025 level (1-sided).
For each dengue serotype, the hypotheses to be tested are: 
H0: p1-p2 ≤-0.1
Versus 
H1: p1-p2 >-0.1
where p1 represents the seroconversion rate at Day 28 postvaccination in the V181 group and 
p2 represents the seroconversion rate at Day 28 postvaccination in the Butantan-DV group. 
For each dengue serotypes, V181 is non-inferior to Butantan-DV if the lower bound of the 
2-sided 95% CI for the between-treatment differences (V181 minus Butantan-DV) is greater 
than -0.1. The M&N method an unconditional, asymptotic method, will be used for this 
analysis [Miettinen, O. and Nurminen, M. 1985].
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Table 5
Analysis Strategy for Primary Immunogenicity Variables
Endpoint/Variable
(Description, Time Point)
Primary vs. 
Supportive 
Approacha
Statistical Method
Analysis 
Population
Missing Data 
Approach
DENV-neutralizing antibody 
GMTs (H1) for each of the 4 
dengue serotypes at Day 28 
postvaccination as measured 
by VRNT
P
S
t-distribution with 
the variance 
estimate from a 
linear modelb
(estimate, 95% CI, 
p-value)
PP
FAS
Missing data 
will not be 
imputed
DENV-neutralizing antibody 
seroconversion rates (H2) 
for each of the 4 dengue 
serotypes at Day 28 
postvaccination as measured 
by VRNT
P
S
Miettinen and 
Nurminen
(estimate, 95% CI, 
p-value)
PP
FAS
Missing data 
will not be 
imputed
CI=confidence interval; DENV=dengue virus; FAS=Full Analysis Set; GMT=geometric mean titer; PP=Per-
Protocol; VRNT=virus reduction neutralization test
a
P=Primary approach; S=Supportive approach.
b
Estimation of the DENV-neutralizing antibody GMTs and computation of the corresponding 95% CIs 
will be calculated using t-distribution with the variance estimate from a linear model utilizing the log-
transformed antibody titer as the response and a single term for vaccination group.
9.6.2
Statistical Methods for Safety Analyses
Safety and tolerability will be assessed by clinical review of AEs and other relevant 
parameters. 
9.6.2.1
Overall Safety Assessment
The overall safety evaluation will include a summary by vaccination group of the number 
and percentage of participants with at least one AE, vaccine-related AE, MAAEs, vaccine-
related MAAEs, SAE, vaccine-related SAE, discontinuation due to AE, and deaths; solicited 
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injection-site AEs of injection-site pain, injection-site erythema, and injection-site swelling; 
solicited systemic AEs of rash, headache, fatigue (tiredness), myalgia (muscle pain), and 
arthralgia (joint pain); and elevated temperature. Point estimates and 95% CIs for the 
differences between vaccination groups in the percentage of participants with the event will 
be provided based on the criteria described below for specific AEs.
The number and percentage of participants with specific AEs will also be provided. Point 
estimates and 95% CIs for the differences between treatment groups in the percentages of 
participants with specific AEs will be provided for AEs that occur in at least 1% of 
participants in any vaccination group. Events reported less frequently than in 1% of 
participants would obscure the assessment of the overall safety profile and add little to the 
interpretation of potentially meaningful differences.
CIs for between vaccination group differences will be provided using the stratified M&N 
method [Miettinen, O. and Nurminen, M. 1985]. CIs that are not adjusted for multiplicity 
should only be regarded as helpful descriptive measures for the review of the safety profile 
and not as a formal method for assessing statistical significance of between-group 
differences. Rainfall plots with point estimates and 95% CIs will be displayed for AEs that 
occur in at least 1% of participants in any vaccination group. Point estimates and 95% CIs 
will be provided for the percentage of participants with safety parameters that meet 
predefined limits of change based on the same criteria used above for the specific AEs.
9.6.2.2
Assessment of Safety Topics of Special Interest
There is no safety topic of special interest in this study.
Table 6 summarizes analysis strategy for safety endpoints in this study.
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Table 6
Analysis Strategy for Safety Parameters
Analysis Part
Safety Endpoint
Descriptive 
Statistics
95% Between-
Group CI
Inferential 
Analysis
Graphical 
Display
Overall 
Safety 
Assessment
Any [serious] [vaccine-related] AE
X
X
Any [vaccine-related] MAAE
X
X
Discontinuation due to AE
X
X
Death
X
Solicited injection-site AEs: pain, 
erythema, and swelling (Day 1 
through Day 5 postvaccination)
X
X
Solicited systemic AEs: rash, 
headache, fatigue (tiredness), 
myalgia (muscle pain), and 
arthralgia (joint pain) (Day 1 
through Day 28 postvaccination)
X
X
Elevated temperature
X
X
Specific AEs by SOC and PT 
X
Xa
Xa
Assessment 
of Safety 
Topics of 
Special 
Interest
None
AE=adverse event; CI=confidence interval; MAAE=medically attended adverse event; SOC=System Organ Class; 
PT=Preferred Term; X=results will be provided.
a
Threshold for incidence will be applied for CI and Graphical Display
9.6.3
Summaries of Baseline Characteristics, Demographics, and Other Analyses
The comparability of the vaccination groups for each relevant characteristic will be assessed 
by the use of tables and/or graphs. No statistical hypothesis tests will be performed on these 
characteristics. The number and percentage of participants screened and randomized, the 
primary reasons for screening failure, and the primary reason for discontinuation will be 
displayed. Demographic variables (eg, age), baseline characteristics, primary and secondary 
diagnoses, and prior and concomitant therapies will be summarized by vaccination group 
either by descriptive statistics or categorical tables.
9.7
Interim Analyses 
There are no planned interim analyses for this study. Participant safety will be monitored by 
an eDMC that will perform periodic reviews of safety data throughout the study 
(Appendix 1). An external unblinded statistician and statistical programmer not directly 
involved in the conduct of the study will be responsible for providing unblinded report 
deliverables to the eDMC. Details will be provided in the eDMC charter.
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9.8
Multiplicity 
The study will be considered to have met its primary objectives for immunogenicity if, at 
Day 28 postvaccination, V181 is demonstrated non-inferior to Butantan-DV for the 4 dengue 
serotypes for both primary endpoints (DENV-neutralizing antibody GMTs and 
DENV-neutralizing antibody seroconversion rates). All hypotheses will be tested 
individually for each serotype at a 1 sided 0.025 alpha level. This approach controls the 1-
sided type-I error rate at 0.025, thus no multiplicity adjustment is required. 
9.9
Sample Size and Power Calculations 
9.9.1
Sample Size and Power for Immunogenicity Analyses
This study will randomize participants in a 1:1 ratio into the 2 vaccination groups (V181 vs 
Butantan-DV). The overall sample size will be approximately 1240 with 620 participants in 
each vaccination group. This sample size ensures sufficient power (approximately 90%) to 
assess the endpoints for both primary hypotheses. The power for each individual hypothesis 
is provided below.
Primary Endpoints/Hypothesis (H1)
With this study sample size and the assumptions listed below, the power for the primary 
hypothesis to establish that V181 is non-inferior to Butantan-DV for all 4 dengue serotypes at 
an overall 1-sided, 2.5% alpha level based on GMTs is >95%. The power and sample size are 
based on the following assumptions: 1) an approximately 20% non-evaluable rate (496 
evaluable participants per vaccination group) which includes an assumption of 10% of the 
participants being excluded due to be seropositivity at baseline; 2) the non-inferiority margin 
of 0.67; 3) the true GMT ratio is assumed to be 1; and
 
 
Primary Endpoints/Hypothesis (H2)
With the assumptions listed below, the power for the primary hypothesis to establish that 
V181 is non-inferior to Butantan-DV for all 4 dengue serotypes at an overall 1-sided, 2.5% 
alpha level based on seroconversion rates is ~90%.The power is based on the following 
assumptions: 1) an approximately 20% non-evaluable rate (496 evaluable participants per 
vaccination group) which includes an assumption of 10% of the participants being excluded 
due to be seropositivity at baseline; 2) the non-inferiority margin of -0.1 for the difference 
(V181 – Butantan-DV); and
 
9.9.2
Sample Size and Power for Safety Analyses
The probability of observing at least 1 vaccine-related SAE in this study depends on the 
number of participants vaccinated and the underlying percentage of participants with a 
CCI
CCI
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vaccine-related SAE in the study population. If the underlying incidence of a vaccine-related 
SAE is 0.11% (1 of every 895 participants receiving the vaccine), there is a 50% chance of 
observing at least 1 vaccine-related SAE among 620 participants in each vaccination group. 
If the incidence rate is 1 of every 386 recipients (0.26%), there is an 80% chance of 
observing at least 1 vaccine-related SAE. If no vaccine-related SAEs are observed among the 
620 participants in each vaccination group, this study will provide 97.5% confidence that the 
underlying percentage of participants with vaccine-related SAE is <0.6% in each vaccination 
group.
Table 7 summarizes the percentage point differences between the 2 vaccination groups that
could be detected with 80% probability for a variety of hypothetical underlying incidences of
an AE. These calculations assume 620 participants each in the V181 group and the 
Butantan-DV group, and are based on a 2-sided 5% alpha level. The calculations are based 
on an asymptotic method proposed by Farrington and Manning (1990) [Farrington, C. P. and 
Manning, G. 1990]; no multiplicity adjustments will be made.
Table 7
Differences in Incidence of Adverse Event Rates Between the 2 Vaccination 
Groups That Can be Detected With an ~80% Probability (Assuming a 2-Sided 5% 
Alpha Level With 620 Participants in the V181 Group and 620 Participants in the 
Butantan-DV Group)
Incidence of an Adverse Event
Risk Difference
V181 (%)
Butantan-DV (%)
Percentage Points
1.5
0.1
1.4
4.9
2.0
2.9
9.1
5.0
4.1
15.3
10.0
5.3
21.1
15.0
6.1
26.7
20.0
6.7
37.5
30.0
7.5
Incidences presented here are hypothetical and do not represent actual adverse experiences in either group. Based on an 
asymptotic method proposed by Farrington and Manning (1990).
9.10
Subgroup Analyses 
 
 
9.11
Compliance (Medication Adherence) 
The number and proportion of randomized participants receiving each vaccine will be 
summarized (see Section 9.12).
CCI
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9.12
Extent of Exposure 
The extent of exposure will be summarized by the number and proportion of randomized 
participants administered V181 or Butantan-DV.
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10
SUPPORTING DOCUMENTATION AND OPERATIONAL 
CONSIDERATIONS
10.1
Appendix 1: Regulatory, Ethical, and Study Oversight Considerations
10.1.1
Code of Conduct for Clinical Trials
Merck Sharp & Dohme LLC, Rahway, NJ, USA (MSD)
Code of Conduct for Interventional Clinical Trials
I. Introduction
A. Purpose
MSD, through its subsidiaries, conducts clinical trials worldwide to evaluate the safety and effectiveness of our 
products. As such, we are committed to designing, implementing, conducting, analyzing, and reporting these trials 
in compliance with the highest ethical and scientific standards. Protection of participants in clinical trials is the 
overriding concern in the design and conduct of clinical trials. In all cases, MSD clinical trials will be conducted 
in compliance with local and/or national regulations (including all applicable data protection laws and
regulations), and International Council for Harmonisation Good Clinical Practice (ICH-GCP), and also in 
accordance with the ethical principles that have their origin in the Declaration of Helsinki.
B. Scope
Highest ethical and scientific standards shall be endorsed for all clinical interventional investigations sponsored by 
MSD irrespective of the party (parties) employed for their execution (e.g., contract research organizations, 
collaborative research efforts). This Code is not intended to apply to trials that are observational in nature, or 
which are retrospective. Further, this Code does not apply to investigator-initiated trials, which are not under the 
full control of MSD.
II. Scientific Issues
A. Trial Conduct
1. Trial Design
Except for pilot or estimation trials, clinical trial protocols will be hypothesis-driven to assess safety, efficacy 
and/or pharmacokinetic or pharmacodynamic indices of MSD or comparator products. Alternatively, MSD 
may conduct outcomes research trials, trials to assess or validate various endpoint measures, or trials to 
determine patient preferences, etc.
The design (i.e., participant population, duration, statistical power) must be adequate to address the specific 
purpose of the trial and shall respect the data protection rights of all participants, trial site staff and, where 
applicable, third parties. Participants must meet protocol entry criteria to be enrolled in the trial. 
2. Site Selection
MSD selects investigative sites based on medical expertise, access to appropriate participants, adequacy of 
facilities and staff, previous performance in clinical trials, as well as budgetary considerations. Prior to trial 
initiation, sites are evaluated by MSD personnel (or individuals acting on behalf of MSD) to assess the ability 
to successfully conduct the trial.
3. Site Monitoring/Scientific Integrity
Investigative trial sites are monitored to assess compliance with the trial protocol and Good Clinical Practice 
(GCP). MSD reviews clinical data for accuracy, completeness, and consistency. Data are verified versus 
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source documentation according to standard operating procedures. Per MSD policies and procedures, if
potential fraud, scientific/research misconduct, privacy incidents/breaches or Clinical Trial-related 
Significant Quality Issues are reported, such matters are investigated. When necessary, appropriate corrective 
and/or preventative actions are defined and regulatory authorities and/or ethics review committees are 
notified.
B. Publication and Authorship
Regardless of trial outcome, MSD commits to publish the primary and secondary results of its registered trials of 
marketed products in which treatment is assigned, according to the pre-specified plans for data analysis. To the 
extent scientifically appropriate, MSD seeks to publish the results of other analyses it conducts that are important 
to patients, physicians, and payers. Some early phase or pilot trials are intended to be hypothesis-generating rather 
than hypothesis testing; in such cases, publication of results may not be appropriate since the trial may be 
underpowered and the analyses complicated by statistical issues such as multiplicity.
MSD’s policy on authorship is consistent with the recommendations published by the International Committee of 
Medical Journal Editors (ICMJE). In summary, authorship should reflect significant contribution to the design and 
conduct of the trial, performance or interpretation of the analysis, and/or writing of the manuscript. All named 
authors must be able to defend the trial results and conclusions. MSD funding of a trial will be acknowledged in 
publications.
III. Participant Protection
A. Regulatory Authority and Ethics Committee Review (Institutional Review Board [IRB]/Independent Ethics 
Committee [IEC])
All protocols and protocol amendments will be submitted by MSD for regulatory authority 
acceptance/authorization prior to implementation of the trial or amendment, in compliance with local and/or 
national regulations.
The protocol, protocol amendment(s), informed consent form, investigator’s brochure, and other relevant trial 
documents must be reviewed and approved by an IRB/IEC before being implemented at each site, in compliance 
with local and/or national regulations. Changes to the protocol that are required urgently to eliminate an 
immediate hazard and to protect participant safety may be enacted in anticipation of ethics committee approval. 
MSD will inform regulatory authorities of such new measures to protect participant safety, in compliance with 
local and/or national regulations.
B. Safety
The guiding principle in decision-making in clinical trials is that participant welfare is of primary importance. 
Potential participants will be informed of the risks and benefits of, as well as alternatives to, trial participation. At 
a minimum, trial designs will take into account the local standard of care.
All participation in MSD clinical trials is voluntary. Participants enter the trial only after informed consent is 
obtained. Participants may withdraw from an MSD trial at any time, without any influence on their access to, or 
receipt of, medical care that may otherwise be available to them.
C. Confidentiality
MSD is committed to safeguarding participant confidentiality, to the greatest extent possible, as well as all 
applicable data protection rights. Unless required by law, only the investigator, Sponsor (or individuals acting on 
behalf of MSD), ethics committee, and/or regulatory authorities will have access to confidential medical records 
that might identify the participant by name.
D. Genomic Research
Genomic research will only be conducted in accordance with a protocol and informed consent authorized by an 
ethics committee.
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IV. Financial Considerations
A. Payments to Investigators
Clinical trials are time- and labor-intensive. It is MSD’s policy to compensate investigators (or the sponsoring 
institution) in a fair manner for the work performed in support of MSD trials. MSD does not pay incentives to 
enroll participants in its trials. However, when enrollment is particularly challenging, additional payments may be 
made to compensate for the time spent in extra recruiting efforts.
MSD does not pay for participant referrals. However, MSD may compensate referring physicians for time spent 
on chart review and medical evaluation to identify potentially eligible participants.
B. Clinical Research Funding
Informed consent forms will disclose that the trial is sponsored by MSD, and that the investigator or sponsoring 
institution is being paid or provided a grant for performing the trial. However, the local ethics committee may 
wish to alter the wording of the disclosure statement to be consistent with financial practices at that institution. As 
noted above, all publications resulting from MSD trials will indicate MSD as a source of funding.
C. Funding for Travel and Other Requests
Funding of travel by investigators and support staff (e.g., to scientific meetings, investigator meetings, etc.) will be 
consistent with local guidelines and practices.
V. Investigator Commitment
Investigators will be expected to review MSD’s Code of Conduct as an appendix to the trial protocol, and in signing the 
protocol, agree to support these ethical and scientific standards.
10.1.2
Financial Disclosure
Financial disclosure requirements are outlined in the US Food and Drug Administration 
Regulations, Financial Disclosure by Clinical Investigators (21 CFR Part 54). It is MSD’s 
responsibility to determine, based on these regulations, whether a request for financial 
disclosure information is required. It is the investigator's/subinvestigator's responsibility to 
comply with any such request.
The investigator/subinvestigator(s) agree, if requested by the Sponsor or delegate in 
accordance with 21 CFR Part 54, to provide his/her financial interests in and/or arrangements 
with the Sponsor and MSD to allow for the submission of complete and accurate certification 
and disclosure statements. The investigator/subinvestigator(s) further agree to provide this 
information on a Certification/Disclosure Form, commonly known as a financial disclosure 
form, provided by MSD. The investigator/subinvestigator(s) also consent to the transmission 
of this information to MSD in the United States for these purposes. This may involve the 
transmission of information to countries that do not have laws protecting personal data. 
10.1.3
Data Protection
The Sponsor and MSD will conduct this study in compliance with all applicable data 
protection regulations.
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Participants will be assigned a unique identifier by MSD. Any participant records or datasets 
that are transferred to MSD will contain the identifier only; participant names or any 
information that would make the participant identifiable will not be transferred.
The participant must be informed that his/her personal study-related data will be used by the 
Sponsor and MSD in accordance with local data protection law. The level of disclosure must 
also be explained to the participant. 
The participant must be informed that his/her medical records may be examined by Clinical 
Quality Assurance auditors or other authorized personnel appointed by the Sponsor and 
MSD, by appropriate IRB/IEC members, and by inspectors from regulatory authorities.
10.1.3.1
Confidentiality of Data
By signing this protocol, the investigator affirms to the Sponsor and MSD that information 
furnished to the investigator by the Sponsor or MSD will be maintained in confidence, and 
such information will be divulged to the IRB, IEC, or similar or expert committee; affiliated 
institution and employees, only under an appropriate understanding of confidentiality with 
such board or committee, affiliated institution and employees. Data generated by this study 
will be considered confidential by the investigator, except to the extent that it is included in a 
publication as provided in the Publications section of this protocol.
10.1.3.2
Confidentiality of Participant Records
By signing this protocol, the investigator agrees that the Sponsor, MSD (or Sponsor or MSD
representative), IRB/IEC, or regulatory authority representatives may consult and/or copy 
study documents to verify worksheet/CRF data. By signing the consent form, the participant 
agrees to this process. If study documents will be photocopied during the process of verifying 
worksheet/CRF information, the participant will be identified by unique code only; full 
names/initials will be masked prior to transmission to MSD.
By signing this protocol, the investigator agrees to treat all participant data used and 
disclosed in connection with this study in accordance with all applicable privacy laws, rules 
and regulations.
10.1.3.3
Confidentiality of IRB/IEC Information
MSD is required to record the name and address of each IRB/IEC that reviews and approves 
this study. MSD, on behalf of the Sponsor, is also required to document that each IRB/IEC 
meets regulatory and ICH GCP requirements by requesting and maintaining records of the 
names and qualifications of the IRB/IEC members and to make these records available for 
regulatory agency review upon request by those agencies.
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10.1.4
Committees Structure
10.1.4.1
Executive Oversight Committee
The EOC is comprised of members of Sponsor and MSD Senior Management. The EOC will 
receive and decide upon any recommendations made by the eDMC regarding the study.
10.1.4.2
External Data Monitoring Committee
To supplement the routine study monitoring outlined in this protocol, an external DMC will 
monitor the periodic data from this study. The voting members of the committee are external 
to the Sponsor and MSD. The members of the DMC must not be involved with the study in 
any other way (eg, they cannot be study investigators) and must have no competing interests 
that could affect their roles with respect to the study.
The DMC will make recommendations to the EOC regarding steps to ensure both participant 
safety and the continued ethical integrity of the study. Also, the DMC will review periodic 
study results, consider the overall risk and benefit to study participants and recommend to the 
EOC whether the study should continue in accordance with the protocol.
Specific details regarding composition, responsibilities, and governance, including the roles 
and responsibilities of the various members and the MSD protocol team; meeting facilitation; 
the study governance structure; and requirements for and proper documentation of DMC 
reports, minutes, and recommendations will be described in the DMC charter that is reviewed 
and approved by all the DMC members.
10.1.5
Publication Policy
The results of this study may be published or presented at scientific meetings. The Sponsor 
and MSD will comply with the requirements for publication of study results. In accordance 
with standard editorial and ethical practice, the Sponsor and MSD will generally support 
publication of multicenter studies only in their entirety and not as individual site data. In this 
case, a coordinating investigator will be designated by mutual agreement.
If publication activity is not directed by the Sponsor and MSD, the investigator agrees to 
submit all manuscripts or abstracts to the Sponsor and MSD before submission. This allows 
the Sponsor and MSD to protect proprietary information and to provide comments.
Authorship will be determined by mutual agreement and in line with International Committee 
of Medical Journal Editors authorship requirements.
10.1.6
Compliance with Study Registration and Results Posting Requirements
Under the terms of the FDAAA of 2007, the Sponsor of the study is solely responsible for 
registering the study and posting its results to http://www.clinicaltrials.gov or other local 
registries. Butantan, as Sponsor of this study, will review this protocol and submit the 
information necessary to fulfill these requirements. Information posted will allow 
participants to identify potentially appropriate studies for their disease conditions and pursue 
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participation by calling a central contact number for further information on appropriate study 
locations and study site contact information.
By signing this protocol, the investigator acknowledges that the statutory obligations under 
FDAAA or other locally mandated registries are that of the Sponsor and agrees not to submit 
any information about this study or its results to those registries.
10.1.7
Compliance with Law, Audit, and Debarment
By signing this protocol, the investigator agrees to conduct the study in an efficient and 
diligent manner and in conformance with this protocol; generally accepted standards of GCP
(eg, International Council on Harmonisation of Technical Requirements for Registration of 
Pharmaceuticals for Human Use GCP: Consolidated Guideline and other generally accepted 
standards of GCP); and all applicable federal, state and local laws, rules and regulations 
relating to the conduct of the clinical study.
The Code of Conduct, a collection of goals and considerations that govern the ethical and 
scientific conduct of clinical investigations sponsored by MSD, is provided in this appendix 
under the Code of Conduct for Clinical Trials.
This study, sponsored by Butantan, will be conducted in a manner consistent with the MSD 
Code of Conduct for Clinical Trials (Section 10.1.1). 
Section III.A. (Regulatory Authority and Ethics Committee Review) of the Code of Conduct 
is adapted for this study to clarify that it is the Sponsor’s responsibility to submit the protocol 
and protocol amendments to the regulatory authorities, as follows:
All protocols and protocol amendments will be submitted by the Sponsor for regulatory 
authority acceptance/authorization prior to implementation of the trial or amendment, in 
compliance with local and/or national regulations.
The protocol, protocol amendment(s), informed consent form, investigator’s brochure, 
and other relevant trial documents must be reviewed and approved by an IRB/IEC before 
being implemented at each site, in compliance with local and/or national regulations. 
Changes to the protocol that are required urgently to eliminate an immediate hazard and 
to protect participant safety may be enacted in anticipation of ethics committee approval. 
The Sponsor will inform regulatory authorities of such new measures to protect 
participant safety, in compliance with local and/or national regulations.
Section IV.B. (Clinical Research Funding) of the Code of Conduct is adapted for this study 
to accurately identify Butantan as the trial Sponsor, as follows: 
Informed consent forms will disclose that the trial is sponsored by Butantan, and that the 
investigator or sponsoring institution is being paid or provided a grant for performing the 
trial. However, the local ethics committee may wish to alter the wording of the disclosure 
statement to be consistent with financial practices at that institution. As noted above, all 
publications resulting from this trial will indicate MSD as a source of funding.
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The investigator agrees not to seek reimbursement from participants, their insurance 
providers, or from government programs for procedures included as part of the study 
reimbursed to the investigator by MSD.
The investigator will promptly inform MSD of any regulatory authority inspection conducted 
for this study.
The investigator agrees to provide MSD with relevant information from inspection 
observations/findings to allow the Sponsor and/or MSD to assist in responding to any 
citations resulting from regulatory authority inspection and will provide MSD with a copy of 
the proposed response for consultation before submission to the regulatory authority. 
Persons debarred from conducting or working on clinical studies by any court or regulatory 
authority will not be allowed to conduct or work on MSD’s studies. The investigator will 
immediately disclose in writing to MSD if any person who is involved in conducting the 
study is debarred or if any proceeding for debarment is pending or, to the best of the 
investigator’s knowledge, threatened.
10.1.8
Data Quality Assurance
All participant data relating to the study will be recorded on printed or electronic CRF unless 
transmitted to MSD or designee electronically (eg, laboratory data). The investigator or 
qualified designee is responsible for verifying that data entries are accurate and correct by 
physically or electronically signing the CRF.
Detailed information regarding Data Management procedures for this protocol will be 
provided separately.
The investigator must maintain accurate documentation (source data) that supports the 
information entered in the CRF.
The investigator must permit study-related monitoring, audits, IRB/IEC review, and 
regulatory agency inspections and provide direct access to source data documents.
Study documentation will be promptly and fully disclosed to MSD by the investigator upon 
request and also shall be made available at the study site upon request for inspection, 
copying, review, and audit at reasonable times by representatives of MSD or any regulatory 
authorities. The investigator agrees to promptly take any reasonable steps that are requested 
by MSD or any regulatory authorities as a result of an audit or inspection to cure deficiencies 
in the study documentation and worksheets/CRFs.
MSD or designee is responsible for the data management of this study including quality 
checking of the data.
Study monitors will perform ongoing source data review and verification to confirm that data 
entered into the CRF by authorized site personnel are accurate, complete, and verifiable from 
source documents; that the safety and rights of participants are being protected; and that the 
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study is being conducted in accordance with the currently approved protocol and any other 
study agreements, ICH GCP, and all applicable regulatory requirements.
Records and documents, including participants’ documented informed consent, pertaining to 
the conduct of this study must be retained by the investigator for 15 years after study 
completion unless local regulations or institutional policies require a longer retention period. 
No records may be destroyed during the retention period without the written approval of 
MSD. No records may be transferred to another location or party without written notification 
to MSD.
10.1.9
Source Documents
Source documents provide evidence for the existence of the participant and substantiate the 
integrity of the data collected. The investigator/institution should maintain adequate and 
accurate source documents and study records that include all pertinent observations on each 
of the site’s participants. Source documents and data should be attributable, legible, 
contemporaneous, original, accurate, and complete. Changes to source data should be 
traceable, should not obscure the original entry, and should be explained if necessary (eg, via 
an audit trail). Source documents are filed at the investigator’s site.
Data reported on the CRF or entered in the eCRF that are transcribed from source documents 
must be consistent with the source documents or the discrepancies must be explained. The 
investigator/institution may need to request previous medical records or transfer records, 
depending on the study. Also, current medical records must be available.
10.1.10
Study and Site Closure
MSD in collaboration with the Sponsor or its designee may stop the study or study site 
participation in the study for medical, safety, regulatory, administrative, or other reasons 
consistent with applicable laws, regulations, and GCP.
In the event MSD in collaboration with the Sponsor prematurely terminates a particular study 
site, MSD or designee will promptly notify that study site’s IRB/IEC as specified by 
applicable regulatory requirement(s).
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10.2
Appendix 2: Clinical Laboratory Tests
Safety laboratory assessments (ie, blood chemistry, hematology, and urinalysis) are not 
planned for this study.
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10.3
Appendix 3: Adverse Events: Definitions and Procedures for Recording, 
Evaluating, Follow-up, and Reporting
10.3.1
Definitions of Medication Error, Misuse, and Abuse
Medication Error
This is an unintended failure in the drug treatment process that leads to or has the potential to 
lead to harm to the participant.
Misuse
This refers to situations where the medicinal product is intentionally and inappropriately used 
not in accordance with the terms of the product information.
Abuse
This corresponds to the persistent or sporadic, intentional excessive use of a medicinal 
product for a perceived psychological or physiological reward or desired non-therapeutic 
effect.
10.3.2
Definition of AE
AE definition
    An AE is any untoward medical occurrence in a clinical study participant, temporally 
associated with the use of study intervention, whether or not considered related to the 
study intervention.
    NOTE: An AE can therefore be any unfavorable and unintended sign (including an 
abnormal laboratory finding), symptom, or disease (new or exacerbated) temporally 
associated with the use of a study intervention.
    NOTE: For purposes of AE definition, study intervention (also referred to as Sponsor or 
MSD’s product) includes any pharmaceutical product, biological product, vaccine, 
diagnostic agent, medical device, combination product, or protocol-specified procedure 
whether investigational or marketed (including placebo, active comparator product, or 
run-in intervention), manufactured by, licensed by, provided by, or distributed by the 
Sponsor or MSD for human use in this study.
Events meeting the AE definition
    Any abnormal laboratory test results (hematology, clinical chemistry, or urinalysis) or 
other safety assessments (eg, ECG, radiological scans, vital signs measurements), 
including those that worsen from baseline, considered clinically significant in the medical 
and scientific judgment of the investigator.
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    Exacerbation of a chronic or intermittent pre-existing condition including either an 
increase in frequency and/or intensity of the condition.
    New conditions detected or diagnosed after study intervention administration even 
though it may have been present before the start of the study.
    Signs, symptoms, or the clinical sequelae of a suspected drug-drug interaction.
    Signs, symptoms, or the clinical sequelae of a suspected overdose of either study 
intervention or a concomitant medication.
    For all reports of overdose (whether accidental or intentional) with an associated AE, the 
AE term should reflect the clinical symptoms or abnormal test result. An overdose 
without any associated clinical symptoms or abnormal laboratory results is reported using 
the terminology “accidental or intentional overdose without adverse effect.”

Any new cancer or progression of existing cancer.
Events NOT meeting the AE definition
    Medical or surgical procedure (eg, endoscopy, appendectomy): the condition that leads to 
the procedure is the AE.
    Situations in which an untoward medical occurrence did not occur (social and/or 
convenience admission to a hospital).
    Anticipated day-to-day fluctuations of pre-existing disease(s) or condition(s) present or 
detected at the start of the study that do not worsen.
    Surgery planned prior to informed consent to treat a pre-existing condition that has not 
worsened.
    Refer to Section 8.4.6 for protocol-specific exceptions.
Definition of Solicited and Unsolicited AE

Solicited AEs are predefined local (at the injection site) and systemic events for which 
the participant is specifically questioned, and which are noted by the participant in the 
eVRC.

An unsolicited AE is an AE that was not solicited using an eVRC and that is 
communicated by a participant who has provided documented informed consent. 
Unsolicited AEs include serious and nonserious AEs and may be reported via the eVRC 
or via other methods.
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Definition of MAAE

AEs in which medical attention is received during an unscheduled, non-routine outpatient 
visit, such as an ER visit, office visit, or an urgent care visit with any medical personnel 
for any reason. Routine visits are not considered MAAEs. Examples of routine visits 
include: physical examination, wellness visits, or vaccinations.

Determination of MAAEs is the responsibility of the investigator or a qualified designee. 
Once identified, MAAEs should be reported to MSD per the timeline for reporting
AEs/SAEs. 
NOTE: For this study a febrile event reported during an acute visit (see Section 8.3.6) is
considered an MAAE.
10.3.3
Definition of SAE
If an event is not an AE per definition above, then it cannot be an SAE even if serious 
conditions are met.
An SAE is defined as any untoward medical occurrence that, at any dose:
a.   Results in death
b.   Is life-threatening
•
The term “life-threatening” in the definition of “serious” refers to an event in which 
the participant was at risk of death at the time of the event. It does not refer to an 
event, which hypothetically might have caused death, if it were more severe.
c.   Requires inpatient hospitalization or prolongation of existing hospitalization
•
Hospitalization is defined as an inpatient admission, regardless of length of stay, even 
if the hospitalization is a precautionary measure for continued observation. (Note: 
Hospitalization for an elective procedure to treat a pre-existing condition that has not 
worsened is not an SAE.) A pre-existing condition is a clinical condition that is 
diagnosed prior to the use of Sponsor or MSD’s product and is documented in the 
participant’s medical history.
d.   Results in persistent or significant disability/incapacity
•
The term disability means a substantial disruption of a person’s ability to conduct 
normal life functions.
•
This definition is not intended to include experiences of relatively minor medical 
significance such as uncomplicated headache, nausea, vomiting, diarrhea, influenza, 
and accidental trauma (eg, sprained ankle) that may interfere with or prevent 
everyday life functions but do not constitute a substantial disruption.
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e.   Is a congenital anomaly/birth defect
•
In offspring of participant taking the product regardless of time to diagnosis.
f.   Other important medical events
•
Medical or scientific judgment should be exercised in deciding whether SAE 
reporting is appropriate in other situations such as important medical events that may 
not be immediately life-threatening or result in death or hospitalization but may 
jeopardize the participant or may require medical or surgical intervention to prevent 1 
of the other outcomes listed in the above definition. These events should usually be 
considered serious.
Examples of such events include invasive or malignant cancers, intensive treatment in 
an emergency room or at home for allergic bronchospasm, blood dyscrasias or 
convulsions that do not result in hospitalization, or development of drug dependency 
or drug abuse.
10.3.4
Additional Events Reported
Additional events that require reporting
In addition to the above criteria, AEs meeting either of the below criteria, although not 
serious per ICH definition, are reportable to MSD.
•
Is a cancer
•
Is associated with an overdose 
10.3.5
Recording AE and SAE
AE and SAE recording
    When an AE/SAE occurs, it is the responsibility of the investigator to review all 
documentation (eg, hospital progress notes, laboratory, and diagnostics reports) related to 
the event.
    The investigator will record all relevant AE/SAE information on the AE 
CRFs/worksheets at each examination.

It is not acceptable for the investigator to send photocopies of the participant’s medical 
records to MSD in lieu of completion of the AE CRF page.
    There may be instances when copies of medical records for certain cases are requested by 
MSD. In this case, all participant identifiers, with the exception of the participant 
number, will be blinded on the copies of the medical records before submission to MSD.
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    The investigator will attempt to establish a diagnosis of the event based on signs, 
symptoms, and/or other clinical information. In such cases, the diagnosis (not the 
individual signs/symptoms) will be documented as the AE/SAE.
Assessment of intensity
    An event is defined as “serious” when it meets at least 1 of the predefined outcomes as 
described in the definition of an SAE, not when it is rated as severe.

The investigator will make an assessment of overall intensity grade for each AE and SAE 
(and other reportable event) reported during the study. An overall intensity grade will be 
assigned to injection-site AEs, specific systemic AEs, other systemic AEs, and vital sign 
(temperature) AEs as shown in the following tables. The overall intensity grading scales 
used in this study are adapted from the “FDA Guidance for Industry: Toxicity Grading 
Scale for Healthy Adult and Adolescent Volunteers Enrolled in Preventive Vaccine 
Clinical Trials, September 2007” [Food and Drug Administration 2007].
Injection-Site AE Overall Intensity Grading Scale
Injection-Site 
Reaction to Study 
Vaccinea
Mild 
(Grade 1)
Moderate
(Grade 2)
Severe 
(Grade 3)
Potentially
Life-Threatening 
(Grade 4)
Injection-site AEs occurring Days 1 through 5 following receipt of study vaccine
Pain/Tenderness
Does not interfere 
with activity
Repeated use of 
non-narcotic pain 
reliever >24 hours 
or interferes with 
activity
Any use of 
narcotic pain 
reliever or 
prevents daily 
activity
ER visit or 
hospitalization
Erythema/Redness
≤5 cm
(size measured as
A or B)
5.1 to 10 cm
(size measured as
C or D)
>10 cm
(size measured as
E→)
Necrosis or 
exfoliative 
dermatitis or 
results in ER visit 
or hospitalization
Swelling
≤5 cm
(size measured as 
A or B)
5.1 to 10 cm
(size measured as 
C or D)
>10 cm
(size measured as 
E→)
Necrosis or ER 
visit or 
hospitalization
Other
Does not interfere 
with activity
Repeated use of 
non-narcotic pain 
reliever >24 hours 
or interferes with 
activity
Any use of 
narcotic pain 
reliever or 
prevents daily 
activity
ER visit or 
hospitalization
Any injection-site reaction that begins ≥6 days after receipt of study vaccine
Pain/Tenderness
Erythema/Redness
Swelling
Other
Does not interfere 
with activity
Repeated use of 
non-narcotic pain 
reliever >24 hours 
or interferes with 
activity
Any use of 
narcotic pain 
reliever or 
prevents daily 
activity
ER visit or 
hospitalization
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Injection-Site 
Reaction to Study 
Vaccinea
Mild 
(Grade 1)
Moderate
(Grade 2)
Severe 
(Grade 3)
Potentially
Life-Threatening 
(Grade 4)
Injection-site AEs occurring Days 1 through 5 following receipt of study vaccine
AE=adverse event; ER=emergency room; eVRC=electronic Vaccination Report Card
The overall intensity grading scales used in this study are adapted from the “FDA Guidance for Industry: Toxicity 
Grading Scale for Healthy Adult and Adolescent Volunteers Enrolled in Preventive Vaccine Clinical Trials, September 
2007” [Food and Drug Administration 2007].
a
Based upon information provided by the participant on the eVRC and verbally during eVRC review.
Erythema/Redness and Swelling are specific injection-site AEs with size designations of letters A (<2.5 cm), B (2.5 
to 5 cm), C (5.1 to 7.4 cm), D (7.5 to 10 cm), and E (>10 cm), based upon a graphic in the eVRC user guide. If the 
participant has an ER visit or is hospitalized for any injection-site AE, that AE is to be assigned an intensity grade of 
4, regardless of the size measured.
Specific Systemic AE Overall Intensity Grading Scale
Systemic (General)
Mild 
(Grade 1)
Moderate 
(Grade 2)
Severe 
(Grade 3)
Potentially 
Life-Threatening
(Grade 4)
Headache
No interference 
with activity
Repeated use of 
non-narcotic pain 
reliever >24 hours 
or some 
interference with 
activity
Significant; any 
use of narcotic 
pain reliever or 
prevents daily 
activity
ER visit or 
hospitalization
Fatigue/tiredness
No interference 
with activity
Some interference
with activity
Significant; 
prevents daily 
activity
ER visit or 
hospitalization
Muscle 
pain/myalgia
No interference 
with activity
Some interference 
with activity
Significant; 
prevents daily 
activity
ER visit or 
hospitalization
Joint pain/arthralgia
No interference 
with activity
Some interference 
with activity
Significant; 
prevents daily 
activity
ER visit or 
hospitalization
Rash
No interference 
with activity
Some interference 
with activity
Significant; 
prevents daily 
activity
ER visit or 
hospitalization
ER=emergency room
The overall intensity grading scales used in this study are adapted from the “FDA Guidance for Industry: Toxicity 
Grading Scale for Healthy Adult and Adolescent Volunteers Enrolled in Preventive Vaccine Clinical Trials, September 
2007” [Food and Drug Administration 2007].
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Other Systemic AE Overall Intensity Grading Scale
Systemic Illnessa
Mild 
(Grade 1)
Moderate 
(Grade 2)
Severe 
(Grade 3)
Potentially 
Life-Threatening
(Grade 4)b
Illness or clinical 
AE (as defined 
according to 
applicable 
regulations)
No interference 
with activity
Some interference 
with activity not 
requiring medical 
intervention
Prevents daily 
activity and 
required medical 
intervention
ER visit or 
hospitalization
AE=adverse event; ER=emergency room; eVRC=electronic Vaccination Report Card; SAE=serious adverse event
The overall intensity grading scales used in this study are adapted from the “FDA Guidance for Industry: Toxicity 
Grading Scale for Healthy Adult and Adolescent Volunteers Enrolled in Preventive Vaccine Clinical Trials, September 
2007” [Food and Drug Administration 2007].
a
Based upon information provided by the participant on the eVRC and verbally during the eVRC review during the 
primary safety follow-up period. For SAEs reported beyond the primary safety follow-up period, grading will be 
based upon the initial report and/or follow-up of the event.
b
AEs resulting in death will be assessed as Grade 4.
Vital Sign (Temperature) Overall Intensity Grading Scale
Vital Signsa
Mild 
(Grade 1)
Moderate 
(Grade 2)
Severe 
(Grade 3)
Potentially 
Life-Threatening
(Grade 4)
Fever 
(°C)b
(°F)b
38.0 to 38.4
100.4 to 101.1
38.5 to 38.9
101.2 to 102.0
39.0 to 40.0
102.1 to 104.0
>40.0
>104.0
The overall intensity grading scales used in this study are adapted from the “FDA Guidance for Industry: Toxicity 
Grading Scale for Healthy Adult and Adolescent Volunteers Enrolled in Preventive Vaccine Clinical Trials, September 
2007” [Food and Drug Administration 2007].
a
Participant should be at rest for all vital sign requirements.
b
Oral temperature; no recent hot or cold beverages or smoking.
Assessment of causality
•
Did the Sponsor or MSD’s product cause the AE?
•
The determination of the likelihood that the Sponsor or MSD’s product caused the AE 
will be provided by an investigator who is a qualified physician. The investigator’s 
signed/dated initials on the source document or worksheet that supports the causality 
noted on the AE form, ensures that a medically qualified assessment of causality was 
done. This initialled document must be retained for the required regulatory time frame. 
The criteria below are intended as reference guidelines to assist the investigator in 
assessing the likelihood of a relationship between the test product and the AE based upon 
the available information.
•
The following components are to be used to assess the relationship between the 
Sponsor or MSD’s product and the AE; the greater the correlation with the 
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components and their respective elements (in number and/or intensity), the more likely 
the Sponsor or MSD’s product caused the AE:
-
Exposure: Is there evidence that the participant was actually exposed to the 
Sponsor or MSD’s product such as: reliable history, acceptable compliance 
assessment (diary, etc.), seroconversion or identification of vaccine virus in bodily 
specimen?
-
Time Course: Did the AE follow in a reasonable temporal sequence from 
administration of the Sponsor or MSD’s product? Is the time of onset of the AE 
compatible with a vaccine-induced effect?
-
Likely Cause: Is the AE not reasonably explained by another etiology such as 
underlying disease, other drug(s)/vaccine(s), or other host or environmental factors?
-
Rechallenge: Was the participant re-exposed to the Sponsor or MSD’s product in 
the study?
◦
If yes, did the AE recur or worsen?
◦
If yes, this is a positive rechallenge.
◦
If no, this is a negative rechallenge.
(Note: This criterion is not applicable if: (1) the initial AE resulted in death or 
permanent disability, or (2) the study is a single-dose vaccine study; or (3) Sponsor
or MSD’s product(s) is/are used only 1 time.)
NOTE: IF A RECHALLENGE IS PLANNED FOR AN AE THAT WAS SERIOUS AND 
MAY HAVE BEEN CAUSED BY THE SPONSOR OR MSD’S PRODUCT, OR IF RE-
EXPOSURE TO THE SPONSOR OR MSD’S PRODUCT POSES ADDITIONAL 
POTENTIAL SIGNIFICANT RISK TO THE PARTICIPANT THEN THE 
RECHALLENGE MUST BE APPROVED IN ADVANCE BY THE MSD CLINICAL 
DIRECTOR, AND IF REQUIRED, THE IRB/IEC.
•
Consistency with study intervention profile: Is the clinical/pathological presentation of 
the AE consistent with previous knowledge regarding the Sponsor or MSD’s product or 
drug class pharmacology or toxicology?
•
The assessment of relationship will be reported on the CRFs/worksheets by an 
investigator who is a qualified physician according to his/her best clinical judgment, 
including consideration of the above elements.
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•
Use the following scale of criteria as guidance (not all criteria must be present to be 
indicative of a Sponsor or MSD’s product relationship).
-
Yes, there is a reasonable possibility of Sponsor or MSD’s product relationship:
◦
There is evidence of exposure to the Sponsor or MSD’s product. The temporal 
sequence of the AE onset relative to the administration of the Sponsor or MSD’s 
product is reasonable. The AE is more likely explained by the Sponsor or 
MSD’s product than by another cause.
-
No, there is not a reasonable possibility of Sponsor or MSD’s product relationship:
◦
Participant did not receive the Sponsor or MSD’s product OR temporal 
sequence of the AE onset relative to administration of the Sponsor or MSD’s 
product is not reasonable OR the AE is more likely explained by another cause 
than the Sponsor or MSD’s product. (Also entered for a participant with 
overdose without an associated AE.)
•
For each AE/SAE, the investigator must document in the medical notes that he/she has 
reviewed the AE/SAE and has provided an assessment of causality.
•
There may be situations in which an SAE has occurred and the investigator has minimal 
information to include in the initial report to MSD. However, it is very important that the 
investigator always make an assessment of causality for every event before the initial 
transmission of the SAE data to MSD.
•
The investigator may change his/her opinion of causality in light of follow-up 
information and send an SAE follow-up report with the updated causality assessment.
•
The causality assessment is 1 of the criteria used when determining regulatory reporting 
requirements.
Follow-up of AE and SAE
    The investigator is obligated to perform or arrange for the conduct of supplemental 
measurements and/or evaluations as medically indicated or as requested by MSD to 
elucidate the nature and/or causality of the AE or SAE as fully as possible. This may 
include additional laboratory tests or investigations, histopathological examinations, or 
consultation with other health care professionals.
    New or updated information will be recorded in the CRF.
    The investigator will submit any updated SAE data to MSD within 24 hours of receipt of 
the information.
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10.3.6
Reporting of AEs, SAEs, and Other Reportable Safety Events to MSD
AE, SAE, and other reportable safety event reporting to MSD via electronic data 
collection tool
    The primary mechanism for reporting to MSD will be the EDC tool.
-
Electronic reporting procedures can be found in the EDC data entry guidelines (or 
equivalent).
-
If the electronic system is unavailable for more than 24 hours, then the site will 
use the paper AE Reporting form.
◦
Reference Section 8.4.1 for reporting time requirements.
    The site will enter the SAE data into the electronic system as soon as it becomes 
available.
    After the study is completed at a given site, the EDC tool will be taken off-line to prevent 
the entry of new data or changes to existing data.
    If a site receives a report of a new SAE from a study participant or receives updated data 
on a previously reported SAE after the EDC tool has been taken off-line, then the site can 
report this information on a paper SAE form or by telephone (see next section).
    Contacts for SAE reporting can be found in the Investigator Study File Binder (or 
equivalent).
SAE reporting to MSD via paper CRF
    If the EDC tool is not operational, facsimile transmission or secure e-mail of the SAE 
paper CRF is the preferred method to transmit this information to MSD.
    In rare circumstances and in the absence of facsimile equipment, notification by 
telephone is acceptable with a copy of the SAE data collection tool sent by overnight 
mail or courier service.
    Initial notification via telephone does not replace the need for the investigator to complete 
and sign the SAE CRF pages within the designated reporting time frames.
    Contacts and instructions for SAE reporting and paper reporting procedures can be found 
in the Investigator Trial File Binder (or equivalent).
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10.3.7
2009 WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and 
Control
Criteria for diagnosing dengue (with or without warning signs) and severe dengue from the 
2009 WHO Dengue Guidelines [World Health Organization 2009] are presented in Figure 3.
Figure 3
Suggested Dengue Case Classification and Levels of Severity
ALT=alanine amino transferase; AST=aspartate amino transferase; CNS=central nervous system; DSS=dengue shock 
syndrome; HCT=hematocrit.
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10.4
Appendix 4: Device Events, Adverse Device Events, and Medical Device 
Incidents: Definitions, Collection, and Documentation
Not applicable.
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10.5
Appendix 5: Contraceptive Guidance
10.5.1
Definitions 
Women of Childbearing Potential (WOCBP)
A woman is considered fertile following menarche and until becoming postmenopausal 
unless permanently sterile (see below):
If fertility is unclear (eg, amenorrhea in adolescents or athletes) and a menstrual cycle cannot 
be confirmed before first dose of study intervention, additional evaluation should be 
considered.
Women in the following categories are not considered WOCBP:
•
Premenarchal
•
Premenopausal female with 1 of the following:
- Documented hysterectomy
- Documented bilateral salpingectomy
- Documented bilateral oophorectomy
For individuals with permanent infertility due to an alternate medical cause other than the 
above (eg, Mullerian agenesis, androgen insensitivity), investigator discretion should be 
applied to determining study entry.
Note: Documentation can come from the site personnel’s review of the participant’s 
medical records, medical examination, or medical history interview.
•
Postmenopausal female
- A postmenopausal state is defined as no menses for 12 months without an alternative 
medical cause.
◦
A high FSH level in the postmenopausal range may be used to confirm a 
postmenopausal state in women not using hormonal contraception or HRT. 
However, in the absence of 12 months of amenorrhea, confirmation with two 
FSH measurements in the postmenopausal range is required.
- Females on HRT and whose menopausal status is in doubt will be required to use one 
of the non-hormonal highly effective contraception methods if they wish to 
continue their HRT during the study. Otherwise, they must discontinue HRT to 
allow confirmation of postmenopausal status before study enrollment.
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10.5.2
Contraception Requirements
Contraceptives allowed during the study includea:
Highly Effective Contraceptive Methods That Have Low User Dependencyb
Failure rate of <1% per year when used consistently and correctly.
•
Progestogen-only subdermal contraceptive implantc
•
IUSd
•
Non-hormonal IUD
•
Bilateral tubal occlusion
•
Azoospermic partner (vasectomized or secondary to medical cause)
This is a highly effective contraception method provided that the partner is the sole male sexual partner of 
the WOCBP and the absence of sperm has been confirmed. If not, an additional highly effective method of 
contraception should be used. A spermatogenesis cycle is approximately 90 days.
Note: Documentation of azoospermia can come from the site personnel’s review of the participant’s 
medical records, medical examination, or medical history interview. 
Highly Effective Contraceptive Methods That Are User Dependentb
Failure rate of <1% per year when used consistently and correctly.
•
Combined (estrogen- and progestogen- containing) hormonal contraceptionc
- Oral
- Intravaginal
- Transdermal
- Injectable
•
Progestogen-only hormonal contraceptionc
- Oral
- Injectable
Sexual Abstinence
•
Sexual abstinence is considered a highly effective method only if defined as refraining from heterosexual 
intercourse during the entire period of risk associated with the study intervention. The reliability of sexual 
abstinence needs to be evaluated in relation to the duration of the study and the preferred and usual lifestyle 
of the participant.
a   Contraceptive use by men or women should be consistent with local regulations regarding the use of 
contraceptive methods for participants of clinical studies.
b   Typical use failure rates are higher than perfect-use failure rates (ie, when used consistently and correctly).
c   If locally required, in accordance with CTFG guidelines, acceptable contraceptive implants are limited to 
those which inhibit ovulation.
   d IUS is a progestin releasing IUD.
Note: The following are not acceptable methods of contraception:
-  Periodic abstinence (calendar, symptothermal, post-ovulation methods), withdrawal (coitus 
interruptus), spermicides only, and LAM.
-  Male condom with cap, diaphragm, or sponge with spermicide.
-  Male and female condom should not be used together (due to risk of failure with friction).
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10.6
Appendix 6: Collection and Management of Specimens for Future Biomedical 
Research
Not applicable.
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10.7
Appendix 7: Country-specific Requirements
Not applicable.
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10.8
Appendix 8: Abbreviations
Abbreviation
Expanded Term
AE
adverse event 
ANVISA
Agência Nacional de Vigilância Sanitária (Brazilian Health Regulatory Agency)
APaT
All Participants as Treated
AxMP
auxiliary medicinal product
BP
blood pressure
Butantan-DV
Butantan Dengue Vaccine
CFR
Code of Federal Regulations
CI
confidence interval
CONSORT
Consolidated Standards of Reporting Trials
CRF
case report form 
CSR
clinical study report
CTFG
clinical trial facilitation group
DENV
dengue virus
DF
dengue fever
DHF
dengue hemorrhagic fever
DMC
Data Monitoring Committee 
DSS
dengue shock syndrome
ECG
electrocardiogram 
ECI
event of clinical interest
eCRF
electronic case report form
EDC
electronic data collection 
eDMC
external DMC
EEA
European Economic Area
ELISA
enzyme-linked immunosorbent assay
EOC
Executive Oversight Committee
ER
emergency room
eVRC
electronic Vaccination Report Card
FAS
Full Analysis Set
FDA
Food and Drug Administration (US)
FDAAA
Food and Drug Administration Amendments Act
FSH
follicle-stimulating hormone
GCP
Good Clinical Practice 
GMO
genetically modified organism
GMT
geometric mean titer
hCG
human chorionic gonadotropin
HEENT
head, eyes, ears, nose, and throat
HIV
human immunodeficiency virus
HRT
hormone replacement therapy
IB
Investigator’s Brochure 
ICF
Informed Consent Form
ICH
International Council for Harmonisation of Technical Requirements for 
Pharmaceuticals for Human Use
ICMJE
International Committee of Medical Journal Editors
IEC
Independent Ethics Committee
IgG
Immunoglobulin G
IgM
Immunoglobulin M
IMP
Investigational Medicinal Product
IRB
Institutional Review Board
IRT
interactive response technology
IUD
intrauterine device
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Abbreviation
Expanded Term
IUS
intrauterine hormone-releasing system
LAM
lactational amenorrhea method
LATV
live-attenuated tetravalent vaccine
LLOQ
lower limit of quantitation
MAAE
medically attended adverse event
M&N
Miettinen and Nurminen
mFRNT
micro-focus reduction neutralization test
NIH
National Institute of Health
NIMP
Non-Investigational Medicinal Product
NS
nonstructural protein
NSAE
nonserious adverse event
PCR
polymerase chain reaction
PFU
plaque forming unit
POC
point of care
PP
Per-Protocol
PT
preferred term
RT-PCR
reverse transcription polymerase chain reaction
SAE
serious adverse event 
SAP
statistical analysis plan
SC
subcutaneous
SINAN
Brazil Information System for Notifiable Diseases
SoA
schedule of activities
SOC
system organ class
sSAP
supplemental statistical analysis plan
SUSAR
suspected unexpected serious adverse reaction
US
United States
VRC
Vaccination Report Card
VRNT
virus reduction neutralization test
WHO
World Health Organization
WOCBP
woman/women of childbearing potential 
WT
wild type
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11
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