A Phase 2, Multi-Center, Randomized Clinical Trial to Evaluate the Efficacy and Safety of Human Anti-SARS-CoV-2 Convalescent Plasma in Severely Ill Adults With COVID-19
Phase: PHASE2
Conditions: SARS-CoV-2 Infection
Sponsor: Max O'Donnell

NCT04359810 
Protocol (Population A) V 17AUG2020  
 
Long title: A Phase 2, Randomized Clinical Trial to Evaluate the Efficacy and Safety of Human Anti-SARS-
CoV-2 Convalescent Plasma in Severely Ill Adults with COVID-19 (AAAS9924) 
Short title: Population A: Convalescent Plasma in Severe COVID-19 Clinical  
Phase: 2 IND Sponsor: Andrew B. Eisenberger, MD  
Principal Investigator: Max O’Donnell, MD, MPH  
Conducted by: Columbia University  
Sample Size: 220  
Study Population: Subjects aged ≥18 years with severe COVID-19  
Study Duration: Approximately 1 year. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Study Design: Randomized blinded phase 2 trial to assess the efficacy and safety of anti-SARS-CoV-2 
plasma among adults with severe COVID-19. A total of 220 eligible subjects will be randomized in a 2:1 
ratio, stratified by country (US, Brazil) to receive either convalescent plasma qualitatively positive for 
SARS-CoV-2 antibody (anti-SARS-CoV-2 plasma) or non-convalescent fresh frozen plasma (control 
plasma). The patient and the study clinician assessing the clinical outcome will be blinded to the 
treatment arm.  
The following will be assessed in all subjects:  
Safety and efficacy: Day 0 (baseline) to Day 28.  
Study Agent:  
• Anti-SARS-CoV-2 convalescent plasma (1 unit; ~200-250 mL collected by apheresis from a volunteer 
who recovered from COVID-19 (collection and qualification covered by IRB protocol AAAS9845 
(Convalescent plasma donors)) and was found to be a qualitatively positive for SARS-CoV-2 antibody 
(“anti-SARS-CoV-2 plasma”). 
• Control plasma: 1 unit of standard plasma collected prior to December 2019 Protocol (Population A) V 
17AUG2020  
Primary Efficacy Objective: To evaluate the efficacy of treatment with anti-SARS-CoV-2 plasma versus 
control plasma with respect to Day 28 severity outcome.  
Primary Endpoint: The primary endpoint is Day 28 severity outcome on a seven-category scale:  
1. Not hospitalized with resumption of normal activities  
2. Not hospitalized, but unable to resume normal activities  
3. Hospitalized, not requiring supplemental oxygen  
4. Hospitalized, requiring supplemental oxygen  
5. Hospitalized, requiring high-flow oxygen therapy or noninvasive mechanical ventilation  
6. Hospitalized, requiring extracorporeal membrane oxygenation (ECMO), invasive mechanical 
ventilation, or both  
7. Death  
 
Primary Safety Objective: To evaluate the safety and tolerability of treatment with anti- SARS-CoV-2 
plasma versus control (control plasma) in adults with severe COVID-19.  
Primary Safety Endpoints:  
1. Cumulative incidence of grade 3 and 4 adverse events during the study period  
2. Cumulative incidence of serious adverse events during the study period  
 
Secondary Objectives:  
 
1. To compare duration of need for supplemental oxygen and/or mechanical ventilation between 
recipients of the anti-SARS-CoV-2 plasma and control plasma.  
2. To compare duration of hospitalization between recipients of the anti-SARSCoV-2 plasma and control 
plasma.  
3. To compare in-hospital and 28-day mortality between recipients of the anti-SARS-CoV-2 plasma and 
control plasma.  

 
Ancillary Endpoints:  
 
1. To compare the proportion and duration of SARS-CoV-2 PCR positivity (RT PCR) between the 
recipients of the anti-SARS-CoV-2 plasma and control plasma at days 0, 7, and 14.  
2. To compare the levels of SARS-CoV-2 RNA between recipients of the anti0SARS-CoV-2 plasma and 
control plasma at days 0, 7, and 14.  
3. To assess for genetic and transcriptomic differences at Day 0 (genomic) and Day 0,7,14 
(transcriptomic) between the recipients of the anti-SARS-CoV-2 plasma and control plasma.  
 
STUDY POPULATION  
1.1.1. Inclusion Criteria for Enrollment  
1. Willing and able to provide written informed consent prior to performing study procedures or have a 
legally authorized representative available to do so.  
2. Age ≥18 years.  
3. Evidence of SARS-CoV-2 infection by PCR test of nasopharyngeal swab or oropharyngeal 
swab/tracheal aspirate sample within 14 days of randomization.  
4. Peripheral capillary oxygen saturation (SpO2) ≤ 94% on room air or requiring supplemental oxygen, 
non-invasive or invasive mechanical ventilation at screening.  
5. Evidence of infiltrates on chest radiography.  
6. Females of childbearing age and males must be willing to practice an effective contraceptive method 
or remain abstinent during the study period.  
1.1.2. Exclusion Criteria  
1. Participation in another clinical trial of anti-viral agent(s)* for COVID-19.  
2. Receipt of any anti-viral agent(s)* with possible activity against SARS-CoV-2 <24 hours prior to study 
drug administration. 
3. Mechanically ventilated (including veno-venous (VV)-ECMO) ≥ 5 days. 
4. Severe multi-organ failure.  
5. History of prior reactions to transfusion blood products meeting definitive case definition criteria, at 
least severe severity, and probable or definite imputability per National Healthcare Safety Network 
(NHSN)/Centers for Disease Control and Prevention (CDC) criteria.  
6. Known IgA deficiency.  
7. Females who are pregnant or breastfeeding. 
* Use of Remdesivir as treatment for COVID-19 is permitted. 
 

BACKGROUND AND SCIENTIFIC RATIONALE  
There are currently no proven treatment options for coronavirus disease (COVID-19), which is caused by 
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). Human convalescent plasma has been 
successfully used for treatment of other severe coronavirus infections and thus may provide an option 
for treatment of COVID-19 and could be rapidly available from people who have recovered from disease 
and can donate plasma. Passive antibody therapy involves the administration of antibodies against a 
given infectious agent to a susceptible or ill individual for the purpose of preventing or treating an 
infectious disease caused by that agent. Experience from prior outbreaks with other coronaviruses, such 
as SARS-CoV-1, shows that convalescent plasma contains neutralizing antibodies to the relevant virus 
(Zhang et al., 2005). In the case of SARS-CoV-2, the anticipated mechanism of action by which passive 
antibody therapy would mediate protection is viral neutralization. However, other mechanisms may be 
possible, such as antibody dependent cellular cytotoxicity and/or phagocytosis. Convalescent serum was 
also used in the 2013 African Ebola epidemic. A small 73 non-randomized study in Sierra Leone revealed 
a significant increase in survival for those 74 treated with convalescent whole blood relative to those 
who received standard treatment (Sahr et al., 2017). The only antibody type that is currently available 
for immediate use against SARS-CoV-2 is that found in human convalescent plasma. As more individuals 
contract COVID-19 and recover, the number of potential donors will continue to increase. When used 
for therapy, antibody is most effective when administered shortly after the onset of symptoms. The 
reason for temporal variation in efficacy is not well understood but could reflect that passive antibody 
works by neutralizing the initial inoculum, which is likely to be much smaller than that of established 
disease. Another explanation is that antibody works by modifying the inflammatory response, which is 
also easier during the initial immune response, which may be asymptomatic (Casadevall & Pirofski, 
2003). As an example, passive antibody therapy for pneumococcal pneumonia was most effective when 
administered shortly after the onset of symptoms and there was no benefit if antibody administration 
was delayed past the third day of disease (Casadevall & Scharff, 1994). For passive antibody therapy to 
be effective, a sufficient amount of antibody must be administered. When given to a susceptible person, 
this antibody will circulate in the blood, reach tissues and provide protection against infection. 
Depending on the antibody amount and composition, the protection conferred by the transferred 
immunoglobulin can last from weeks to months. 
Experience with the use of convalescent plasma against coronavirus diseases  
In the 21st century, there were two other epidemics with coronaviruses that were associated with high 
mortality, SARS1 in 2003 and MERS in 2012. In both outbreaks, the high mortality and absence of 
effective therapies led to the use of convalescent plasma. The largest study involved the treatment of 80 
patients in Hong Kong with SARS (Cheng et al., 2005). Patients treated before day 14 had improved 
prognosis defined by discharge from hospital before day 22, consistent with the observation that earlier 
administration is more likely to be effective. In addition, those who were PCR positive and seronegative 
for coronavirus at the time of therapy had improved prognosis. There is also some anecdotal 
information on the use of convalescent plasma in seriously ill individuals. Three patients with SARS in 
Taiwan were treated with 500 ml of convalescent plasma, resulting in a reduction in plasma virus titer 
and each survived (Yeh et al., 2005). Three patients with MERS in South Korea were treated with 
convalescent plasma, but only two of the recipients had neutralizing antibody in their plasma (Ko et al., 
2018). The latter study highlights a challenge in using convalescent plasma, namely, that some who 
recover from viral disease may not have high titers of neutralizing antibody (Arabi et al., 2016). 

Consistent with this point, an analysis of 99 samples of convalescent sera from patients with MERS 
showed that 87 had neutralizing antibody with a geometric mean titer of 1:61. This suggests that 
antibody declines with time and/or that few patients make high titer responses. It is also possible that 
other types of non-neutralizing antibodies are made that contribute to protection and recovery as 
described for other viral diseases (Gunn et al., 2018; van Erp, Luytjes, Ferwerda, & van Kasteren, 2019). 
There are reports that convalescent plasma was used for therapy of patients with COVID-19 in China 
during the current outbreak (Xinhua, 2020). Although few details are available from the Chinese 
experience and published studies involved small numbers of patients, the available information suggests 
that convalescent plasma administration reduces viral load and was safe.  
Overview of known potential risks  
Historical and current anecdotal data on use of convalescent plasma suggest it is safe in coronavirus 
infection. Therefore, the large number of exposed healthcare workers, public servants and first 
responders, in combination with high morbidity and mortality in severe COVID-19, particularly in elderly 
and vulnerable persons, suggest that the benefits of convalescent plasma outweigh its possible risks in 
patients with severe illness. However, for all cases where convalescent plasma administration is 
considered, a risk-benefit assessment must be conducted to assess individual variables. 
The theoretical risk involves the phenomenon of antibody-mediated enhancement of infection (ADE). 
ADE can occur for several viral diseases and involves an enhancement of disease in the presence of 
certain antibodies. For coronaviruses, several mechanisms for ADE have been described and there is the 
theoretical concern that antibodies to one type of coronavirus could enhance infection to another viral 
strain (Wan et al., 2020). It may be possible to predict the risk of ADE of SARS-CoV-2 experimentally, as 
proposed for MERS. Since the proposed use of convalescent plasma in the COVID-19 epidemic would 
rely on preparations with high titers of neutralizing antibody against the same virus, SARS2-CoV-2, ADE 
may be unlikely. The available evidence from the use of convalescent plasma in patients with SARS1 and 
MERS (Mair-Jenkins et al., 2015), and anecdotal evidence of its use in patients with COVID-19 (Xinhua, 
2020), suggest it is safe. Nevertheless, caution and vigilance will be required in for any evidence of 
enhanced infection. Another theoretical risk is that antibody administration to those exposed to 
SARSCoV-2 may avoid disease but modify the immune response such that those individuals mount 
attenuated immune responses, which would leave them vulnerable to subsequent re-infection. In this 
regard, passive antibody administration before vaccination with respiratory syncytial virus was reported 
to attenuate humoral but not cellular immunity (Crowe, Firestone, & Murphy, 2001). This concern will 
be investigated as part of this clinical trial by measuring immune responses in those exposed and 
treated with convalescent plasma to prevent disease. If the concern proved real these individuals could 
be vaccinated against COVID-19 when a vaccine becomes available. Passive antibodies are derived from 
human serum. The antibodies used in this study will be derived from serum obtained from convalescent 
patients, and will be subjected to testing protocols that are similar to those used by blood banks and 
transfusion services. However, as is the case with any biological product, there is a very small risk of 
allergy/anaphylaxis, or passive transfer of potential unknown infectious agents or infections. While most 
adverse effects are mild and transient including headaches, flushing, fever, chills, fatigue, nausea, 
diarrhea, transient changes in blood pressure and tachycardia, there is also the risk of transfusion 
related acute lung injury (TRALI), and transfusion associated circulatory overload (TACO), which could 
worsen hypoxemia in patients requiring supplemental oxygen or non-invasive or mechanical ventilation. 
Late adverse events are rare and include acute renal failure and thromboembolic events.  

Known potential benefits  
A benefit of convalescent plasma administration is that it can prevent infection and subsequent disease 
in those who are at high risk for disease following close contacts of patients with COVID-19. This is 
especially so for those with underlying medical conditions. Many who will qualify for prophylaxis are 
health care workers and first responders who are critical to maintenance of stability of the healthcare 
system. 
Passive antibody administration to prevent disease is already used in clinical practice. For example, 
patients exposed to hepatitis B and rabies viruses are treated with hepatitis B immune globulin (HBIG) 
and human rabies immune globulin (RIG), respectively. Botulism Immune Globulin Intravenous (Human) 
(BIG-IV) is an intravenous preparation for infant botulism. In addition, passive antibody is used for the 
prevention of severe respiratory syncytial virus (RSV) disease in high-risk infants. Until recently, 
polyclonal hyperimmune globulin (RSV-IG) prepared from donors selected for having high plasma titers 
of RSV neutralizing antibody, was used but these preparations have now been replaced by palivizumab, 
a humanized murine monoclonal antibody. Another potential benefit is societal: If the frequency with 
which exposed persons become infected decreases, the risk of further transmission (R naught) might be 
reduced and the epidemic slowed. Another avenue (not pursued in this protocol) is as a treatment for 
established infection. Convalescent plasma would be administered to those with clinical disease in an 
effort to reduce their symptoms and mortality. Based on the historical experience with antibody 
administration, it can be anticipated that antibody administration would be more effective in preventing 
disease than in the treatment of established disease. However, potential benefits in patients with 
known infection include reduced severity of symptoms, reduced duration of hospitalization, reduced 
likelihood of death due to infection, and increased speed of recovery. Given that historical and current 
anecdotal data on use of convalescent plasma suggest it is safe in coronavirus infection, the high 
mortality of COVID-19, particularly in elderly and vulnerable persons, suggests that the benefits of its 
use in those at high risk for or with early disease outweigh the risks. However, for all cases where 
convalescent plasma administration is considered, a risk-benefit assessment must be conducted to 
assess individual variables. 
INVESTIGATIONAL PLAN  
Study Objectives  
Primary Objectives:  
Primary Efficacy Objective: To evaluate the efficacy of treatment with anti-SARS-CoV-2 plasma versus 
control plasma with respect to Day 28 severity outcome on a seven-category ordinal scale.  
Primary Safety Objective: To evaluate the safety and tolerability of treatment with anti- SARS-CoV-2 
plasma versus control plasma in adults with severe COVID-19.  
 
Secondary Objectives:  
 
1. To compare duration of need for supplemental oxygen and/or mechanical ventilation between 
recipients of the anti-SARS-CoV-2 plasma and control plasma.  
2. To compare duration of hospitalization between recipients of the anti-SARS-CoV-2 plasma and control 
plasma.  

3. To compare in-hospital and 28-day mortality between recipients of the anti-SARS-CoV-2 plasma and 
control plasma.  
 
Ancillary Endpoints:  
 
1. To compare the proportion and duration of SARS-CoV-2 PCR positivity (RT PCR) between recipients of 
the anti-SARS-CoV-2 plasma and control plasma at days 0, 7, and 14.  
2. To compare the levels of SARS-CoV-2 RNA between recipients of the anti-SARS-CoV-2 plasma and 
control plasma at days 0, 7, and 14.  
3. To compare genetic differences between recipients of the anti-SARS-CoV-2 plasma and control plasma 
to explore possible associations with poor outcome.  
4. To compare transcriptomic differences between recipients of the anti-SARS-CoV-2 plasma and control 
plasma at Day 0, 7, and 14 to explore possible associations with poor outcome. 
 
Definitions 
 
Enrolled: From time consented to participate until designated as a screen failure or have either been 
discontinued from the study or completed it. II. Randomized: when a study arm is assigned. III. Screen 
Failures: signed informed consent, but then determined to be ineligible or withdraws before being 
randomized. IV. Discontinued: randomized, but then withdrawn by investigator or withdraws consent. V. 
Completed: Subjects are considered completed when they are followed through to day 28, if they die 
before day 28, or are discharged prior to day 14. 
 
Study population  
 
Inclusion Criteria for Enrollment 1. Willing and able to provide written informed consent prior to 
performing study procedures or having a legally authorized representative available to do so. 2. Age ≥18 
years. 3. Evidence of SARS-CoV-2 infection by PCR test of nasopharyngeal swab or oropharyngeal 
swab/tracheal aspirate sample within 14 days of randomization 4. SPO2 ≤ 94% on room air or requiring 
supplemental oxygen, non-invasive or invasive mechanical ventilation at screening 5. Evidence of 
infiltrates on chest radiography 6. Females of childbearing age and males must be willing to practice an 
effective contraceptive method or remain abstinent during the study period. 
 
Exclusion Criteria for Enrollment 1. Participation in another clinical trial of anti-viral agent(s)* for COVID-
19 2. Receipt of any anti-viral agent(s)* with possible activity against SARS-CoV-2 < 24 hours prior to 
plasma infusion. 3. Mechanically ventilated (including VV-ECMO) ≥ 5 days 4. Severe multi-organ failure 
5. History of allergic reactions to transfusion blood products per NHSN/CDC criteria 6. Known IgA 
deficiency 7. Females who are pregnant or breastfeeding. *Use of remdesivir as treatment for COVID-19 
is permitted. 
 
Subject Withdrawal  
 
Subjects can terminate study participation and/or withdraw consent at any time without prejudice. II. 
Randomized subjects who withdraw from the study will not be replaced. III. The investigator may 
withdraw subjects if they are lost to follow up, non-compliant with study procedures or if the 
investigator determines that continued participation in the study would be harmful to the subject or the 
integrity of the study data. IV. Discontinuation of the study: The study sponsor, FDA and IRB all have the 
right to terminate this study at any time. 

Intervention  
 
Subjects will be randomized in a 2:1 ratio, stratified by country, to receive treatment vs. frozen fresh 
plasma. II. Study drug: The investigational product is anti-SARS-CoV-2 plasma. Patients identified as 
having recovered from COVID-19 will serve as potential donors. Testing will confirm presence of anti-
SARS-CoV-2 antibody prior to donation. Potential donors and samples will be screened for transfusion-
transmitted infections (e.g. HIV, HBV, HCV, WNV, HTLV-I/II, T. cruzi, ZIKV) and plasma will be collected 
using apheresis technology. This is similar to standard blood bank protocols. III. Active arm will receive 1 
unit of anti-SARS-CoV-2 plasma. IV. Control arm will receive 1 unit of control plasma. V. The study drug 
will be in a standard plasma unit bag, with a studyspecific ISBT label and will include the following 
statement: “Caution: New Drug--Limited by Federal (or United States) law to investigational use." VI. 
The blood bank will not be blinded to treatment allocation, nor will the clinical study team. VII. The 
patient and the clinician who will assess the end of treatment outcome will be blinded to treatment 
allocation. 
 
Randomization  
 
Subjects enrolled in the study will be randomized to receive study drug vs. control using a web-based 
randomization platform that will pre-generate all treatment assignments in a 2:1 ratio using random 
permuted blocks of random block sizes, stratified by country (US and Brazil) The assignment list is 
maintained by designated staff at the DCC, independent from the study, and then sent to the Principal 
Investigator/research team for each participant that is deemed eligible. 
 
Study product considerations  
 
The preparation of the anti-SARS plasma and the control plasma will take place at the New York City 
Blood Center and the CUIMC-NYPH Blood Bank will dispense the plasma products. The plasma collection 
procedures are not part of this research protocol and are described in separate protocols, which has 
separate IRB approval (AAAS9845). The description below provides a summary of study product 
considerations as context.  
 
Collection: 
 
All activities pertaining to the collection and processing of plasma will take place at [New York Blood 
Center/NYBC]. NYBC is one of the largest independent, community-based, nonprofit blood centers in the 
United States. NYBC has a longstanding research program and is well versed in the regulatory and 
ethical aspects of research, including clinical trials. The organization is FDA-licensed to produce 
convalescent plasma and AABB (American Association of Blood Banks) accredited, attesting to robust 
quality oversight of all operations. The donation and collection of donor convalescent plasma will occur 
under CUIMC IRB protocol AAAS9845. 
 
Collection and processing: 
 
• Standard apheresis plasma collection will be performed per routine standard operating procedure at 
the collection facility (NYBC). • As per routine practice, samples will be collected at time of donation for 
testing for transfusion-transmissible infections (all donors), ABO and red cell antibodies (all donors) and 
HLA antibodies (female donors with prior pregnancies). • Target collection volume: ~450-600mL; this 
will allow for later splitting (separation) into 200-250mL daughter units. • The plasma will be processed 

per routine practice; it will be frozen within 24hrs of collection per AABB standards. • The plasma will be 
maintained in quarantine at the blood center pending laboratory test results (i.e. infectious screening, 
ABO and RhD status, Red cell and HLA antibodies). • If laboratory testing is acceptable (i.e. negative 
infectious and antibody screening), the products will be distributed to hospital blood bank for storage. • 
In the event of an abnormal test result, the product will be discarded and the donor will be notified by 
the blood center as is standard practice. 
 
Control arm plasma:  
 
The control arm plasma follows identical collection and processing procedures, but will have been 
collected from community blood donors prior to documented SARS-CoV-2 in the United States (i.e., to 
be conservative, all control arm plasma will be the oldest available plasma and should be from 
collections prior to 31 December 2019). 
 
Rationale for dosing:  
 
We will utilize 1 unit (200-250 mL) of plasma with anti-SARS-CoV-2 antibody. Dosing was based on 
experience with previous use of convalescent plasma therapy in SARS1 where 5 mL/kg of plasma at titer 
≥ 1:160 was utilized [European journal of clinical microbiology & infectious diseases: official publication 
of the European Society of Clinical Microbiology. 2005; 24(1):44- 6.]. Historical precedence allowing for 
0.25 of treatment dose was taken into account. Hence, considering first order linear proportionality, 
3.125mL/kg of plasma with titer >1:64 would provide equivalent immunoglobulin level to one quarter of 
5ml/kg plasma with titer ≥ 1:160. For a typical patient (~80 Kg) this would result in 250 mL of plasma 
(3.125ml/kg x 80kg = 250 mL > 1:64). 
 
Study drug administration: 
 
• Drug will be administered within 48 hours of randomization. • Infusion rate ≤ 250 mL/hour at 
physician discretion • Pretreatment to minimize transfusion reactions (e.g. acetaminophen, 
diphenhydramine) will not be given, but will be available as needed to treat fever or allergic reaction. 
For severe allergic reactions corticosteroids (e.g., 125mg solu-medrol IV) may be used. For rare severe 
anaphylaxis, epinephrine will be available. • If an AE develops during infusion, the infusion may be 
slowed or stopped as per investigator’s decision. • Most reactions to plasma are relatively minor and the 
infusion can generally be continued. Infusion site burning and non-allergic systemic effects can generally 
be managed with slowing of the infusion. Infusion is generally stopped in cases of itching; participant is 
treated and then infusion cautiously re-started. • Severe allergic reactions generally require 
discontinuation of the infusion. These include: • Respiratory compromise: dyspnea, wheezing, stridor, 
hypoxemia A decrease in systolic blood pressure to < 90 mmHg or >30% decrease from baseline or a 
diastolic drop of >30% from baseline. • Tachycardia with an increase in resting heart rate to > 130bpm; 
or bradycardia. 
 
Concomitant medications will be documented on the CRF: 
 
• Prescription medications • Over the counter medications • Herbal treatments/nutritional supplements 
• Blood products 
 
Prohibited Medications:  
 

Any approved or investigational drug* with established or potential activity against SARS-CoV-2 given 
within 24 hours of plasma infusion. *Concurrent use of Remdesivir as treatment for COVID-19 during the 
course of the study is permitted. 
 
STATISTICAL CONSIDERATIONS AND DATA MANAGEMENT  
 
Design Overview  
 
This randomized blinded phase 2 trial will assess the efficacy and safety of anti-SARS-CoV-2 plasma 
among adults with severe COVID-19. Eligible participants will be randomized in a 2:1 ratio to receive 
anti-SARS-CoV-2 plasma or fresh frozen plasma without known anti-SARS-CoV-2 antibodies. We plan to 
enroll up to 220 participants (US and Brazil). Each participant will be evaluated at baseline and daily 
during the follow-up period using a seven-category severity scale: 1. Not hospitalized with resumption of 
normal activities, 2. Not hospitalized, but unable to resume normal activities, 3. Hospitalized, not 
requiring supplemental oxygen, 4. Hospitalized, requiring supplemental oxygen, 5. Hospitalized, 
requiring high---flow oxygen therapy or noninvasive mechanical ventilation, 6. Hospitalized, requiring 
extracorporeal membrane oxygenation (ECMO), invasive mechanical ventilation, or both, and 7. Death. 
 
According to the inclusion/exclusion criteria, all enrolled participants will have a score ranging 3—6 on 
this scale at baseline. The primary study endpoint is defined as the Day 28 outcome on the scale.  
 
Safety will also be evaluated daily. Secondary endpoints include: 
• SARS-CoV-2 PCR positivity from nasopharyngeal swab, collected on baseline (Day 0), Days 7, and 14. • 
Levels of SARS-CoV-2 RNA on Days 0, 7, and 14. • During of need for supplemental oxygen and/or 
mechanical ventilation • Duration of hospitalization • Mortality. 
 
Statistical Analysis  
 
• Efficacy Objective  
 
1. Primary Analysis, go/no-go decision, and power consideration  
 
The primary analysis of the endpoint will be a one-sided nonparametric stratified Mann-Whitney test; 
stratification is done by country (US, Brazil). A “go decision” in this phase 2 trial will be a one-sided 
P<.015, suggesting evidence of promise of the treatment arm for further investigation in a phase 3 trial. 
Adaptive seamless phase 2/3: The results in this proof-of-concept study will be used to plan the sample 
size in a Phase 3 trial, which may include the data in this Phase 2 in the final analysis using adjusted P 
value as in a seamless phase 2/3 trial. Details of P value adjustment and sample size calculation will be 
decided before the final analysis of this study data. 
 
The calculation was based on blinded pooled data of the Day 28 outcome and an odds ratio of 1.7 under 
a proportional odds assumption. With a 2:1 randomization ratio and a total sample size of 219 
participants (146 in convalescent plasma vs. 73 control), a onesided Mann Whitney test at 15% level will 
have about 82% power to detect an odds ratio of 1.7. Since the difference in power between 219 and 
220 is minimal, N=219 can be used to justify an enrollment total of 220. We note a recent study of 
antiviral drug yields an odds ratio of 1.15, with 95% CI: 0.67 to 1.96, which covers our assumed odds 
ratio. 
 

2. Secondary and Ancillary Analyses 
 
All secondary and ancillary efficacy analyses will also be intent-totreat. With a sample size of 220, 
assuming 20% mortality up top day 28, we expect a total of 43 events. Longitudinal data collected over 
multiple days during the study period (e.g., PCR positivity, RNA) will be analyzed using the framework of 
generalized linear mixed model. Time-to-event variables (e.g., time to death) will be analyzed using Cox 
proportional hazards model. Continuous variables (e.g. duration of hospitalization) will be analyzed 
using Mann Whitney test. Treatment effects on these variables will be estimated with 95% confidence 
intervals. 
 
3. Safety Analyses  
 
Serious adverse events will be summarized by grades and types using proportions and 95% confidence 
intervals for the two study arms. Relative safety profile of the two arms will be compared using Fisher’s 
exact test. 
 
4. Missing data and non-compliance  
 
We will compare the missing data patterns between the study arms; and perform sensitivity analyses 
using different imputation approaches. However, due to the short study period, we anticipate minimal 
missing data. All efficacy analyses will be done intent-to-treat, although as-treat analyses will also be 
conducted as sensitivity. 
 
STUDY PROCEDURES  
 
Screening  
 
A. Screening (must be completed before randomization)  
B. Informed consent (obtained before performing study related activities)  
C. Baseline Evaluation (at screening) 1. Demographics (age, sex, ethnicity, race) 2. Medical history (acute 
and chronic medical conditions, medications, allergies) (any medical condition arising after consent 
should be recorded as AE) 3. COVID-19 symptom screen (fever, cough, shortness of breath) 4. 
Confirmation of SARS-CoV-2 testing (RT-PCR) for eligibility (within 14 days of randomization) 5. Vital 
signs 6. Physical examination 7. Blood typing 8. Urine or serum pregnancy test for females of 
childbearing potential. Results from laboratory tests obtained up to 7 days before enrollment may be 
used for the pregnancy test. 9. Determination of eligibility as per inclusion/exclusion criteria  
 
Baseline (Randomization)  
 
1. Randomization of eligible subject 2. Vital signs 3. COVID-19 symptom screen (fevers, cough, shortness 
of breath) 4. New medical conditions, concomitant medication 5. Assessment of clinical status (using 7-
point ordinal outcome scale) 6. CBC, comprehensive metabolic panel (abstracted from routine clinical 
lab results in electronic medical record) 7. Stored samples for future studies (only if feasible) 8. SARS-
CoV-2 testing (RT-PCR) from nasopharyngeal swab (only if feasible) 
 
Day 0 Infusion (Within 48 hours from randomization) 1. Study Plasma Administration: A single unit of 
plasma will be transfused. Time at start and end of infusion will be recorded and vital signs will be 
measured immediately prior to infusion, 10-20 minutes after start of infusion, and at completion of 

infusion. 2. Vital signs 3. Physical examination (acceptable to use clinician notes from electronic medical 
record) 4. COVID-19 symptom screen (fevers, cough, shortness of breath) 5. New medical conditions, 
concomitant medication, AE evaluation 
 
Day 1 ± 1 1. Vital signs 2. COVID-19 symptom screen (fevers, cough, shortness of breath) 3. Assessment 
of clinical status (using 7-point ordinal outcome scale) 4. New medical conditions, AE evaluation 5. 
Physical examination (acceptable to use clinician notes from electronic medical record) 6. CBC, 
comprehensive metabolic panel (abstracted from routine clinical lab results in electronic medical record) 
7. Stored samples for future studies (only if feasible)  
 
Day 3 ± 2 1. Vital signs 2. COVID-19 symptom screen (fevers, cough, shortness of breath) 3. Assessment 
of clinical status (using 7-point ordinal outcome scale) 4. New medical conditions, AE evaluation 5. 
Physical examination (acceptable to use clinician notes from electronic medical record)  
 
Day 7 ± 2 1. Vital signs 2. COVID-19 symptom screen (fevers, cough, shortness of breath) 3. Assessment 
of clinical status (using 7-point ordinal outcome scale) 4. New medical conditions, AE evaluation 5. 
Physical examination (acceptable to use clinician notes from electronic medical record) 6. SARS-CoV-2 
testing (RT-PCR) from nasopharyngeal swab (only if feasible) 7. CBC, comprehensive metabolic panel 
(abstracted from routine clinical lab results in electronic medical record) 8. Stored samples for future 
studies (only if feasible)  
 
Day 14 ± 2 1. Vital signs 2. COVID-19 symptom screen (fevers, cough, shortness of breath) 3. Assessment 
of clinical status (using 7-point ordinal outcome scale) 4. New medical conditions, AE evaluation 5. 
Physical examination (acceptable to use clinician notes from electronic medical record) 6. SARS-CoV-2 
testing (RT-PCR) from nasopharyngeal swab (only if feasible) 7. CBC, comprehensive metabolic panel 
(abstracted from routine clinical lab results in electronic medical record) 8. Stored samples for future 
studies (only if feasible) 
 
Day 28 ± 3 1. Vital signs 2. COVID-19 symptom screen (fevers, cough, shortness of breath) 3. Assessment 
of clinical status (using 7-point ordinal outcome scale) 4. New medical conditions, AE evaluation 5. 
Physical examination (acceptable to use clinician notes from electronic medical record) 
 
EFFICACY, VIROLOGIC AND PK MEASURES  
 
Primary Endpoint:  
 
Day 28 severity outcome on a seven-category ordinal scale consisting of the following categories: 1. Not 
hospitalized with resumption of normal activities 2. Not hospitalized, but unable to resume normal 
activities 3. Hospitalized, not requiring supplemental oxygen 4. Hospitalized, requiring supplemental 
oxygen 5. Hospitalized, requiring high-flow oxygen therapy or noninvasive mechanical ventilation 6. 
Hospitalized, requiring extracorporeal membrane oxygenation (ECMO), invasive mechanical ventilation, 
or both 7. Death  
 
Virologic measures: 
 
1. Rates and duration of SARS-CoV-2 PCR positivity (RT PCR) at days 0, 7 and 14.  
2. Peak quantity levels of SARS-CoV-2 RNA at days 0, 7 and 14. 
 

RISKS AND BENEFITS  
 
Potential benefits of treatment  
 
The potential benefits of antiviral treatment with anti-SARS CoV-2 plasma in patients with severe COVID-
19 is unknown. However, based on available evidence from use of convalescent plasma in SARS-CoV-1 
patients, shortened duration of illness and improved mortality are potential benefits. 
 
Potential benefits of clinical monitoring and virologic testing  
 
Subjects enrolled in the study will undergo close virological monitoring that may facilitate improved 
understanding of viral shedding that may have benefit to the individual, their family and the community 
at large.  
 
Potential risks of study procedures  
 
1. Risks of plasma: Fever, chills, rash, headache, serious allergic reactions, transmission of infectious 
agents 
2. Transfusion related acute lung injury (TRALI) and transfusion related circulatory overload (TACO), both 
of which may worsen oxygen saturation and increase work-of-breathing  
3. Risks of phlebotomy: local discomfort, bruising, hematoma, bleeding, fainting 
4. Total blood draws will not exceed 500 mL  
5. Risks of nasopharyngeal swab: local discomfort, vomiting  
6. Risks of IV placement: bleeding, infection, thrombosis  
 
Potential risks of genetic testing  
 
Samples obtained for future research may include a search for genetic correlates of COVID-19 
susceptibility or severity. Specimens will be labeled by study IDs, rather than names. This information 
will not be released to participants and will not become part of their medical records. Risks related to 
discrimination or other problems are deemed highly unlikely.  
 
Alternatives  
 
The alternative to participation in this study is continued standard-of-care clinical management.  
 
Safety monitoring  
 
1. Safety Evaluations: Will assess for the safety of anti-SARS-CoV-2 plasma in terms of treatment 
emergent adverse events.  
2. Clinical evaluations: Vital signs and symptom screen on days 0-28 (or until hospital discharge, 
whichever is sooner).  
3. Laboratory evaluations:  
4. Safety laboratory tests (ABO typing, pregnancy testing, CBC and comprehensive metabolic panel) will 
be performed at the local CLIA-certified hospital clinical laboratory on days 0-14 (or until hospital 
discharge, whichever is sooner).  
 
Adverse event reporting 

 
An Adverse Event (AE) is any untoward or unfavorable medical occurrence in a human subject 
administered an investigational product, including any abnormal sign, symptom or disease, temporally 
associated with the subject’s participation in research, whether or not considered related to the 
subject’s participation in the research.  
 
An AE does not include the following: • Medical or surgical procedures such as surgery, endoscopy, 
tooth extraction, and transfusion. The condition that led to the procedure may be an AE and must be 
reported. • Preexisting diseases, conditions, or laboratory abnormalities present or detected before the 
screening visit that do not worsen • Situations where an untoward medical occurrence has not occurred 
(e.g., hospitalization for elective surgery, social and/or convenience admissions) • Any medical condition 
or clinically significant laboratory abnormality with an onset date before the investigational product is 
administered to the subject and not related to a protocol-associated procedure is not an AE. It is 
considered to be preexisting and should be documented as medical history.  
 
Preexisting events or conditions that increase in severity or change in nature after the subject receives 
the investigational product will be considered AEs.  
 
Serious Adverse Event (SAE):  any adverse event temporarily associated with the subject's participation 
in research that meets any of the following criteria: • Results in death; • Is life-threatening (places the 
subject at immediate risk of death from the event as it occurred); • Requires inpatient hospitalization or 
prolongation of existing hospitalization; • Results in a persistent or significant disability/incapacity; • 
Results in a congenital anomaly/birth defect; or • Any other adverse event that, based upon appropriate 
medical judgment, may jeopardize the subjects' health and may require medical or surgical intervention 
to prevent one of the other outcomes listed in this definition.  
 
Prolonged Hospitalization or Surgery Protocol – any AE that results in prolonged hospitalization should 
be documented and reported as a SAE. Any condition responsible for surgery should be documented as 
an AE if the condition meets the criteria for an AE. Neither the condition, prolonged hospitalization nor 
surgery are reported as an AE in the following circumstances: • Prolonged hospitalization for diagnostic 
or elective surgical procedures for a preexisting co144ndition. Surgery should not be reported as an 
outcome of an AE if the purpose of the surgery was elective or diagnostic and the outcome was 
uneventful. • Prolonged hospitalization for required to allow efficacy measurement for the study.  
 
An Unanticipated Problem (UP) is any incident, experience or outcome involving risk to subjects or 
others in any human subjects research that meets all of the following criteria: • Unexpected (in terms of 
nature, severity or frequency) given (a) the research procedures that are described in the IRB-approval 
protocol and informed consent document, and (b) the characteristics of the subject population being 
studied; • Related or possibly related to participation in such research (i.e., there is a reasonable 
possibility that the incident, experience or outcome may have been caused by the procedures involved 
in such research); and • Suggests that the research places subjects or others at a greater risk of harm 
(including physical, psychological, economic or social harm) than was previously known or recognized  
 
A Suspected Adverse Reaction (SAR) is any AE for which there is a reasonable possibility that it was 
caused by the drug. Reasonable possibility means that there is evidence to suggest a causal relationship 
between the drug and the AE. Examples of reasonable possibility are: • A single occurrence of an event 
that is uncommon and known to be strongly associated with drug exposure. • One or more occurrences 
of an event that is not commonly associated with drug exposure, but is otherwise uncommon in the 

population exposed to the drug. • An aggregate analysis of specific events observed in a clinical trial that 
indicates that those events occur more frequently in the drug treatment group than in a concurrent or 
historical control group.  
 
Investigator Reporting Requirements 
 
The Principal Investigator will report all AEs and SAEs to the IND sponsor within 48 hours of becoming 
aware of the event. The report to the IND sponsor will include the study investigator’s preliminary 
assessment of seriousness, severity and relatedness to the investigational product.  
 
To IRB: Unanticipated Problems (UPs) must be reported promptly, but not later than 7 calendar days 
following the occurrence of the UP or the Principal Investigator’s acquiring knowledge of the UP.  
 
To DSMB: Serious adverse events not constituting an unanticipated problem is to be reported to the 
DSMB and the IND sponsor. Reporting should occur within 48 hours of knowledge of the SAE 
occurrence.  
 
IND Sponsor Reporting Requirements  
 
The IND sponsor will report the following SARs to the FDA: • To the FDA, as soon as possible, but no 
later than 7 calendar days after the SI's initial receipt of the information, any unexpected fatal or life-
threatening SAR. • To the FDA and all participating investigators, as soon as possible but no later than 15 
calendar days after the S-I determines that information qualifies for reporting, in an IND safety report, 
any SAR that is both serious and unexpected. • To the FDA and all participating investigators, as soon as 
possible but no later than 15 calendar days after the S-I determines that the information qualifies for 
reporting, any findings from epidemiological studies, pooled analysis of multiple studies or clinical 
studies, whether or not conducted under an IND or by the S-I, that suggest a significant risk in humans 
exposed to the drug. • To the FDA and all participating investigators, as soon as possible, but no later 
than 15 calendar days after the S-I determines that the information qualifies for reporting, any findings 
from animal or in vitro testing, whether or not conducted by the S-I, that suggest a significant risk in 
humans exposed to the drug. • To the FDA and all participating investigators, as soon as possible, but no 
later than 15 calendar days after the S-I determines that the information qualifies for reporting, any 
clinically important increase in the rate of a Serious SAR over that listed in the protocol or Investigator 
Brochure. • Expected SAEs and AEs should be included in the IND Annual Reports.  
 
Follow-up information to a safety report will be submitted as soon as the relevant information is 
available. However, if the results of a sponsor’s investigation show that an adverse drug experience not 
initially determined to be reportable are so reportable, the sponsor must report such experience as soon 
as possible, but no later than 15 calendar days after the determination is made.  
 
SAFETY OVERSIGHT 
 
Monitoring Plan  
 
1. All AEs and SAEs will be reviewed by the study team in real time.  
2. A data safety monitoring board (DSMB), composed of independent experts without conflict of 
interests will be established. The Board will review the study before initiation and quarterly thereafter. 

The Board will review study data to evaluate the safety, efficacy, study progress, and conduct of the 
study. 
 
Study monitoring  
 
As per ICH-GCP 5.18 and FDA 21 CFR 312.50, clinical protocols are required to be adequately monitored 
by the study sponsor. Monitors will verify that  
(1) There is documentation of the informed consent process and signed informed consent documents 
for each subject  
(2) There is compliance with recording requirements for data points  
(3) All SAEs are reported as required  
(4) Individual subjects’ study records and source documents align  
(5) Investigators are in compliance with the protocol 
(6) Regulatory requirements as per Office for Human Research Protections (OHRP), FDA, and applicable 
guidelines (ICH-GCP) are being followed. 
 
Halting Criteria for the Study  
 
The study enrollment and dosing will be stopped and an ad hoc review will be performed if any of the 
specific following events occur or, if in the judgment of the study physician, subject safety is at risk of 
being compromised:  
1. Unexpected death of a dosed subject in relation to infusion  
2. Occurrence of a life-threatening allergic/hypersensitivity reaction (anaphylaxis), manifested by 
bronchospasm with or without urticaria or angioedema requiring hemodynamic support with pressor 
medications or mechanical ventilation. 
3. One subject with an unexpected SAE associated with study product.  
4. Two subjects with a Grade 3 or higher toxicity for the same parameter associated with study product.  
5. An overall pattern of symptomatic, clinical, or laboratory events that the medical monitor, ISM, or 
SMC consider associated with study product and that may appear minor in terms of individual events 
but that collectively may represent a serious potential concern for safety.  
6. Any other event(s) which is considered to be a serious adverse event in the good clinical judgment of 
the responsible physician. This will be appropriately documented. 
 
Furthermore, given that ADE may be an issue with convalescent antibody treatment, out of an 
abundance of caution we will monitor the number of subjects in each trial arm that progresses to an 
indication for need of mechanical ventilation. In monitoring the number of subjects that progresses to 
this stage, we will present these data to the DSMB and a masked outcomes accessor so that they may 
objectively evaluate and determine whether they would like to be unmasked. After at least 50% of trial 
participants have accumulated follow-up, the number of subjects that progress to this stage will be 
presented to the masked outcomes assessor and formally asked whether they (1) see a clinically 
meaningful difference between trial arms and (2) if so do they require a formal interim analysis. At any 
point should the DSMB require a formal interim analysis, we will examine the difference in treatment 
arms for need for mechanical ventilation. This interim analysis will adjust for factors related to need for 
mechanical ventilation including age and presence of cardiopulmonary comorbidities.  
 
Upon completion of this review and receipt of the advice of the DSMB, the IND sponsor will determine if 
study entry or study dosing should be interrupted or if study entry and study dosing may continue 
according to the protocol. Should the trial not be stopped at this time point, the final analysis would 

need to account the number of interim analyses that were conducted. Therefore, we would penalize any 
final analysis dividing our 0.05 alpha in half for each interim analysis. 
 
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