Randomized, Placebo-Controlled, Double-Blind Study to Assess Safety, Immunogenicity, and Protective Efficacy of Two Regimens of Radiation Attenuated Plasmodium Falciparum NF54 Sporozoites (PfSPZ Vaccine) During Natural Transmission Season in Healthy African Adults in Mali
Phase: PHASE1
Conditions: Malaria
Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)

Two Regimens of PfSPZ Vaccine in Mali, Africa 
 
15 August 2019, Version 7.0 
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Randomized, Placebo-Controlled, Double-Blind Study to Assess Safety, 
Immunogenicity, and Protective Efficacy of Two Regimens of Radiation 
Attenuated Plasmodium falciparum NF54 Sporozoites (PfSPZ Vaccine) During 
Natural Transmission Season in Healthy African Adults in Mali 
 
NIAID Protocol Number: 18-I-N084 
IND Sponsor’s protocol ID: MLSPZV3 
Project Assurance: FWA #00005897 
Multi-institution: Yes 
 
FMPOS Protocol Number: No2018/39/CE/FMPOS 
Project Assurance: FWA #00001769 
Sponsored by: 
National Institute of Allergy and Infectious Diseases (NIAID) 
Laboratory of Malaria Immunology and Vaccinology (LMIV) 
National Institutes of Health (NIH) 
 
IND Sponsor: 
Sanaria, Inc. 
IND: BB-IND # 14826 
 
Principal Investigators: 
Halimatou Diawara, MD 
Patrick Duffy, MD 
Version Number: 7.0 
15 August 2019 
CONFIDENTIAL 
 
 

Two Regimens of PfSPZ Vaccine in Mali, Africa 
 
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Table of Contents  
 
TABLE OF CONTENTS ............................................................................................................................................ 2 
TEAM ROSTER .......................................................................................................................................................... 6 
PARTICIPATING SITES........................................................................................................................................... 8 
LIST OF ABBREVIATIONS ................................................................................................................................... 10 
PROTOCOL SUMMARY ........................................................................................................................................ 12 
PRECIS ...................................................................................................................................................................... 15 
1 
BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE ..................................................... 16 
 
THE NEED FOR A MALARIA VACCINE ........................................................................................................ 16 
 
CHALLENGES OF DEVELOPING A MALARIA VACCINE ............................................................................... 16 
 
THE RATIONALE FOR A WHOLE ORGANISM P. FALCIPARUM SPOROZOITE-BASED VACCINE ...................... 17 
 
THE PRODUCT PFSPZ VACCINE ................................................................................................................ 17 
 
Rationale for Intravenous Administration of PfSPZ Vaccine .............................................................. 17 
 
Previous Trials with Radiation Attenuated PfSPZ (PfSPZ Vaccine) ................................................... 18 
 
Results from Malaria Exposed Populations ......................................................................................... 18 
1.4.3.1 
Mali (NIAID Protocol 14-I-N010) .................................................................................................................. 18 
1.4.3.2 
Tanzania, BSPZV1 .......................................................................................................................................... 22 
1.4.3.3 
Mali (NIAID Protocol 16-I-N004) .................................................................................................................. 22 
1.4.3.4 
Tanzania, BSPZV2 .......................................................................................................................................... 25 
 
RATIONALE FOR DECREASING THE DOSE OF PFSPZ VACCINE FROM 1.8X106 TO 9X105 IN A THREE-DOSE 
REGIMEN .................................................................................................................................................................. 26 
 
RATIONALE FOR ASSESSING VARIOUS VACCINATION SCHEDULES .............................................................. 28 
 
RATIONALE FOR ADMINISTERING THE BOOSTER DOSE (4TH VACCINATION) ................................................ 28 
 
Safety ................................................................................................................................................... 28 
 
Malaria infection rate .......................................................................................................................... 29 
 
Booster dose administration ................................................................................................................ 30 
2 
STUDY OBJECTIVES .................................................................................................................................... 31 
 
PRIMARY OBJECTIVE ................................................................................................................................. 31 
 
SECONDARY OBJECTIVE ............................................................................................................................ 31 
 
EXPLORATORY OBJECTIVES ...................................................................................................................... 31 
3 
STUDY DESIGN .............................................................................................................................................. 31 
 
STUDY GROUPS ......................................................................................................................................... 33 
4 
STUDY ENDPOINTS ...................................................................................................................................... 33 
 
PRIMARY ENDPOINTS ................................................................................................................................ 33 
 
SECONDARY ENDPOINTS ........................................................................................................................... 33 
 
EXPLORATORY ENDPOINTS ....................................................................................................................... 34 
 
SAMPLE SIZE AND ESTIMATED DURATION OF THE STUDY ........................................................................ 34 
5 
STUDY AGENTS ............................................................................................................................................. 35 
 
PFSPZ VACCINE ........................................................................................................................................ 35 
 
Storage and Handling .......................................................................................................................... 36 
 
Disposition and Dispensation .............................................................................................................. 36 
 
Administration ..................................................................................................................................... 36 
 
PBS AND HSA DILUENT ........................................................................................................................... 37 
 
Storage and Handling .......................................................................................................................... 37 
 
Disposition and Dispensation .............................................................................................................. 37 
 
Administration and Dosage ................................................................................................................. 37 
 
Accountability ...................................................................................................................................... 37 

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CONTROL PRODUCT .................................................................................................................................. 37 
 
Storage and Handling .......................................................................................................................... 37 
 
Disposition and Dispensation .............................................................................................................. 38 
 
Administration and Dosage ................................................................................................................. 38 
 
Accountability ...................................................................................................................................... 38 
 
ANTIMALARIAL DRUGS ............................................................................................................................. 38 
 
Preparation and Administration .......................................................................................................... 38 
 
Storage and Handling .......................................................................................................................... 38 
 
Return of Study Product ....................................................................................................................... 38 
 
Drugs used for Pre-emptive Treatment of Malaria .............................................................................. 38 
 
Drugs Used for Management of Clinical Malaria ............................................................................... 38 
 
CONTRAINDICATIONS TO VACCINATION ................................................................................................... 39 
 
Indications for Deferral of Vaccination ............................................................................................... 39 
 
PROHIBITED MEDICATIONS ....................................................................................................................... 39 
6 
STUDY POPULATION................................................................................................................................... 40 
 
CLINICAL SITE ........................................................................................................................................... 40 
 
RECRUITMENT ........................................................................................................................................... 41 
 
INCLUSION CRITERIA IN THE MAIN PHASE AND BOOSTER PHASE ................................................................ 41 
 
EXCLUSION CRITERIA IN THE MAIN PHASE AND BOOSTER PHASE .............................................................. 42 
 
JUSTIFICATION FOR THE EXCLUSION OF PREGNANT WOMEN .................................................................... 43 
 
JUSTIFICATION FOR EXCLUSION OF CHILDREN .......................................................................................... 43 
7 
STUDY SCHEDULE ....................................................................................................................................... 45 
 
SCREENING ................................................................................................................................................ 45 
 
ASSIGNMENT OF GROUPS .......................................................................................................................... 46 
 
DETAILED STUDY PROCEDURES ................................................................................................................ 46 
8 
STUDY PROCEDURES/EVALUATIONS ................................................................................................... 47 
 
PHOTOGRAPHS OF RASH OR INJECTION SITE REACTIONS .......................................................................... 47 
 
CLINICAL LABORATORY TESTING ............................................................................................................. 47 
 
ELECTROCARDIOGRAM ............................................................................................................................. 47 
 
Electrocardiogram for the Study ......................................................................................................... 47 
 
MALARIA DIAGNOSTICS ............................................................................................................................ 47 
 
Malaria Blood Smears ......................................................................................................................... 47 
 
Malaria qPCR ...................................................................................................................................... 48 
 
UNSCHEDULED BLOOD SMEAR POSITIVE VISITS ....................................................................................... 48 
 
IMMUNOLOGIC LABORATORIES ................................................................................................................. 49 
 
TRANSCRIPTOMIC ANALYSIS ..................................................................................................................... 50 
9 
RESEARCH USE OF STORED HUMAN SPECIMENS ............................................................................ 50 
10 
DATA SHARING PLAN ................................................................................................................................. 52 
11 
ASSESSMENT OF SAFETY .......................................................................................................................... 52 
 
DOCUMENTING, RECORDING, AND REPORTING ADVERSE EVENTS ............................................................ 52 
 
DEFINITIONS .............................................................................................................................................. 52 
 
INVESTIGATOR ASSESSMENT OF ADVERSE EVENTS .................................................................................. 54 
 
Severity ................................................................................................................................................ 55 
 
Causality .............................................................................................................................................. 55 
 
INVESTIGATOR REPORTING RESPONSIBILITIES TO THE SPONSOR............................................................... 56 
 
Adverse Events ..................................................................................................................................... 56 
 
Serious Adverse Events ........................................................................................................................ 56 
 
Unanticipated Problems (UPs) ............................................................................................................ 57 
 
Pregnancy ............................................................................................................................................ 58 
 
REPORTING PROCEDURES TO NIAID IRB AND FMPOS EC ...................................................................... 58 
 
Expedited Reporting to the NIAID IRB and FMPOS EC ..................................................................... 58 

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Waiver of Reporting Anticipated Protocol Deviations and Expected UPnonAEs to the NIAID IRB and 
FMPOS EC .......................................................................................................... Error! Bookmark not defined. 
 
Annual Reporting to the NIAID IRB and FMPOS EC ........................... Error! Bookmark not defined. 
 
ADDITIONAL INVESTIGATOR REPORTING RESPONSIBILITIES TO THE LOCAL IRB (NIAID IRB AND FMPOS 
EC) 
58 
 
REPORTING TO THE DATA AND SAFETY MONITORING BOARD .................................................................. 58 
 
FOLLOW-UP ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS .............................................................. 59 
 
SPONSOR’S REPORTING RESPONSIBILITIES ................................................................................................ 59 
 
PAUSING CRITERIA FOR THE STUDY .......................................................................................................... 59 
 Reporting of Study Pausing ................................................................................................................. 60 
 Resumption of a Paused Study ............................................................................................................. 60 
 
PAUSING CRITERIA FOR A SUBJECT ........................................................................................................... 60 
 Reporting of Pausing for a Subject ...................................................................................................... 60 
 Resumption of a Paused Subject .......................................................................................................... 61 
 
DISCONTINUATION OF STUDY ................................................................................................................... 61 
 
WITHDRAWAL OF AN INDIVIDUAL SUBJECT .............................................................................................. 61 
 Replacement of Withdrawn Subjects .................................................................................................... 62 
 
UNBLINDING FOR THE STUDY .................................................................................................................... 62 
 
SAFETY OVERSIGHT .................................................................................................................................. 62 
 Sponsor Medical Monitor .................................................................................................................... 62 
 Independent Safety Monitor (ISM) in Mali .......................................................................................... 62 
 Data and Safety Monitoring Board (DSMB) ....................................................................................... 63 
12 
CLINICAL MONITORING ........................................................................................................................... 63 
 
SITE MONITORING PLAN ........................................................................................................................... 63 
13 
STATISTICAL CONSIDERATIONS ............................................................................................................ 65 
 
ENDPOINTS AND STATISTICAL METHODS .................................................................................................. 65 
 
Safety analysis ..................................................................................................................................... 65 
 
Vaccine efficacy analysis ..................................................................................................................... 65 
 
Immunogenicity analysis ...................................................................................................................... 65 
 
Interim analysis ................................................................................................................................... 65 
 
SAMPLE SIZE CONSIDERATION .................................................................................................................. 66 
 
RANDOMIZATION AND BLINDING .............................................................................................................. 66 
14 
HUMAN SUBJECT PROTECTIONS AND ETHICAL OBLIGATIONS ................................................. 67 
 
INSTITUTIONAL REVIEW BOARD ............................................................................................................... 67 
 
INFORMED CONSENT PROCESS .................................................................................................................. 67 
 
Community Permission in Mali ........................................................................................................... 67 
 
Individual Informed Consent in Mali ................................................................................................... 68 
 
SUBJECT CONFIDENTIALITY ...................................................................................................................... 68 
15 
POTENTIAL RISKS AND BENEFITS ......................................................................................................... 69 
 
VENIPUNCTURE ......................................................................................................................................... 69 
 
DVI IMMUNIZATIONS (EITHER PFSPZ VACCINE OR NORMAL SALINE) ..................................................... 69 
 
PFSPZ VACCINE ........................................................................................................................................ 69 
 
NORMAL SALINE ....................................................................................................................................... 70 
 
ANTIMALARIAL MEDICATION ................................................................................................................... 70 
 
Coartem® (Artemether/Lumefantrine) ................................................................................................ 70 
 
CARDIAC ABNORMALITIES ........................................................................................................................ 71 
 
PREGNANCY .............................................................................................................................................. 71 
 
RISK TO THE COMMUNITY ......................................................................................................................... 72 
 
BENEFITS ................................................................................................................................................... 72 
16 
COMPENSATION ........................................................................................................................................... 72 
17 
DATA HANDLING AND RECORD KEEPING .......................................................................................... 74 

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DATA CAPTURE AND MANAGEMENT ......................................................................................................... 74 
 
TYPES OF DATA ......................................................................................................................................... 74 
 
RETENTION OF STUDY RECORDS ............................................................................................................... 74 
 
PROTOCOL REVISIONS ............................................................................................................................... 74 
18 
APPENDICES .................................................................................................................................................. 75 
APPENDIX A: STUDY SCHEDULE ...................................................................................................................... 75 
APPENDIX B: TOXICITY TABLE ........................................................................................................................ 79 
APPENDIX C: REFERENCES ................................................................................................................................ 84 
 
LIST OF TABLES 
Table 1: Maximum Local and Systemic Reactogenicity .............................................................. 19 
Table 2: Vaccine Related Laboratory Abnormalities ................................................................... 20 
Table 3: Summary of clinical adverse events of BSPZV2 during vaccination............................. 26 
Table 4: Summary of AEs to date ................................................................................................. 29 
Table 5: Current rates* of malaria infection after vaccination #3 ................................................ 30 
Table 6: Solicited Adverse Events ................................................................................................ 54 
Table 7: AE Severity Grading Definitions.................................................................................... 55 
Table 8: Power for group-wise comparison based on logrank test on time to infection .............. 66 
Table 9: Estimated Compensation for the Study .......................................................................... 72 
 
LIST OF FIGURES 
Figure 1: Protective Efficacy: First Positive Blood Smear (BS) Starting 28 Days Post 
Vaccination #5 .............................................................................................................................. 21 
Figure 2: USA vs Mali PfCSP ELISA Results ............................................................................. 22 
Figure 3: Protective Efficacy of 18x105 PfSPZ Vaccine at 0, 8, 16 weeks against Homologous 
PfSPZ Challenge ........................................................................................................................... 23 
Figure 4: Protective Efficacy of PfSPZ Vaccine Against Naturally Occurring Infection ............ 25 
Figure 5: Study Schema ................................................................................................................ 32 
 
 

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TEAM ROSTER 
 
University of Sciences, Techniques and Technology, Bamako (USTTB)  
Principal Investigator: 
 
Halimatou Diawara, MD, MPH  
 
Malaria Research and Training Center (MRTC) 
Faculty of Medicine, Pharmacy, and Dentistry (FMPOS),  
University of Sciences, Techniques and Technology, Bamako  
BP 1805, Point G 
Bamako, Mali 
hdiawara@icermali.org 
Phone +223-6674-2274 
Senior Investigator: 
Alassane Dicko, MD, PhD 
 
Associate Investigators: 
 
Djibrilla Issiaka, MD, MPH 
Gaoussou Santara, MD 
Moussa Traore , MD,  
Mamoudou Samassekou, MD 
Seydou Traore, MD 
Mahamoudou Maiga, MD 
Ibrahim H. Soumbounou, MD 
Almahamoudou Mahamar, PharmD, MS 
Oumar Attaher, PharmD 
Amatigue Zeguime, PharmD 
Amagana Dolo, PharmD, PhD 
Kalifa Diarra, Pharm D 
Kadidia Baba Cisse, MS 
 
National Institute of Allergy and Infectious Diseases (NIAID)  
Principal Investigator: 
Patrick Duffy, MD 
Laboratory of Malaria Immunology and Vaccinology 
National Institute of Allergy and Infectious Diseases 
National Institutes of Health 
Building 29B 
Room 4NN06 
29 Lincoln Drive 
Bethesda, MD 20892 
Patrick.Duffy@nih.gov 
Office 301 761 5089 
Fax 301 480 1962 
 
Associate Investigators: 
 
 
 
 
David Cook, MD 
Michal Fried, PhD 
Sara Healy MD, MPH 
Jacquelyn Lane, PA-C 
 

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Biostatistician: 
Zonghui Hu, PhD 
NIAID/NIH/BRB 
5601 Fishers Lane, Room 4C21 
Rockville, Maryland 20852 
 
 

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PARTICIPATING SITES 
Clinical Trial Sites  
Mali, West Africa 
Ouelessebougou, Health Research Center 
Malaria Research and Training Center 
Faculty of Medicine, Pharmacy and Odonto-Stomatology 
Mali 
Study Site 
 
 
Ouelessebougou and surrounding villages, Mali 
Institutional Review Board (IRB)   
National Institute of Allergy and Infectious Diseases Institutional 
Review Board and Faculty of Medicine, Pharmacy and Odonto-
Stomatology Ethics Committee 
 
Clinical Laboratory:  
Malaria Research and Training Center 
DEAP Clinical Laboratory 
Faculty of Medicine, Pharmacy and Odonto-Stomatology, 
University of Sciences, Techniques & Technologies, Bamako 
 
 
 
 
BP 1805, Point G 
 
 
 
 
Bamako, Mali 
 
Rodolphe Merieux Laboratory 
Bamako, Mali 
Additional Laboratories 
Laboratory of Malaria Immunology and Vaccinology 
National Institute of Allergy and Infectious Diseases 
National Institutes of Health 
 
 
 
 
12441 Parklawn Drive, Twinbrook II 
 
 
 
 
Rockville, MD 20852, USA 
 
Malaria Research and Training Center/DEAP Immunology 
Laboratory 
Faculty of Medicine, Pharmacy and Odonto-Stomatology, 
University of Sciences, Techniques & Technologies, Bamako 
 
 
 
 
BP 1805, Point G 
 
 
 
 
Bamako, Mali  
 
 
 
 
 
Antigen Discovery Inc. 
Irvine, CA 92618, USA 
 
Protein Potential LLC 
9800 Medical Center Drive 
Rockville, MD 20850, USA 
 
National Institute of Allergy and Infectious Diseases 
National Institutes of Health 
Vaccine Research Center (VRC) Laboratories 

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40 Convent Drive 
Bethesda, MD 20892, USA 
 
Sanaria Incorporated  
9800 Medical Center Drive 
Rockville, MD 20850, USA 
 
National Institutes of Health Research Technologies Branch 
 
 
 
 
Genomic Technologies Section 
 
 
 
 
Building 50, Room 5509 
 
 
 
 
50 South Drive, MSC 8005 
 
 
 
 
Bethesda, MD 20892, USA 
 
 
 
 
 
 
 
 
 
Laboratory of Parasitic Diseases 
 
 
 
 
National Institute of Allergy and Infectious Diseases 
National Institutes of Health 
 
 
 
 
Building 4, Room B1-03 
 
 
 
 
4 Memorial Drive 
 
 
 
 
Bethesda, MD 20892, USA 
 
 
 
 
 
Center for Human Immunology, Autoimmunity, and Inflammation 
 
 
 
 
National Heart, Lung and Blood Institute (NHLBI) 
 
 
 
 
Building 10 - Magnuson CC, 7N110a 
 
 
 
 
10 Center Drive 
 
 
 
 
Bethesda, MD 20892-1655, USA 
 
 
 
 
 
University of Bamako 
 
 
 
 
Laboratory of Immunogenetics and Parasitology 
 
 
 
 
Malaria Research and Training Center 
Mahamadou Diakite, PharmD DPhil 
Bamako, Mali, West Africa 
 
 
 
 
 
Naval Medical Research Center 
 
 
 
 
502 Robert Grant Avenue 
 
 
 
 
Silver Spring, MD 20910, USA 
 
 
 
 
 
University of Maryland 
685 W. Baltimore Street, HSF I, Rm. 480  
Baltimore, MD 21201, US 
 
 
 

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LIST OF ABBREVIATIONS 
AGC 
absolute granulocyte count 
AE 
adverse event/adverse experience 
AL 
artemether/lumefantrine 
ALT 
alanine aminotransferase 
ANC 
absolute neutrophil count 
ASAQ 
artesunate-amodiaquine 
BS 
blood smear 
CBC 
complete blood count 
CFR 
Code of Federal Regulations 
cGMP 
Current Good Manufacturing Practice 
CHMI 
controlled human malaria infection 
CoA 
Certificate of Analysis 
Cr 
creatinine 
CSP 
circumsporozoite protein 
DSMB 
Data Safety Monitoring Board 
DVI 
direct venous inoculation 
EC 
Ethics Committee 
ECG 
electrocardiogram 
EDTA 
ethylene diamine tetraacetic acid 
ELISA 
enzyme-linked immunosorbent assay 
FDA 
Food and Drug Administration 
FMPOS 
Faculty of Medicine, Pharmacy and Odonto-Stomatology, Bamako, Mali 
GCP 
good clinical practice 
GMP 
good manufacturing practice 
Hb 
hemoglobin 
HBV 
hepatitis B virus 
HCV 
hepatitis C virus 
HIV 
human immunodeficiency virus 
HRPP 
Human Research Protection Program 
HSA 
human serum albumin 
IB 
Investigator’s Brochure 
ICF 
informed consent form 
ICH 
International Conference on Harmonisation 
IFA 
immunofluorescence assay 
IND 
Investigational New Drug 
IPTp 
intermittent preventive treatment during pregnancy 
IRB 
Institutional Review Board 
ISM 
Independent Safety Monitor 

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ITN 
insecticide-treated bed net 
ITT 
intention to treat 
IV 
intravenous 
LMIV 
Laboratory of Malaria Immunology and Vaccinology 
LNVP 
liquid nitrogen vapor phase 
MRTC 
Malaria Research and Training Center 
NIAID 
National Institute of Allergy and Infectious Diseases  
NIH 
National Institutes of Health 
NOCI 
New Onset of Chronic Illness 
OCRPRO 
Office of Clinical Research Policy and Regulatory Operations 
OHRP 
Office for Human Research Protections 
PBS 
phosphate buffered saline 
Pf 
Plasmodium falciparum 
PfCSP 
Plasmodium falciparum circumsporozoite protein 
PfSPZ 
Plasmodium falciparum sporozoite 
PfSPZ 
Challenge  
viable Plasmodium falciparum sporozoites produced by Sanaria, Inc. 
PfSPZ Vaccine  radiation attenuated Plasmodium falciparum Sporozoites produced by Sanaria, 
Inc. 
PI 
Principal Investigator 
qPCR 
quantitative polymerase chain reaction 
QTc 
QT interval 
SAE 
serious adverse event 
SAR 
suspected adverse reaction 
SNP 
single-nucleotide polymorphism  
SOP 
standard operating procedure 
SUSAR 
Serious and Unexpected Suspected Adverse Reaction 
UP 
unanticipated problem 
UPnonAE 
unanticipated problem that is not an adverse event 
USD 
US dollar ($) 
VE 
vaccine efficacy 
VRC 
Vaccine Research Center 
WBC 
white blood cells 
WHO 
World Health Organization 
 
 
 

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PROTOCOL SUMMARY 
 
Full Title: 
Randomized, Placebo-Controlled, Double-Blind Study to Assess 
Safety, Immunogenicity, and Protective Efficacy of Two Regimens 
of Radiation Attenuated Plasmodium falciparum NF54 Sporozoites 
(PfSPZ Vaccine) During Natural Transmission Season in Healthy 
African Adults in Mali 
Short Title: 
Two regimens of PfSPZ Vaccine in Mali, Africa  
Clinical Phase: 
Phase 1 
IND Sponsor: 
 
Sanaria, Inc. 
Clinical Sponsor:  
Office of Clinical Research Policy and Regulatory Operations 
(OCRPRO) 
Conducted by: 
Malaria Research and Training Center (MRTC), in collaboration 
with the Laboratory of Malaria Immunology and Vaccinology 
(LMIV) 
Principal Investigators:  
Halimatou Diawara (MRTC) 
Patrick Duffy (National Institute of Allergy and Infectious 
Diseases [NIAID] / National Institutes of Health [NIH]) 
Vaccine Sample Size: 
 
N=210 (Main study) 
Accrual Ceiling: 
 
N=700  
 
 
 
 
Reconsent for Booster phase: Previously enrolled and vaccinated 
 
 
 
 
N=200 
Study Population: 
 
Healthy adults (18 to 35 years of age), residents in 
Ouelessebougou and surrounding villages, Mali  
Accrual Period: 
 
Approximately April 2018 to April 2019 (MAIN PHASE) 
 
 
Approximately April 2019 to March 2020 (BOOSTER PHASE) 
 
Study Design: 
 
A randomized double blind, placebo-controlled study to assess the 
safety, tolerability, immunogenicity and protective efficacy of 9 
x105 irradiated Plasmodium falciparum sporozoite (PfSPZ 
Vaccine) in healthy adults when given at 0, 8 and 16 weeks and at 
0, 1 and 4 weeks. Participants will be randomized into four arms. 
At the completion of the follow up period in the first transmission 
season, the study will remain blinded and will assess the safety, 
tolerability, immunogenicity and protective efficacy of a 4th 
vaccination (booster dose). Arms 1 and 2 will receive  9 x105 
PfSPZ Vaccine whereas Arm 3a and 3b will receive normal saline. 
The booster phase will evaluate efficacy in the subsequent 
transmission season.  
 
 
 

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Arm 1: (n=70) will receive 3 doses of PfSPZ Vaccine (9 x105) via 
direct venous inoculation (DVI) at 0, 8, and 16 weeks. A 4th dose 
at 38 weeks post 3rd vaccination 
  
 
 
Arm 2: (n=70) will receive 3 doses of PfSPZ Vaccine (9 x105) via 
DVI at 0, 1 and 4 weeks. A 4th dose at 38 weeks post 3rd 
vaccination 
 
 
 
Arm 3a: (n=35): Will be the control for Arm 1. Volunteers will 
receive 3 doses of placebo saline injection via DVI at 0, 8 and 16 
weeks. A 4th dose at 38 weeks post 3rd injection 
 
 
 
Arm 3b: (n=35): Will be the control for Arm 2. Volunteers will 
receive 3 doses of placebo saline injection via DVI at 0, 1 and 4 
weeks. A 4th dose at 38 weeks post 3rd injection 
  
• All injections will be administered by DVI.  
• All volunteers will receive antimalarial treatment with 
artemether/lumefantrine (AL) 2 weeks prior to 3rd injection and 4th 
injection 
• Participants will be monitored for safety, immunogenicity, malaria 
infection and disease during the follow-up period.  
Study Duration: 
 
MAIN PHASE 
 
 
Start Date: Approximately April 2018  
 
 
End Date: Approximately April2019 
 
 
BOOSTER PHASE 
 
 
Start Date: Approximately April  2019  
 
 
End Date: Approximately March 2020 
Study Agent Description: 
Radiation attenuated, aseptic, purified, vialed, cryopreserved, 
NF54 Plasmodium falciparum sporozoites (referred to as PfSPZ 
Vaccine) produced by Sanaria, Inc. will be administered via DVI at 
the doses and time intervals specified above.  
Primary Objective:  
Safety:  
1. Assess safety and tolerability of PfSPZ Vaccine primary series 
in healthy Malian adults when given at 0, 8 and 16 weeks and 
at 0, 1 and 4 weeks (Main phase) 
2. Assess safety and tolerability of PfSPZ Vaccine booster dose 
(4th dose) in healthy Malian adults (Booster phase) 
 
 

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Secondary Objectives: 
Protective Efficacy: 
1. Assess the efficacy of PfSPZ Vaccine primary series in healthy 
Malian adults when given at 0, 8 and 16 weeks and at 0, 1, and 
4 weeks.  
2. Assess the efficacy of PfSPZ Vaccine booster dose (4th dose) in 
healthy Malian adults  
 
Exploratory Objectives: 
Immunogenicity  
• Characterize and compare host immune responses to malarial 
antigens, and host proteomic profiles and transcriptomes in 
African adults prior to and after vaccination with PfSPZ 
Vaccine and between uninfected and infected subjects. 
• Explore the impact of PfSPZ Vaccine on the genotype and 
transcriptome profile of parasites isolated from study subjects.  
Primary Endpoints:  
Safety:  
1. Incidence of local and systemic adverse events (AEs) graded 
by severity occurring within 7 days after each vaccine 
administration (Main phase).  
2. Incidence of local and systemic adverse events (AEs) graded 
by severity occurring within 7 days after vaccine 
administration (Booster phase).  
 
Secondary Endpoints:  
Protective Efficacy:  
1. P. falciparum blood stage infection defined as time to first 
positive blood smear (detection of at least 2 P. falciparum 
parasites by microscopic examination of 0.5 µL) starting 
immediately following 3rd injection (Main Phase). 
2. P. falciparum blood stage infection defined as time to first 
positive blood smear (detection of at least 2 P. falciparum 
parasites by microscopic examination of 0.5 µL) starting 
immediately following 4th injection (Booster Phase). 
 
Exploratory Endpoints: 
Immunogenicity  
• Measurement and comparison of various immunological 
parameters: 
    - in the same subject prior to and after vaccination 
- between parasitemic and aparasitemic subjects 
• Determination of the genotype of parasites isolated from study 
subjects, using microsatellite typing, sequencing, and/or single-
nucleotide polymorphism (SNP) chip assays. 

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PRECIS 
It is known that humans can be protected against malaria by repeated immunization with 
radiation-attenuated sporozoites. Sanaria, Inc. has developed a process for manufacturing, in 
compliance with current Good Manufacturing Practices (cGMPs) aseptic, purified, radiation-
attenuated cryopreserved sporozoites from a well-characterized isolate of Plasmodium 
falciparum (Pf) (Hoffman et al., 2010). This product, which is called PfSPZ Vaccine, can be 
administered by needle and syringe.  
 
A collaboration among the Malaria Research and Training Center (MRTC, Mali), the Laboratory 
of Malaria Immunology and Vaccinology (LMIV) National Institute of Allergy and Infectious 
Diseases (NIAID), and Sanaria, Inc. (Sissoko et al., 2017) has shown that sterile protection 
against naturally occurring malaria infection can be achieved. In this study, five doses of 2.7 × 10⁵ 
PfSPZ during the dry season resulted in protective efficacies of about 48% by time to first positive 
blood smears (BS) and about 29% by proportion of participants with at least one positive BS during 
a full malaria transmission season (20 weeks), higher than those reported for other malaria vaccine 
candidates (Sissoko et al., 2017).  
 
A follow up study in 2015 (ClinicalTrials.gov Identifier: NCT02627456) that reduced the number 
of vaccinations (from 5 to 3) while increasing the dose of sporozoites at each vaccination (2.7 
x105 to 1.8x106 PfSPZ Vaccine) was conducted. Preliminary results show that 42 of 55 (77.8%) 
participants from the placebo group and 32 of 54 participants (58.1%) from the vaccine group 
developed Pf infection. Per protocol, the vaccine efficacy (VE) was 51% (p=0.004, 95% CI 20-
70) by time-to-infection analysis (intention to treat [ITT] 39%, p=0.033) and 24% (p=0.031, 95% 
CI 2-41) by proportional analysis (ITT 22%, p= 0.041), similar to the previous study.  
 
Studies are ongoing to establish a vaccination regimen, optimum dose and schedule, that will 
lead to improved sterile protection in endemic regions. Preliminary results from more recent 
studies in malaria-naïve and malaria-experienced participants have shown that 9.0x105 PfSPZ 
Vaccine dose per vaccination (lower than 1.8 x106 used in studies above) in a three-dose regimen 
may be an optimal dose for immunization. In addition, there is emerging evidence that a 
condensed, more practical regimen may also lead to development of sterile immunity. This 
proposed study is therefore designed to assess safety, immunogenicity and protective efficacy of 
two separate three-dose vaccination regimens during natural transmission season.  
 
Participants in the main phase were randomized into arms receiving either PfSPZ Vaccine or 
normal saline injections. Each group received three doses of the respective injection. After 
completion of the follow up in the main phase, all participants that are still enrolled in the study 
will be offered continued participation to receive a booster dose of the vaccine (4th dose) with 
9.0x105 PfSPZ or normal saline (depending on the group they were originally randomized to) at 
approximately 10 months post 3rd vaccination. The booster dose is timed prior to ensuing malaria 
transmission season. Participants will be followed, similarly to the follow up during the main 
phase, for safety and vaccine efficacy for approximately 6 months during this second 
transmission season. 
 
 

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1 BACKGROUND INFORMATION AND SCIENTIFIC 
RATIONALE 
  The Need for a Malaria Vaccine 
In recent years, the fight against malaria has received a considerable boost, with major funding 
organizations proposing eradication (Grabowsky, 2008; Roberts & Enserink, 2007). The 
increased use of several proven cost-effective measures available to reduce malaria such as 
insecticide-treated bed nets (ITNs), indoor residual spraying (IRS), artemisinin-based 
combination therapy (ACT) and intermittent preventative treatment during pregnancy (IPTp) 
over the last decade is thought to have contributed to the recently observed decline in clinical 
malaria in many parts of Sub-Saharan Africa (Ceesay et al., 2008; O'Meara, Bejon, et al., 2008; 
O'Meara, Mwangi, et al., 2008; B. Walther & Walther, 2007). However, despite concerted efforts 
by the World Health Organization (WHO), the United Nations Children’s Fund, and the World 
Bank’s Roll Back Malaria initiative to scale up these measures, the WHO Malaria Report 2017 
estimates that only 19% of pregnant women received the recommended three doses or more of 
IPTp, and although the ownership of ITNs has increased to 80% in 2016 compared to 50% in 
2010, the proportion of households with an adequate number of ITNs remains at 46%. 
Additionally, WHO estimates that 6 billion US dollars (USD) per annum would be necessary to 
sustain and increase current control efforts; however, in 2016, only 2.7 billion USD were 
available (Das & Horton, 2010; WHO, 2017; World malaria report 2011, 2011). It is also worth 
noting that mortality attributable to malaria remained stable in West Africa, and even increased 
in East and South Africa throughout the last 2 decades (Korenromp, Williams, Gouws, Dye, & 
Snow, 2003; Ndugwa et al., 2008). Moreover, recent estimates suggest that malaria mortality in 
individuals aged five years or older has been grossly underestimated (Murray et al., 2012). 
Collectively, these data raise concern for the hope of eradicating malaria with currently available 
means and highlight the urgent need to develop an efficient vaccine to eliminate malaria. 
Vaccination targeted toward the clinically silent liver-stage of infection would ideally provide 
sterile protective immunity, preventing progression to blood-stage infection and clinical disease, 
and transmission of parasites to mosquitoes. This is the target of leading vaccine strategies 
including the partially effective recombinant circumsporozoite protein (CSP)-based Mosquirix 
(RTS,S) vaccine, currently in implementation studies throughout Africa. Subunit vaccines of this 
type utilize conserved antigenic targets to elicit protection against sporozoite migration, 
hepatocyte infection and intrahepatocytic parasite replication. Mosquirix has protected malaria-
naïve adults against controlled human malaria infection (CHMI) with Plasmodium falciparum 
(Pf) and reduced malaria-associated episodes in children living in malaria endemic areas, but the 
level and length of immunity seen is relatively modest (Agnandji et al., 2011; Rts, 2015; Stoute 
et al., 1998). Although follow-up studies of Mosquirix (RTS,S) vaccine have shown decreases in 
clinical malaria in vaccinated children, at 6 months post-vaccination follow-up, the levels of 
antibodies were not significantly different between vaccinated and unvaccinated children and did 
not predict protection against clinical malaria in the following 12 months (Campo et al., 2014). 
The mechanism by which Mosquirix (RTS,S) and other sporozoites (SPZ) and liver-stage 
vaccine strategies confer protective immunity is still under investigation.  
  Challenges of Developing a Malaria Vaccine 
Designing a malaria vaccine is not straightforward (M. Walther, 2006). In contrast to most 
infectious diseases, natural sterile immunity to P. falciparum has not been demonstrated. Nature 

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does not provide a clear template for protective immune mechanisms that a vaccine could mimic. 
The inability to completely clear parasitemia or to prevent re-infection may be the result of an 
array of sophisticated immune evasion strategies used by the parasite, such as clonal antigenic 
variation, antigenic diversity, and impairment of dendritic cell maturation by parasitized red 
blood cells (Casares & Richie, 2009; Chen et al., 1998; Plebanski et al., 1999; Urban et al., 
1999). A prospective vaccine will have to overcome all of these. 
  The Rationale for a Whole Organism P. falciparum Sporozoite-based Vaccine 
Hopes that sterile protection against malaria infection can be induced by a whole organism 
vaccine stem from studies demonstrating that immunization by bites of mosquitoes with 
radiation-attenuated (>120 Gray units) Plasmodium falciparum sporozoites (PfSPZ) in their 
salivary glands can induce full protection of considerable longevity in mice and humans lasting 
for up to 10 months, with some evidence of strain-transcending protection (Clyde, 1990; Clyde, 
McCarthy, Miller, & Hornick, 1973; Hoffman et al., 2002; Nussenzweig, Vanderberg, Most, & 
Orton, 1967; Rieckmann, Carson, Beaudoin, Cassells, & Sell, 1974). Irradiation of infectious 
mosquitoes disrupts the gene expression of sporozoites, which remain capable of hepatocyte 
invasion but are no longer able to complete liver-stage maturation or progress to the pathogenic 
blood stage (Mellouk, Lunel, Sedegah, Beaudoin, & Druilhe, 1990). Infection of human subjects 
with irradiated sporozoites thus exposes them to liver-stage antigens and generates pre-
erythrocytic immunity. However, the requirement of a minimum of 1,000 bites by irradiated 
mosquitoes during five or more immunization sessions in order to successfully induce sterile 
immunity in humans precludes this method for routine immunization (Hoffman et al., 2002). 
  The Product PfSPZ Vaccine 
Over the last decade, Sanaria, Inc. (Rockville, MD) has developed a novel manufacturing 
process for obtaining aseptic, purified, cryopreserved sporozoites from the NF54 isolate of P. 
falciparum. PfSPZ are produced by raising adult A. stephensi mosquitoes aseptically and having 
them feed on blood cultures containing aseptic P. falciparum gametocytes. Within P. falciparum 
-infected mosquitoes, these P. falciparum gametocytes develop into sporozoites. To prepare 
radiation-attenuated PfSPZ, mosquitoes are irradiated at this stage. This product is named 
‘PfSPZ Vaccine’ (Epstein et al., 2011; Hoffman et al., 2010). The salivary glands are 
subsequently removed by dissection and triturated to release the sporozoites. The sporozoites 
undergo several purification steps, are counted, and cryopreserved at a specified concentration. 
This process is in compliance with cGMPs and regulatory requirements for production of high-
quality PfSPZ (for more detailed information, see Section 5.1 of this protocol). 
 Rationale for Intravenous Administration of PfSPZ Vaccine 
Several animal studies indicate that the immunogenicity and protective efficacy of radiation-
attenuated PfSPZ depends to a large extent on the amount of sporozoites reaching the liver which 
can be influenced by the route of immunization. Compared to subcutaneous (SC) or intradermal 
(ID) administration, intravenous (IV) immunization using PfSPZ Vaccine induced a significantly 
higher frequency of PfSPZ-specific CD8+ IFN-γ producing T cells in the liver (demonstrated in 
nonhuman primates and mice), and conferred protection (tested in mice) (Epstein et al., 2011). 
Further, protection in IV-vaccinated mice was associated with a 30-fold higher parasite liver load 
compared to the ID regimen, indicating a high number of sporozoites reaching the liver is a 
prerequisite for the development of protective immune responses, and that this can be achieved 

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more easily with IV administration of sporozoites (Nganou-Makamdop et al., 2012; Ploemen et 
al., 2013). 
 Previous Trials with Radiation Attenuated PfSPZ (PfSPZ Vaccine) 
Multiple clinical trials in the US and abroad have used radiation attenuated Plasmodium 
falciparum sporozoites produced by Sanaria, Inc. (PfSPZ Vaccine) delivered by DVI. Studies 
conducted in malaria-exposed populations are summarized here briefly. 
 Results from Malaria Exposed Populations 
Four trials in African adults have been completed to date: the first in minimally malaria-exposed 
Tanzanian adults (clinicaltrials.gov: NCT02132299), the second in heavily malaria-exposed 
Malian adults (NIAID Protocol 14-I-N010; clinicaltrials.gov: NCT01988636), and the third, in 
moderately to heavily malaria-exposed Equatoguinean adults (clinicaltrials.gov: NCT02418962). 
The fourth study in minimally malaria-exposed Tanzanian adults and children as young as six 
months (ClinicalTrials.gov Identifier: NCT02613520) has also been completed. There are four 
additional ongoing studies in various African countries evaluating the safety, immunogenicity 
and efficacy of various doses and administration regimens of PfSPZ Vaccine. Below is a 
summary of the four completed studies in malaria-endemic countries to date.  
 
1.4.3.1 Mali (NIAID Protocol 14-I-N010) 
In the trial in Mali (14-I-N010 conducted by the NIAID Laboratory of Malaria Immunology and 
Vaccinology [LMIV] and the Malaria Research and Training Center, University of Bamako 
[MRTC]), healthy Malian adults aged 18 to 35 were immunized with five doses of 2.7×105 
PfSPZ (total of 13.5×105 PfSPZ) or normal saline (placebo) in 2014 (Sissoko et al., 2017). 
Eighty-eight healthy malaria-exposed Malian adults (44 PfSPZ Vaccine; 44 Placebo) received 
five doses of vaccine and 86 (42 PfSPZ Vaccine; 44 Placebo) were followed actively every two 
weeks for up to 24 weeks post-vaccination #5. A total number of 502 immunizations via DVI 
were administered.  
Vaccinations were well-tolerated overall, with no serious adverse events (SAEs) reported 
during the course of the study. Most study subjects reported no local or systemic reactogenicity 
following vaccination. Only Grade 1 (mild) local or systemic reactogenicity were reported. There 
was no local reactogenicity reported in the PfSPZ Vaccine versus four (9%) of the 47 placebo 
subjects reporting local injection site pain. There were very few subjects who reported any 
systemic reactogenicity following vaccination (7% in PfSPZ Vaccine; 9% in the placebo; Table 
1). The most commonly reported solicited systemic adverse event (AE) in both the PfSPZ 
Vaccine group and the placebo group was headache, followed by fatigue, fever, and myalgia 
(Table 1). No significant differences in local or systemic reactogenicity between PfSPZ Vaccine 
and placebo recipients were noted (Sissoko et al., 2017). 
 
 
 

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Table 1: Maximum Local and Systemic Reactogenicity 
 
Note: Placebo – Normal Saline 
 
Laboratory variables were closely monitored prior to each vaccination and on Day 3 and 7 
following each vaccination. There was no noted increase in reporting of laboratory abnormalities 
with subsequent vaccinations. Additionally, there were no noted significant differences in 
laboratory abnormalities between the PfSPZ Vaccine and placebo recipients that were deemed 
related to vaccination (Table 2). Overall, PfSPZ Vaccine was easy to administer by DVI, and 
was safe and well tolerated. 
 
 
 
 
 

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Table 2: Vaccine Related Laboratory Abnormalities 
                         
 
Pilot Safety Cohort 
Main Cohort 
PfSPZ Vaccine 
PfSPZ Vaccine 
Placebo (N=47) 
Total 
Related 
Total 
Related 
Total 
Related 
Laboratory Abnormalities 
Leukopenia 
None 
12 (100%) 
12 (100%) 
39 (85%) 
43 (93%) 
44 (94%) 
45 (96%) 
Mild 
0 (0%) 
0 (0%) 
7 (15%) 
3 (7%) 
3 (6%) 
2 (4%) 
Moderate 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
Leukocytosis 
None 
12 (100%) 
12 (100%) 
45 (98%) 
46 (100%) 
43 (91%) 
45 (96%) 
Mild 
0 (0%) 
0 (0%) 
1 (2%) 
0 (0%) 
4 (9%) 
2 (4%) 
Moderate 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
Granulocyte count decreased 
None 
12 (100%) 
12 (100%) 
42 (91%) 
43 (94%) 
45 (96%) 
46 (98%) 
Mild 
0 (0%) 
0 (0%) 
4 (9%) 
3 (7%) 
2 (4%) 
1 (2%) 
Moderate 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
Thrombocytopenia 
None 
11 (92%) 
11 (92%) 
45 (98%) 
46 (100%) 
45 (96%) 
46 (98%) 
Mild 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
1 (2%) 
1 (2%) 
Moderate 
1 (8%) 
1 (8%) 
1 (2%) 
0 (0%) 
1 (2%) 
0 (0%) 
Haemoglobin decreased 
None 
12 (100%) 
12 (100%) 
44 (93%) 
46 (100%) 
45 (96%) 
45 (96%) 
Mild 
0 (0%) 
0 (0%) 
2 (4%) 
0 (0%) 
2 (4%) 
2 (4%) 
Moderate 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
Blood creatinine increased 
None 
12 (100%) 
12 (100%) 
46 (100%) 
46 (100%) 
46 (98%) 
46 (98%) 
Mild 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
1 (2%) 
1 (2%) 
Moderate 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
Alanine aminotransferase (ALT) increased 
None 
12 (100%) 
12 (100%) 
44 (96%) 
44 (96%) 
47 (100%) 
47 (100%) 
Mild 
0 (0%) 
0 (0%) 
2 (4%) 
2 (4%) 
0 (0%) 
0 (0%) 
Moderate 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
0 (0%) 
Data represents total # of individual subjects experiencing AE (% of subjects experiencing AE). 
Each vaccine receipt is counted once at worst severity for any laboratory abnormality. 
There were no severe laboratory abnormalities. 
 
P. falciparum infections as recorded starting 28 days post vaccination 5 occurred significantly 
earlier in the control group than the PfSPZ Vaccine group; interval censored log-rank p= 0.01 
(VE based on Cox HR, 48.27% 95% CI (14.45, 68.72)). The proportion of individuals with any 
infection as recorded starting 28 days post vaccination 5, during the malaria season, was 28.8% 
lower (95% CI 8.2-47.2, p=0.006) in the PfSPZ Vaccine group than the control group. The non-
parametric maximum likelihood estimation (MLE) curves, accounting for interval censoring, for 
the vaccine and placebo groups in the Mali trial are presented in Figure 1(Sissoko et al., 2017). 

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Figure 1: Protective Efficacy: First Positive Blood Smear (BS) Starting 28 Days Post 
Vaccination #5 
 
In the pilot safety group 7/9 (78%) were blood smear (BS) positive. Protective efficacy was analyzed by time to first 
positive BS, with Day 0 at 28 days after the fifth vaccination. The inverse survival curves include participants who 
received all five vaccinations and were evaluable for the primary exploratory efficacy endpoint. Five subjects (1 
PfSPZ Vaccine; 4 placebo) were censored from primary efficacy analysis as they had a positive BS prior to 28 days 
post Vaccination #5. 
 
PfSPZ vaccination induced only modest antibody responses to CSP and antibody levels. 
Antibody levels were not significantly predictive of infection in the vaccine arm subjects. When 
results of the Plasmodium falciparum circumsporozoite protein (PfCSP) enzyme-linked 
immunosorbent assay (ELISA) were compared between the USA volunteers and the Tanzanian 
and Malian volunteers, it was clear that antibody responses to PfSPZ Vaccine were lower in 
malaria-exposed than in malaria-naive subjects. Figure 2 shows the PfCSP ELISA results (net 
OD 1.0) after three doses for volunteers in VRC 314 and WRAIR 2080 (N = 36) who received 
four or five doses of 2.7×105 PfSPZ/dose versus volunteers in 14-I-N010 (N = 41) who received 
five doses of 2.7×105 PfSPZ/dose. 
27/41 (66%) 
37/40 (93%) 

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Figure 2: USA vs Mali PfCSP ELISA Results 
 
Controls from 14-I-N010 (N = 44) are also included. Assay was performed on serum drawn following the third 
vaccine dose. The Malians had significantly lower responses, with many giving negative results (i.e., lower OD 1.0 
following the third dose than prior to the first vaccination). Green dots represent volunteers who were protected 
against CHMI or natural exposure; red dots represent volunteers who were not protected. 
 
1.4.3.2  Tanzania, BSPZV1 
When healthy, young males in Tanzania (clinical trial BSPZV1 conducted by the Ifakara Health 
Institute) received five doses of either 1.35×105 PfSPZ Vaccine (total of 6.75×105 PfSPZ) or 
2.7×105 PfSPZ Vaccine (total of 13.5×105 PfSPZ)(regimens similar to that which protected 69% 
and 92% of volunteers in the USA, respectively), and underwent homologous CHMI (by DVI of 
3,200 viable Plasmodium falciparum sporozoites produced by Sanaria, Inc. [PfSPZ Challenge]) 
three weeks after the fifth dose, only 4/19 (21%) and 4/20 (20%) were protected. As in Mali, the 
vaccine was well-tolerated and immune responses were markedly reduced compared to those 
recorded in malaria-naïve individuals. 
1.4.3.3 Mali (NIAID Protocol 16-I-N004) 
The phase 1 dose escalating and randomized, placebo-controlled, double-blind study to assess 
the safety, immunogenicity, and protective efficacy of PfSPZ Vaccine in Mali started in 
December 2015 and was completed per protocol in January 2017.  
 Pilot Phase 
In January 2016, enrollment of the open label dose escalation pilot study (n=40) was completed 
and demonstrated the safety and tolerability of PfSPZ Vaccine at 4.5x105, 9x105, and 1.8x106. 

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Overall, PfSPZ Vaccinations were very well tolerated in those receiving 4.5x105 (n=5) and 9x105 
(n=5) with few adverse events (AEs) and no Grade 3 AEs or lab abnormalities reported. Subjects 
then were enrolled and vaccinated in a staggered manner for safety to receive 1.8x106 PfSPZ 
Vaccine (Arm 1c). Arm 1c was also well tolerated by the majority of subjects; however, there 
was one subject (randomized to artesunate-amodiaquine [ASAQ] treatment prior to each 
vaccination) who experienced an asymptomatic Grade 3 elevated ALT following Vaccination #1. 
This AE, along with three other ALT elevations that developed around Vaccination #3 during the 
Main Phase of the study, were reviewed at length by the Data Safety Monitoring Board (DSMB), 
ISM, and Sponsor and are summarized later below. Vaccination #2 and #3 in 1.8x106 PfSPZ 
Vaccine Pilot arm were completed without significant complication and were well tolerated.  
Approximately seven weeks prior to homologous CHMI with 3.2x103 PfSPZ Challenge, 29 
(96.7%) pilot phase PfSPZ vaccinees who received 1.8x106 PfSPZ Vaccine (Arm 1c) and 15 
infectivity controls received a full treatment course ASAQ. All 44 subjects, including 29 PfSPZ 
Vaccinees (Arm 1c), underwent homologous CHMI about five weeks following PfSPZ 
Vaccinees’ receipt of their third PfSPZ Vaccine. All 44 subjects completed CHMI follow-up. 
Reported AEs post CHMI were few, with vaccinees reporting five total AEs (4/29 subjects; 
13.8%) and infectivity controls eight total AEs (7/15 subjects; 46.7%). All reported AEs were 
mild to moderate. Only one AE, granulocyte reduction, was deemed related to CHMI. Of the 29 
PfSPZ vaccinees, 0/29 vaccinees and 1/15 infectivity controls became BS positive. By 
quantitative polymerase chain reaction (qPCR) 0/29 vaccinees and 8/15 (53.3%) infectivity 
controls became positive (Figure 3). Most qPCR positive infectivity controls were qPCR 
positive only for a single timepoint (5/8; 62.5%; Figure 3). By qPCR, VE was significant by 
interval-censored log rank p<0.001 for time-to-infection, and VE was 100% (p<0.001, 95% CI 
73-100%) by proportional analysis. 
Twenty-seven (90%) subjects continued in the study to receive a final fourth booster dose 
(13 weeks post Vaccination #3; 8 weeks post CHMI) of PfSPZ Vaccine in parallel with the main 
cohort’s third vaccination. Of those 27 subjects, 18 (66.7%) became infected during the malaria 
transmission season.  
 
Figure 3: Protective Efficacy of 18x105 PfSPZ Vaccine at 0, 8, 16 weeks against 
Homologous PfSPZ Challenge 
 

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 Main Phase 
Following review of the safety data from the Pilot Phase, 120 subjects were randomized into the 
double blind, placebo-controlled phase of the study in Mar/Apr 2016 to receive 1.8x106 PfSPZ 
Vaccine or normal saline at 0, 8, 16 weeks during the dry season (Mar to Jul). All participants 
received ASAQ to eliminate Pf before first and last vaccination. During the malaria transmission 
season (Aug-Dec 2016), volunteers were examined and BS obtained every 2 weeks for 24 weeks 
in total; the primary efficacy endpoint was detection of first positive BS following third 
vaccination. 60 subjects received at least one dose of PfSPZ Vaccine and 60 subjects received at 
least one dose of placebo. 57/60 (95%) PfSPZ Vaccine subjects received all three doses and 
55/60 (91.7%) normal saline placebo subjects received all three doses. Scheduled unblinding of 
the trial was completed in January 2017. 
PfSPZ vaccinations were safe and well tolerated except as noted prior, there were three 
additional unanticipated significantly elevated transaminases (Grade 3 to 4) in three Main Phase 
participants (1 PfSPZ Vaccine, 2 placebo) at varying stages post vaccination and ASAQ (14 to 
65 days post ASAQ). Including the ALT liver enzyme derangement seen in the Pilot Phase 
subject, all four subjects were asymptomatic at presentation with no associated agranulocytosis. 
All laboratory abnormalities resolved without sequelae (duration 169 to 214 days). At the time of 
the laboratory abnormalities the study was blinded, and the unblinded data was reviewed by the 
DSMB and submitted to the Food and Drug Administration (FDA) for review. Testing for 
potential of other etiologies, through imaging, expanded laboratory testing, and serology, 
identified no other possible contributing causes, except a traditional medicine provided to the 
first subject presenting with liver enzymes derangements. Serum antibodies to AQ are pending at 
this time.  
Overall, there was no significant differences in local or systemic AEs or laboratory 
abnormalities between PfSPZ Vaccine and placebo groups.  
 
55 subjects in the PfSPZ Vaccine group and 54 subjects from the placebo group were evaluable 
for per protocol analysis. Of these participants, 42 (77.8%) from the placebo group and 32 
(58.1%) from the vaccine group developed Pf infection (Figure 4). Per protocol, VE was 51% 
(p=0.004, 95% CI 20-70) by time-to-infection analysis (ITT 39%, p=0.033) and 24% (p=0.031, 
95% CI 2-41) by proportional analysis (ITT 22%, p= 0.041).  

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Figure 4: Protective Efficacy of PfSPZ Vaccine Against Naturally Occurring Infection 
 
Protective efficacy was analyzed by time to first positive blood smear (BS), with Day 0 starting immediately after 
the third and final vaccination. The survival curves include participants who received all three vaccinations.  
1.4.3.4 Tanzania, BSPZV2 
A follow up expanded study was conducted in Tanzania (clinical trial BSPZV2 conducted by the 
Ifakara Health Institute). This double-blind randomized placebo-controlled study enrolled 
children from six months of age to adults 45 years of age to assess the safety and 
immunogenicity of PfSPZ Vaccine. The participants were divided in various 3-dose regimens 
starting from 2.7×105 PfSPZ Vaccine to 1.8x106 PfSPZ Vaccine. In addition, adult participants 
underwent homologous CHMI with PfSPZ Challenge (live NF54 P. falciparum parasites).  
The study results showed that the regimen was safe and tolerable. One adult participant who 
received 1.8x106 PfSPZ Vaccine experienced 3 Grade 1 solicited local AEs that were considered 
possibly, probably or definitely related to vaccination. One teenage participant experienced a 
total of 15, mostly Grade 1 (maximum Grade 2) solicited systemic AEs which occurred after 
different vaccinations that were considered possibly, probably or definitely related to 
vaccination. These symptoms were transient and without sequalae. Safety results during 
vaccination period are summarized in Table 3.  

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Table 3: Summary of clinical adverse events of BSPZV2 during vaccination 
 
Efficacy results: This trial compared 9.0x105 PfSPZ administered at 0, 8 and 16 weeks to twice 
that dose, 1.8x106 PfSPZ, also administered at 0, 8 and 16 weeks. Half the lower dose group (3 
subjects) underwent homologous CHMI at 3 weeks and the other half (3 subjects) at 11 weeks. All 
6/6 (100%) were protected. The higher dose group (six subjects) underwent homologous CHMI 
at 7 weeks and 2/6 (33%) were protected. It appeared that doubling the dose may have resulted in 
a significant fall in VE.  
 
 Rationale for decreasing the dose of PfSPZ Vaccine from 1.8x106 to 9x105 in a 
three-dose regimen 
The hypothesis underlying the sequence of studies done with PfSPZ Vaccine (described above and 
others) was that higher doses of PfSPZ would lead to improved efficacy. It was argued that 
increasing the quantity of the immunogen should increase the antigenic stimulus and should also 
broaden the repertoire of immune responses to include less highly expressed proteins, improving 
VE. The expectations under this hypothesis: (1) long term CHMI (conducted at 24 weeks or longer 
after immunization) should be more stringent than short term CHMI (conducted 3-10 weeks after 
immunization) due to the fact that immune responses likely wane over time; and (2) the use of 
heterologous parasites (different strain than the vaccine) for CHMI should be more stringent than 
the use of homologous parasites (same strain as the vaccine). Therefore, the goal was to investigate 
and determine the most stringent challenge – long-term protection against CHMI performed with 
an antigenically divergent parasite – would most closely mimic field studies, where naturally 
transmitted parasites should all be heterologous to the vaccine strain. 
 
Findings of the 12 studies have shown that the threshold dose hypothesis is only partially true. 
The initial studies did confirm that VE increased with the dose of PfSPZ Vaccine administered. 
There was a clear dose response seen in several cases. For example, VE against homologous CHMI 

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conducted 3 weeks after a 3-dose regimen rose from 33% (3/9) in VRC314 to 87% (13/15) in 
WRAIR 2080 as the dose of PfSPZ administered was increased from 2.7×105 to 4.5×105 PfSPZ 
(Epstein et al., 2017; Ishizuka et al., 2016) VRC314 also tested a higher dose, 9.0x105 PfSPZ, 
administered at 0, 8 and 16 weeks, and VE was 64% (9/14) against a heterologous CHMI 
conducted at 17-20 weeks. VE was still high, despite a considerably more stringent CHMI than 3 
weeks. However, as individual doses were increased above about 9.0x105 PfSPZ Vaccine, further 
improvements were not generally seen. In addition to the BSPZV2 study described above (Section 
1.4.3.4), there have been several examples: 
 
1. Warfighter 2 trial (malaria-naïve population, USA NCT02601716): This trial compared four 
different regimens for protection against heterologous CHMI performed at 3 or 6 months. 
9.0x105 PfSPZ administered at 0, 8 and 16 weeks protected 3/15 (20%) research subjects 
(total dose administered 2.7x106 PfSPZ), while doubling the dose to 1.8x106 PfSPZ 
administered at 0, 8 and 16 weeks protected 3/13 (23%) subjects (total dose administered 
5.4x106 PfSPZ) – no improvement. On the other hand, the most protective regimen used 
doses of only 4.5x105 PfSPZ, administered Days 0, 2, 4, 6 and week 16, protecting 6/15 
(40%) research subjects against a stringent heterologous CHMI (total dose administered 
2.25x106 PfSPZ). This latter dose likely improved VE through the use of the condensed, 4-
dose prime, indicating that dose number and timing were critical. 
 
2. MAVACHE trial (malaria-naïve population, Germany NCT02704533): In addition to 
testing a 3-dose condensed regimen of 9.0x105 PfSPZ (total of 2.7x106 PfSPZ) at 0, 1 and 
4 weeks which protected 5/5 (100%) subjects against homologous CHMI 3 weeks after last 
vaccination. This trial also compared two 2-dose condensed regimens: 1.8x106 PfSPZ 
administered at 0 and 1 week (total of 3.6x106 PfSPZ) protected 4/6 (67%) research subjects 
against homologous CHMI conducted at 3 weeks, while increasing the dose to 2.7x106 
PfSPZ administered at 0 and 1 week (total of 5.4x106 PfSPZ) protected 3/6 (50%) research 
subjects. Thus, no dose response was observed, and it appeared that the higher dose may 
have been less protective. 
 
Although the studies described above have been conducted in malaria naïve subjects, there is 
some evidence that these results can be compared to those seen in field studies in malaria 
experienced. Increasing the dose of PfSPZ Vaccine past a particular threshold does not seem to 
improve VE, total of 1.35x106 PfSPZ Vaccine in NIAID protocol #14-I-N010 versus a total of 
5.4x106 PfSPZ Vaccine in NIAID protocol #16-I-N004, Sections 1.4.3.1 and 1.4.3.3. 
 
As a result of these combined studies, it is the opinion of the sponsor, Sanaria Inc., that 9.0x105 
PfSPZ Vaccine per dose in a 3-dose regimen is an optimal dose in both malaria-naïve and malaria-
exposed populations. It induced 100% protection in the MAVACHE trial administered in a 
condensed regimen (0, 1 and 4 weeks) and it provided 100% protection in Tanzania in BSPV2 trial 
when a higher dose provided only 33% protection, when administered at 0, 8 and 16 weeks. This 
dose will be administered in this proposed study.  

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 Rationale for assessing various vaccination schedules 
A number of PfSPZ Vaccine studies are ongoing to determine a highly effective vaccine schedule. 
There is ample evidence that the timing of each vaccine plays an important role in the development 
of protective immunity. A recent study in malaria naïve subjects, MAVACHE study described in 
Section 1.5, suggests that a condensed regimen of 0, 1 and 4 weeks injections may lead to equal 
or higher protective efficacy. 
 
This condensed vaccine regimen was also found to be safe and well tolerated. Among the six 
subjects, during the time from first injection and prior to CHMI, there was a total of 82 AEs, 74% 
of which were determined related to the study. There was a total of 3 Grade 3 AEs in two subjects 
which were also thought to be related to the study. The first subject had lymphopenia one day after 
3rd vaccination. The second subject had 2/3 Grade 3 AEs; lymphopenia 12 days after 2nd 
vaccination and fever two days after 3rd vaccination. No SAE was observed.  
 
The safety profile and protective efficacy of this regimen are encouraging. Since our goal at 
LMIV is to understand the immune response to vaccine candidates, this proposed study will also 
evaluate a condensed regimen of 0, 1, and 4 weeks in a field setting to assess whether this regimen 
is safe and tolerable in this population. We will also evaluate the protective efficacy observed with 
this condensed regimen and explore the immune response to vaccination.  
 
 Rationale for administering the booster dose (4th vaccination) 
The main phase of the study was designed to assess the safety and immunogenicity of two 
different vaccine regimens, an established regimen of 0, 8 and 16 weeks and a condensed 
regimen of 0, 1, and 4 weeks. The study started in June 2018 and the 3rd vaccination in all Arms 
was administered in September 2018. Currently, the participants are nearing the end of the 
malaria follow up phase during the first transmission season. The current plan is to extend the 
study by evaluating the safety and immunogenicity in the second transmission season after 
administration of a booster vaccination. 
 
 Safety 
Thus far, the vaccine regimen has been safe and well tolerated. There have been no serious 
adverse events (SAEs) or Grade 4 AEs. As expected, there are higher numbers of AEs in 
standard longer regimen Arm (Arm 1/3a) as this group has been enrolled and in follow up for a 
longer period of time than the condensed regimen Arm (Arm 2/3b). However, as demonstrated in 
Table 4, the proportions of AEs are similar between the two regimens indicating that 
administering PfSPZ Vaccine within a short period of time does not result in higher numbers of 
AEs compared to the standard longer regimen. All AEs were transient and have resolved without 
sequelae.   
 
Grade 1 AEs 
There have been 744 Grade 1 AEs to date. Lab abnormalities account for 153 (20.5% of total; 97 
in Arm 1/3a and 56 in Arm 2/3b). The majority have been absolute neutrophil count decreases 
(30 in Arm 1/3a; 22 in Arm 2/3b), white blood cell count decreases (34 in Arm 1/3a; 23 in Arm 
2/3b), and increased blood creatinine (20 in Arm 1/3a; 6 in Arm 2/3b). Most of the clinical AEs 
have been headache, injection site pain, malaria, and upper respiratory like illnesses. 
 

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Grade 2 AEs 
There have been 71 total AEs to date (46 in Arm 1/3a; 25 in Arm 2/3b). Lab abnormalities 
account for 43 (60.5% of total; 29 in Arm 1/3a and 14 in Arm 2/3b). Of the 43 lab abnormalities, 
23 have been from absolute neutrophil count decreases, with 16/23 occurring in Arm 1/3a, 5 
were determined to be related to the study. 7 episodes have occurred in Arm 2/3b, 3 were 
determined to be related to the study. There have been 28 variable clinical AEs, most common 
being hypertension (4/17 in Arm 1/3a; 2/11 in Arm 2/3b) and malaria cases. 
 
Grade 3 AEs 
There have been 16 total AEs to date (10 in Arm 1/3a; 6 in Arm 2/3b). There was only 1 AE of 
decreased platelet count (in Arm 1/3a) thought possibly related to the vaccine due to timing. 
There was a total of 8 Grade 3 malaria AEs, 4 in each arm. These participants presented with 
Grade 3 fever but were otherwise in stable condition.  
 
Table 4: Summary of AEs to date 
 
 
 
 
 
 
 
 
 
 
 
 
X(Y%): Number of AEs (Percentage of the Total combined AEs in Arm) 
 
 Malaria infection rate  
Vaccine efficacy started immediately after the third vaccination. Participants have been 
evaluated for malaria infection using blood smears every two weeks. The study is currently still 
blinded, but in general, there appears to be no significant differences between the study arms in 
the number of positive blood smears, clinical malaria and the unique individuals experiencing 
these events (see Table 5 below).  
 
 
 
Arm 1/3a 
(n=105) 
Arm 2/3b 
(n=105) 
TOTAL 
Clinical AEs 
Grade 1 
397 (72%) 
194 (69%) 
591 (71%) 
Grade 2 
17 (3%) 
11 (4%) 
28 (3.4%) 
Grade 3 
9 (1.6%) 
5 (1.8%) 
16 (1.9%) 
Lab abnormalities 
Grade 1 
97 (18%) 
56 (20%) 
153 (18.4% 
Grade 2 
29 (5.3%) 
14 (5%) 
43 (5.2%) 
Grade 3 
1 (0.2%) 
1 (0.3%) 
2 (0.2%) 
TOTAL 
550 (66%) 
281 (34%) 
831 (100%) 

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Table 5: Current rates* of malaria infection after vaccination #3  
Study Arms            
(# of participants who 
received vaccination 
#3) 
 Positive P. falciparum 
Blood smears          
(Unique individuals) 
Clinical Malaria       
(Unique Individuals) 
1/3a (n=101) 
87 (53) 
45 (35) 
2/3b (n=103) 
77 (51) 
40 (36) 
*September 2018 to Early February 2019  
 Booster dose administration 
A previous PfSPZ Vaccine study (ClinicalTrials.gov Identifier: NCT02627456 ) was conducted 
by LMIV to evaluate whether the vaccine efficacy observed in the first transmission season after 
the primary vaccine series extends to a second transmission season. Although analysis is 
ongoing, the preliminary results indicate that the rates of malaria infection were similar between 
the control and vaccinated groups, indicating that the immunity against malaria may have waned 
with time. Administering a booster vaccine dose is one of the ways we may extend vaccine 
efficacy into subsequent seasons.  
In order to explore the effect of boosting, all participants who received the full primary 
series (3 vaccinations) in the previous year will be invited to receive a 4th dose of 9.0x105 PfSPZ, 
same dose as used in the first three vaccinations. Participants enrolled in the control Arms will 
receive an injection with normal saline. Understanding the role of boosting in this model of 
malaria vaccine is essential to determine whether endemic populations who have received a 
primary vaccination series could benefit from receiving a booster dose only prior to each 
transmission season. In addition in the future, vaccinated individuals could receive a booster 
vaccination at the time when they are more susceptible to malaria such as during pregnancy.  
 
 

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2  STUDY OBJECTIVES 
 Primary Objective 
 
Safety:  
1. Assess safety and tolerability of PfSPZ Vaccine primary series in healthy Malian adults 
when given at 0, 8 and 16 weeks and at 0, 1 and 4 weeks (Main phase) 
2. Assess safety and tolerability of PfSPZ Vaccine booster dose (4th dose) in healthy 
Malian adults (Booster phase) 
 Secondary Objective  
 
Protective Efficacy:  
1. Assess the efficacy PfSPZ Vaccine primary series in healthy Malian adults when given 
at 0, 8 and 16 weeks and at 0, 1, and 4 weeks (Main phase). 
2. Assess the efficacy of PfSPZ Vaccine booster dose (4th dose) in healthy Malian adults 
(Booster phase) 
 Exploratory Objectives 
Immunogenicity  
• Characterize and compare host immune responses to malarial antigens, and host 
proteomic profiles and transcriptomes in African adults prior to and after vaccination 
with PfSPZ Vaccine and between uninfected and infected subjects 
• Explore the impact of PfSPZ Vaccine on the genotype and transcriptome profile of 
parasites isolated from study subjects. 
 
3 STUDY DESIGN 
This study will enroll healthy Malian adults between 18 and 35 years of age to participate in a 
randomized double blind, placebo-controlled study to assess the safety, immunogenicity and 
protective efficacy of boosting during the second transmission season. Participants will be 
immunized with a 3-dose series of 9 x105 PfSPZ Vaccine (cryopreserved radiation attenuated P. 
falciparum sporozoites via DVI) at 0, 8 and 16 weeks interval or 0, 1 and 4 weeks starting during 
the dry season (see Figure 5). Vaccinated subjects and controls will then be assessed for malaria 
infection during the ensuing malaria transmission season. Volunteers will be randomized into 
four arms.Arms 1 and 3a will be randomized first in a 2:1 ratio. Arms 2 and 3b will be 
randomized into a 2:1 ratio a few weeks later.  
 
At the completion of the follow up phase after the primary series, participants who received all 
three vaccine doses and are still enrolled in the study will be invited to continue participation in 
the study to receive a booster vaccine dose. This 4th dose will be administered prior to the 
beginning of the following transmission season, approximately10 months post the 3rd 
vaccination. Those enrolled in the vaccine arms (Arms 1 and 2) will receive one injection of 9 
x105 PfSPZ while those participants enrolled in the control arms (Arms 3a and 3b) will receive 
one injection of normal saline. The study will be maintained blinded as the participants transition 
from the main phase to the booster phase. Vaccinated subjects and controls will then be assessed 
for malaria infection during the ensuing malaria transmission season. 

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Figure 5: Study Schema 
 
 
 
 
 
 
 

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  Study Groups 
Arm 1: (n=70) will receive 3 doses of PfSPZ Vaccine (9 x105) via DVI at 0, 8, and 16 weeks in 
the main phase, booster dose at 38 weeks post 3rd vaccination.  
 
Arm 2: (n=70) will receive 3 doses of PfSPZ Vaccine (9 x105) via DVI at 0, 1 and 4 weeks in 
the main phase, booster dose at 38 weeks post 3rd vaccination. 
 
Arm 3a: (n=35): Will be the control for Arm 1. Volunteers will receive 3 doses of placebo saline 
injection via DVI at 0, 8 and 16 weeks in the main phase, booster dose at 38 weeks post 3rd 
vaccination. 
 
Arm 3b: (n=35): Will be the control for Arm 2. Volunteers will receive 3 doses of placebo saline 
injection via DVI at 0, 1 and 4 weeks in the main phase, booster dose at 38 weeks post 3rd 
vaccination. 
 
All injections will be administered by DVI. All volunteers will receive antimalarial treatment 
with artemether/lumefantrine (AL) two weeks prior to 3rd injection. Post 3rd injection, 
participants will be followed through the rainy transmission season, approximately six months. 
Participants will be monitored for safety, immunogenicity, malaria infection and disease during 
the follow-up period.  
 
Participants enrolled in the booster phase of the study, at the end of the prior transmission 
season, will also receive antimalaria treatment with artemether/lumefantrine (AL) at least two 
weeks prior to booster injection (4th injection overall). Post 4th injection, participants will be 
followed through the rainy transmission season, approximately six months. Participants will be 
monitored for safety, immunogenicity, malaria infection and disease during the follow-up period. 
 
4 STUDY ENDPOINTS 
 Primary Endpoints 
Safety:  
1. Incidence of local and systemic adverse events graded by severity occurring within 7 
days after each vaccine administration. (Main phase). 
2. Incidence of local and systemic adverse events (AEs) graded by severity occurring within 
7 days after each vaccine administration (Booster phase).  
 Secondary Endpoints  
 
 
 
 
 
 
 
 
 
Protective Efficacy:  
1. P. falciparum blood stage infection defined as time to first positive blood smear 
(detection of at least two P. falciparum parasites by microscopic examination of 0.5 µL) 
starting immediately following 3rd injection. (Main Phase) 
2. P. falciparum blood stage infection defined as time to first positive blood smear 
(detection of at least 2 P. falciparum parasites by microscopic examination of 0.5 µL) 
starting immediately following 4th injection (Booster Phase). 

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 Exploratory Endpoints 
Immunogenicity: 
• Measurement and comparison of various immunological parameters: 
- in the same subject prior to and after vaccination  
- between parasitemic and aparasitemic subjects 
• Determination of the genotype of parasites isolated from study subjects, using 
microsatellite typing, sequencing, and/or SNP chip assays. 
 Sample Size and Estimated Duration of the Study 
A total of 210 volunteers will be enrolled/randomized in this trial, 70 subjects in each arm 
vaccine arms (Arm 1 and 2) and 35 subjects in each control arms (Arm 3a and 3b). A total of 140 
subjects will receive PfSPZ Vaccine and 70 will only receive placebo. 
Definitions for the purpose of this study: 
• Screened – subjects will receive a study screening number when the informed consent is 
signed and will either be determined as “eligible” or “screen failure” as noted below. 
o Screening may be completed over the course of multiple visits. 
o Screening, in most cases, will occur within 56 days prior to administration of 
vaccine #1. 
▪ If the screening visit is >56 days administration of vaccine #, then an 
updated medical review and laboratory testing (CBC, ALT, Creatinine, 
ECG, Urinalysis, Pregnancy test (for females) will be completed to 
determine eligibility for enrollment. 
▪ Note: HIV, Hepatitis B, Hepatitis C and ECG are to be repeated during 
booster phase screening ONLY IF clinically indicated 
• Eligible - subjects will be considered eligible to enroll once they have completed the 
screening procedures and have met all inclusion and not met exclusion criteria.  
• Screen Failure – subjects are considered screen failures when they meet one of the 
following criteria after signing consent: 
o Screening results reveal that the subject is ineligible. 
o Subject withdraws consent before being vaccinated and/or randomized.  
o Subject cannot present to clinic for enrollment prior to study completing 
enrollment.  
o Subject is determined eligible for enrollment after study completes enrollment. 
• Randomized – the subjects are considered randomized when they meet the following 
criteria: 
o Meet eligibility criteria. 

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o Study identification number (ID) assigned.  
o Randomization number assigned. 
• Enrolled – In the main phase, subject will be considered enrolled beginning with the 
collection of baseline labs on study Day -14.                     
  – In the booster phase, subject will be considered enrolled beginning with the receipt of 
artemether/lumefantrine prior to receiving 4th vaccination 
o Subjects enrolled in main phase but have not received the first vaccination may be 
replaced up to the accrual ceiling set for the study.  
• Discontinued/Withdrawn – subjects are considered discontinued when they meet one or 
more of the following criteria: 
o Subject withdraws consent after being vaccinated. 
o Subject is withdrawn by the Principal Investigator (PI)/Sponsor after being 
vaccinated.  
• Completed – subjects are considered completed when they complete the final study visit. 
Note: Subjects who do not enroll in the booster phase will be considered completed if 
they complete the main phase final visit; Study day 295 (Arms 1 &3a) or 211 (Arms 
2&3b) 
 
5 STUDY AGENTS 
 PfSPZ Vaccine 
The vaccine referred to as PfSPZ Vaccine contains aseptic, purified, vialed, cryopreserved, 
radiation attenuated NF54 P. falciparum sporozoites (PfSPZ) produced by Sanaria Inc. PfSPZ 
Vaccine is manufactured in compliance with Good Manufacturing Practice (GMP) regulations 
(21 Code of Federal Regulations [CFR] 211), that is described in detail in Investigational New 
Drug (IND) 13969. Manufacture of PfSPZ Vaccine is performed in Sanaria’s Clinical 
Manufacturing Facility (CMF) in Rockville, Maryland, USA. The PfSPZ Vaccine manufacture is 
an aseptic process that includes in process testing according to USP<71> sterility testing. In 
brief, manufacture includes disinfection of mosquito eggs performed by exposure to chemical 
agents. Disinfected eggs are inoculated into vented flasks containing growth medium. The eggs 
hatch and develop into pupae, which are transferred to an adult mosquito container where the 
adult mosquitoes emerge. In vitro culture of P. falciparum parasites is initiated from a working 
cell bank (WCB) vial of P. falciparum isolate NF54, which is described in detail in Biologics 
Master File BMF 13489. The asexual parasite stages are induced to produce gametocytes. The 
adult mosquitoes are fed P. falciparum gametocyte-infected blood in a high-security insectary in 
Rockville, Maryland, USA. Infected adult mosquitoes are maintained and sporozoites migrate to 
the salivary glands in two weeks from the time of infectious feed. The PfSPZ in the mosquito 
salivary glands are attenuated by irradiation at 150 Gy. The salivary glands from the P. 
falciparum sporozoite infected mosquitoes are harvested by manual dissection. Salivary glands 

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are then triturated to release the PfSPZ that are then purified, counted, and, at a specified 
concentration, cryopreserved. Cryopreservation commences with the addition of cryoprotective 
additives to the PfSPZ bulk product to produce the PfSPZ Vaccine final product. The final 
product is dispensed into screw-cap vials that are stored in liquid nitrogen vapor phase (LNVP) 
at -150°C to -196°C. All the procedures are described in more detail in the cross-referenced IND 
13969. 
 Storage and Handling  
PfSPZ Vaccine is cryopreserved in aliquots of 20 μL in 0.5 mL cryovials and stored in LNVP at 
below -150°C. The cryovials are packaged in a latched box and transported from Sanaria, Inc. to 
the clinical study site in a LNVP dry shipper. The LNVP dry shipper has a holding time of at 
least 10 days. The PfSPZ Vaccine remains in the dry shipper at the clinical study site and 
individual cryovials are removed from the dry shipper and thawed as needed for PfSPZ Vaccine 
dilution, syringe preparations and immunizations. Each cryovial is labeled indicating that it 
contains PfSPZ Vaccine, together with the lot number and date of manufacture. The LNVP dry 
shipper is labeled to indicate it is approved by International Air Transport Association (IATA) 
for shipment by air, conforms to UN3373 for Biological Substance, Category B, and packing 
instructions 650 (US 49 CFR, Part 173.199).  
Transfer, receipt and maintenance of PfSPZ Vaccine from its storage site to the clinical 
trial site will follow SOP331 (Cryopreserved Material Transportation), provided by Sanaria, Inc. 
At the study site, the LNVP shipper will be continuously monitored by a data logger as well as a 
temperature probe according to Sanaria standard operating procedure (SOP). Receipt of the 
products will be documented on a tracking log by trained study staff according to Sanaria SOP. 
 Disposition and Dispensation 
The clinical site must confirm that the vials of PfSPZ Vaccine have been transported and stored 
below -150°C according to SOP. Immediately prior to use, the cryovials will be thawed by 
partial submersion of the vials for 30 seconds in a 37°C ± 1°C water bath. Designated study staff 
will be trained by Sanaria, Inc. and then will - either alone or with Sanaria, Inc. staff - prepare, 
dilute (if necessary) and dispense PfSPZ Vaccine to clinical staff at the clinical study site 
according to SOP353 (Preparation of PfSPZ Vaccine and Diluent for Clinical Trial in Mali). 
The diluent is phosphate buffered saline (PBS) containing human serum albumin (HSA). PBS 
and 25% HSA will be provided to the clinical sites by Sanaria, Inc. for preparation of the diluent. 
All PfSPZ Vaccine vials, PBS and HSA that are used will be documented on inventory forms as 
well as documented disposition forms according to SOP. All unused PfSPZ Vaccine vials will be 
returned to Sanaria, Inc. 
 Administration  
PfSPZ Vaccine will be injected by needle and syringe into a peripheral vein by a qualified 
member of the clinical team. The diluted vaccine will be prepared such that a defined volume of 
the suspension (not more than 0.5mL) is administered by DVI.  
During administration of PfSPZ Vaccine, advanced-life-support drugs and resuscitation 
equipment will be immediately available for the management of anaphylaxis. The study staff 
administering PfSPZ Vaccine will wear gloves. The subject will stay in the clinical area for at 
least 30 minutes after vaccine administration. 

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 PBS and HSA Diluent 
The diluent for PfSPZ Vaccine is composed of phosphate-buffered saline (PBS) and human 
serum albumin (HSA). Vials of sterile PBS and HSA will be shipped to the clinical site, where 
diluent composed of PBS and HSA is prepared according to SOP353 (Preparation of Challenge 
and Diluent for Clinical Trials in Mali) provided by Sanaria, Inc.  
PBS that will be used was manufactured in compliance with GMP by Sanaria, Inc. (9800 
Medical Center Dr., Rockville, MD, USA). A Certificate of Analysis (CoA) is generated for each 
lot of PBS that is released for use in clinical studies. In addition, the PBS lots are placed on 
stability.  
HSA is a licensed product which is approved for parenteral, IV administration to humans 
and is purchased by Sanaria, Inc. The HSA is repackaged at Sanaria. Repackaged HSA is 
released with a CoA.  
 Storage and Handling 
The PBS and HSA are stored at ambient temperature within specifications (between 15°C to 
30°C) that is monitored by a continuous data logger in a controlled access room. Receipt of the 
products will be documented on a tracking log by trained study staff according to Sanaria SOP. 
 Disposition and Dispensation 
The clinical site must confirm and document that the vials of PBS and HSA have been 
transported and stored within specified ranges. All PBS and HSA that are used will be 
documented on inventory forms as well as documented disposition forms according to SOP.  
 Administration and Dosage 
PBS and HSA are components of PfSPZ Vaccine diluent. The use of PBS and HSA will be 
according to SOP. The PfSPZ Vaccine dose will be suspended in a diluent composed of PBS and 
about 1% HSA in a total of 0.5 mL.   
 Accountability 
PBS and HSA vial accountability will be maintained to document chain of custody from Sanaria, 
Inc., to study site. An inventory to account for number of vials used will be recorded and kept in 
the study file. 
 Control Product 
Sterile isotonic (0.9%) normal saline will be procured in the US and shipped to Mali at ambient 
temperature. Like the product, normal saline is a clear liquid, making it indistinguishable from 
the study product when drawn up into a syringe. Normal saline will be used as a placebo, rather 
than a comparator vaccine being used, as currently there are no licensed vaccines available as IV 
formulations.  
 Storage and Handling 
The normal saline is stored at room temperature in a controlled room per product standards. Each 
normal saline vial can either be single use or multi-use over a period of a few hours (i.e. the 
duration of vaccine preparation on a given day). 

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 Disposition and Dispensation 
The clinical site must confirm and document that the vials of normal saline have been 
transported and stored within specified ranges.  
 Administration and Dosage 
Normal saline will be administered DVI as placebo in an equal volume to the study product. 
 Accountability 
Normal saline accountability will be maintained to document chain of custody from Sanaria, 
Inc., to study site. An inventory to account for number of vials dispensed for each subject 
injection will be recorded and kept in the study file. 
 Antimalarial Drugs  
All antimalarial medications used for the study will be maintained at the study site and 
administered by direct observational therapy. Coartem tablets will be purchased from 
commercial sources and provided by the MRTC study team to subjects. Drug accountability will 
be managed by the site clinical team. 
 Preparation and Administration 
Coartem will be provided as tablets for oral administration. Administration is under direct 
observation by study staff according to dosing parameters. 
 Storage and Handling 
Coartem tablets will be maintained in the manufacturer’s original packaging and stored at the 
clinic under recommended storage conditions until prepared for dispensing. 
 Return of Study Product 
Final accountability of drug supplies will be performed at the conclusion of the study. Final 
disposition of any remaining Coartem will be determined and documented. 
 Drugs used for Pre-emptive Treatment of Malaria 
During this study, all Arms will receive pre-emptive antimalarial treatment prior to 3rd injection 
and 4th injection.  
Artemether/lumefantrine (Coartem®) is a licensed antimalarial in the US and Mali for use for 
uncomplicated malaria. It has an excellent safety profile and is widely used to treat malaria. 
Subjects who may have any contraindications to the use of these drugs will be excluded at 
screening. The most common side effects reported in adults are: headache, anorexia, dizziness, 
asthenia, arthralgia and myalgia. 
 Drugs Used for Management of Clinical Malaria 
In accordance with the Malian Government treatment guidelines, volunteers will be treated with 
artemether/ lumefantrine (Coartem®, 80mg/480mg per dose). Artemether/lumefantrine is a 
licensed antimalarial in the US and Mali for use for uncomplicated malaria. It has an excellent 
safety profile and is widely used to treat malaria. Subjects who may have any contraindications 
to the use of these drugs will be excluded at screening. The most common side effects reported in 
adults are: headache, anorexia, dizziness, asthenia, arthralgia and myalgia.  

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Clinical or symptomatic malaria for this study is defined as the presence of asexual P. 
falciparum parasites at any parasitemia level with either an axillary temperature of 37.5 °C or 
more or one or more of the following symptoms: headache, myalgia, arthralgia, malaise, nausea, 
dizziness, or abdominal pain and will be reported as an AE. 
 Contraindications to Vaccination  
The following criteria should be checked prior to each injection and are contraindications to 
further injections:  
• Hypersensitivity reaction following administration of the study product (PfSPZ Vaccine 
or placebo) 
• Positive urine or serum β-hCG test prior to injection in women 
 
Subjects will be encouraged to remain in the safety evaluation for doses already received. 
 Indications for Deferral of Vaccination  
If any of the following AEs occurs at the time of the scheduled injection (vaccination with PfSPZ 
Vaccine or normal saline), the subject may be either vaccinated at a later date within the 
allowable visit window as specified in the protocol or withdrawn at the discretion of the 
Investigator: 
• 
Oral temperature >37.5˚C at the time of injection will warrant deferral of injection until 
fever resolves (within protocol-defined window). 
• 
Any other condition that in the opinion of the Investigator poses a threat to the individual 
if vaccinated or that may complicate interpretation of the safety of vaccine following 
vaccination. 
Such individual(s) will be followed in the clinic until the symptoms resolve or the window for 
injection expires. No further injections will be performed if the subject does not recover 
(temperature ≤ 37.5˚C and/or lack of symptoms) or develops a chronic condition deemed unsafe 
for future injections. The subject will be monitored for safety and immunogenicity for at least 3 
months after their last injection (PfSPZ vaccine or normal saline) unless the subject has 
withdrawn consent. If the subject does not receive any further vaccinations, then some scheduled 
safety blood draws may not be performed at the discretion of the PI. Blood draws scheduled to 
measure immune response may be obtained if possible.  
 Prohibited Medications 
Treatment with some medications/procedures may potentially interfere with vaccine-induced 
immunity and/or interpretation of study endpoints. Use of any of the potentially interfering 
medications/procedures during the study may exclude a subject from receiving further doses of 
the study vaccine. However, the subject will be encouraged to remain in the study for safety 
evaluations. The following medications/procedures will not be permitted or may result in the 
withdrawal of the study subject: 
• Licensed killed vaccines in the 2-week period prior to and following each vaccination or 
licensed live vaccines in the 4-week period prior to and following each vaccination; 
• Receipt of immunoglobulins and/or any blood products up to six months prior to the first 
vaccination and for 30 days after administration of the last dose of vaccine; 

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• Chronic oral or IV administration (≥ 14 days) of immunosuppressive doses of steroids, 
i.e., prednisone >10 mg per day, immunosuppressants, or other immune-modifying drugs 
from each day of vaccination to two weeks following each vaccination; 
• Any investigational drug or investigational vaccine other than the study vaccine during 
the study period; and 
• Surgical removal of the spleen or the development of a hematologic or other disease that 
would interfere with normal immunity. 
Medications, such as acetaminophen or ibuprofen, may be used to help relieve symptoms from 
vaccination and are not considered prohibited. All concomitant prescription medications, over-
the-counter medications and non-prescription medications taken at the time of adverse events (all 
grades) or for other reasons, will be documented into the case report form (CRF). 
Subjects are encouraged to contact study clinicians for any medical issues and consult 
with study clinicians prior to taking any medications not prescribed by the study clinician. Any 
medications taken by study subjects will be reviewed at every scheduled and unscheduled study 
visit with study staff. If a new medication has been started since the prior visit, then its potential 
to interact with any prescribed intervention in the study and/or interfere with the performance of 
the clinical trial will be assessed on a case by case basis.  
If the medication is needed for the health of the study subject and is contraindicated or 
cautioned with protocol-defined antimalarial treatment, alternative antimalarial treatments will 
be made available to the study subject if clinically indicated. If the medication is needed for the 
health of the subject and might interfere with the vaccine by posing a safety risk to the subject, 
then the study subject should be withdrawn from further vaccinations and followed for safety. 
Use of antimalarial medications or antibiotics that have antimalarial activity administered during 
the study period is not exclusionary but will be documented by clinical staff and will be taken 
into consideration during data analysis.  
When possible, study subjects should review their plans to electively initiate a new 
medication with study staff before starting that medication; however, medical treatment will 
never be withheld or delayed due to concerns regarding its effect on the execution of the clinical 
trial.  
6 STUDY POPULATION 
The study population will consist of healthy adults aged 18 – 35 years, who reside in 
Ouelessebougou and surrounding villages in Mali.  
 Clinical Site 
The study will be carried out in collaboration between the Laboratory of Malaria Immunology 
and Vaccinology (LMIV) (National Institute of Allergy and Infectious Diseases [NIAID], 
National Institutes of Health [NIH]), the Malaria Research and Training Center (MRTC) in 
Bamako, Mali, and Sanaria, Inc. MRTC is experienced in conducting Good Clinical Practice 
(GCP) compliant clinical trials including two malaria vaccine and drug studies. 
The study will be carried out in Ouelessebougou and surrounding villages, a community 
located 80 km south of Bamako. Ouelessebougou village has been conducting ongoing clinical 
research since 2006 and is endemic for malaria with marked seasonality and a high burden of 
malaria in both children and adult populations.  
For the purpose of vaccine trials, adequate facilities for conducting an interventional trial 
have been put in place at Ouelessebougou within walking distance to the residents’ homes. The 

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study site has a research clinic with an inpatient unit. Study physicians are available 24 hours a 
day, seven days a week.  
At Ouelessebougou, the malaria transmission is highly seasonal, with the transmission 
season taking place from June until December, with peak transmission in August to November. 
Ouelessebougou is situated in a high transmission area, with entomological inoculation rates 
using CDC light traps of about seven infectious bites per person over the period of August to 
December (Dicko et al., 2011). Malaria parasite prevalence during the transmission season varies 
between 20-30% in adults (unpublished data).  
 Recruitment 
Community permission will be obtained from village elders and other community members after 
explanation and discussion of the study at a community meeting (see Section 6714.2.1). A 
general announcement inviting household and family members to the participating clinic to learn 
about the study will be made at the time of community permission, using local radio or any 
traditional channel of communication. 
 Inclusion Criteria in the main phase and booster phase 
Subjects must fulfill all the following criteria to be eligible for the study: 
1. Age ≥ 18 and ≤ 35 years (For booster phase, age ≥ 18 and ≤ 37 years) 
2. Able to provide proof of identity to the satisfaction of the study clinician completing the 
enrollment process 
3. In good general health and without clinically significant medical history 
4. Willing to have blood samples stored for future research 
5. Available for the duration of the study 
6. Females of childbearing potential must be willing to use reliable contraception (as 
defined below) from 21 days prior to Study Day 1 to 28 days after 3rd  vaccination. (For 
the booster phase, from 21 days prior to the booster vaccination to 28 days post booster 
vaccination).  
• 
Reliable methods of birth control include: 
▪ one of the following: confirmed pharmacologic contraceptives 
(parenteral) delivery; intrauterine or implantable device. OR  
▪ two of the following: a documented oral or transdermal or vaginal ring 
contraceptives; PLUS condoms with spermicide or diaphragm with 
spermicide. 
• 
Note- Coartem (artemether specifically) may reduce the effectiveness of 
systemic hormonal contraceptives, therefore additional barrier methods such as 
condoms must also be used during the 3 days of Coartem dosing. 

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• 
Women who are not able to get pregnant will also be required to report date of 
last menstrual period, history of surgical sterility (i.e. tubal ligation, 
hysterectomy) or premature ovarian insufficiency (POI), and will have urine or 
serum pregnancy test performed per protocol. 
7. Enrolled in protocol # 18-I-N084 and are enrolled in the active follow up phase of the 
study (For the booster phase only)  
8. Malaria comprehension exam completed, passed (a score of ≥80% or per 
investigator’s discretion) and reviewed prior to enrollment 
 
 Exclusion Criteria in the main phase and booster phase 
A subject will be excluded from participating in the trial if any one of the following criteria is 
fulfilled: 
1. 
Pregnancy, as determined by a positive urine or serum human chorionic gonadotropin 
(β-hCG) test (if female) 
NOTE: Pregnancy is also a criterion for discontinuation of any further dosing or non-
safety related interventions for that subject. 
2. 
Currently breast-feeding (if female) 
3. 
Behavioral, cognitive, or psychiatric disease that in the opinion of the investigator 
affects the ability of the participant to understand and comply with the study protocol 
4. 
Hemoglobin (Hb), WBC, absolute neutrophils, and platelets outside the local laboratory-
defined limits of normal (subjects may be included at the investigator’s discretion for 
‘not clinically significant’ values) 
5. 
Alanine transaminase (ALT) or creatinine (Cr) level above the local laboratory-defined 
upper limit of normal (subjects may be included at the investigator’s discretion for ‘not 
clinically significant’ values) 
6. 
Infected with human immunodeficiency virus (HIV), hepatitis C virus (HCV), or 
hepatitis B (HBV) (For the booster phase: re-testing NOT required for enrollment unless 
clinically indicated) 
7. 
Known or documented sickle cell disease by history (Note: known sickle cell trait is 
NOT exclusionary) 
8.    Clinically significant abnormal electrocardiogram (ECG) such as abnormal QTc. (For 
the booster phase: re-testing NOT required for enrollment unless clinically indicated) 
9.    Evidence of clinically significant neurologic, cardiac, pulmonary, hepatic, endocrine, 
rheumatologic, autoimmune, hematological, oncologic, or renal disease by history, 
physical examination, and/or laboratory studies including urinalysis 
10. History of receiving any investigational product within the past 30 days 
11. Participation or planned participation in a clinical trial with an investigational product 
prior to completion of the follow-up visit 28 days following last vaccination OR planned 
participation in an investigational vaccine study until the last required protocol visit 
12. Medical, occupational, or family problems as a result of alcohol or illicit drug use during 
the past 12 months 
13. History of a severe allergic reaction(Grade 3 or higher or per PI discretion) or 
anaphylaxis  

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14. Severe asthma (defined as asthma that is unstable or required emergent care, urgent care, 
hospitalization, or intubation during the past two years, or that has required the use of 
oral or parenteral corticosteroids at any time during the past two years) 
15. Pre-existing autoimmune or antibody-mediated diseases including but not limited to: 
systemic lupus erythematosus, rheumatoid arthritis, multiple sclerosis, Sjögren’s 
syndrome, or autoimmune thrombocytopenia 
16. Known immunodeficiency syndrome (For the booster phase: re-assssment NOT required 
for enrollment) 
17. Known asplenia or functional asplenia (For the booster phase: re-assssment NOT 
required for enrollment) 
18.  Use of:  
• Chronic (≥14 days) oral or IV corticosteroids (excluding topical or nasal) at 
immunosuppressive doses (i.e., prednisone >10 mg/day) or immunosuppressive drugs 
within 30 days of vaccination 
• Artemether/lumefantrine within 14 days of vaccination unless it has been prescribed 
by the study investigator as part of study procedures 
• Other antimalarials or systemic antibiotics with known antimalarial activity within 5 
drug half-lives  prior to the first vaccine (such as artemether, sulfadoxine-
pyrimethamine, trimethoprim-sulfamethoxazole, doxycycline, tetracycline, 
clindamycin, erythromycin, ciprofloxacin, other fluoroquinolones or azithromycin) 
 
19. Receipt of a live vaccine within the past four weeks or a killed vaccine within the past 
two weeks prior to Vaccination #1 and every subsequent vaccination day 
20. Receipt of immunoglobulins and/or blood products within the past six months 
21. Previous receipt of an investigational malaria vaccine in the last five years (For booster 
phase: NOT required for enrollment) 
22. Known allergies or other contraindications against Coartem 
23.  Other condition(s) that, in the opinion of the investigator, would jeopardize the safety or 
rights of a participant participating in the trial, interfere with the evaluation of the study 
objectives, or would render the subject unable to comply with the protocol 
 
 Justification for the Exclusion of Pregnant Women 
This study will not enroll pregnant and/or breastfeeding women since the effects of PfSPZ 
Vaccine on the developing human fetus are unknown.  
Artemether/lumefantrine is considered a category C medication, there are no adequate 
studies in pregnant women hence only recommended for use if the potential benefit justifies the 
potential risk to the fetus. However, if a woman becomes pregnant after enrollment she may 
continue in the study for safety follow up, malaria infection evaluation and reduced vaccine 
immunogenicity assays as described in Appendix A and as outlined in Section 15.7. 
 
 Justification for Exclusion of Children 
Children are excluded from this study because there is insufficient data on dosing or adverse 
events available in children at the PfSPZ Vaccine doses proposed to be used in this study. 

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Studies evaluating the safety, tolerability and immunogenicity of various doses of PfSPZ 
Vaccine are ongoing. 
 
 

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7 STUDY SCHEDULE 
 Screening 
The purpose of the screening visit is to determine subject eligibility for study participation. 
Screening procedures include the informed consent process, Malaria Comprehension Exam, 
laboratory assessments (completed within 56 days of receipt of first and fourth vaccination) and 
clinical assessments. Screening activities can occur over multiple visits if necessary, including 
the day of enrollment.  
In the event that a chronic illness and/or HIV, HBV, or HCV is discovered during the 
course of screening, long-term treatment and care will not be reimbursed by the study, but 
referral for continuing care can be provided to subjects.  
 
Per national requirements for reporting communicable diseases, confirmed positive test results 
for HIV, HBV, and HCV will be reported to the local health department according to applicable 
laws and appropriate medical referrals initiated. 
 
The following actions must be completed as part of the screening process for all subjects within 
the 56 days prior to first and fourth vaccination:  
• Explain the study and informed consent document to the subject (For the booster 
phase, informed consent can be signed within 90 days prior to the 4th vaccination). 
• Ensure the subject has acknowledged consent by signing or fingerprinting the 
informed consent document. Ensure that the subject receives a signed copy of the 
informed consent. 
• Ensure the subject has correctly answered ≥80% of the questions (see Section 
14.2.2) on the Malaria Comprehension Exam.  
• Elicit a complete medical history, including menstrual and contraceptive history 
and/or history of surgical sterility for females, and medication use. 
• Confirm that females of childbearing potential are willing to use reliable 
contraception from at least the period from screening through 28 days after the 
third vaccination in the main phase. For the booster phase, use of reliable 
contraception should be at least 21 days prior to vaccination up to 28 days after 
the fourth vaccination.   
• Administer a complete physical examination, including vital signs (height, 
weight, blood pressure, temperature, and heart rate). 
• Complete HIV pre- and post-test counseling as indicated, including follow-up 
contact with subject to report the results and referral for appropriate medical care 
if indicated. 
• Obtain approximately 10 mL of blood for complete blood count (CBC) with 
differential and platelet count, ALT, creatinine (Cr), hepatitis B testing, hepatitis 
C testing, HIV testing, hemoglobinopathy testing (For the booster phase: HIV, 
hepatitis B, and hepatitis C testing will only be repeated if clinically indicated; 
hemoglobinopathy testing will not be repeated). 
• Obtain urine (or serum) for pregnancy testing (for females) and urinalysis/urine 
dipstick for protein and blood. 
• Obtain a 12-lead ECG (For booster screening: an ECG will only be repeated if 
clinically indicated). 

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Sickle cell testing will be completed retrospectively. History of known sickle cell disease is an 
exclusion at the time of enrollment. Discovery of sickle cell disease (HbSS) on subsequent 
laboratory testing will not result in the subject being withdrawn from the study. 
 
Final eligibility will be determined at this point. The subject may be excluded by any of the 
above procedures if they meet the exclusion criteria. Acceptable ranges for hematological and 
biochemistry parameters defined for this study are given in Appendix B. (Note: parasitemia is 
not an exclusion criterion.)  
 
If an abnormal finding is determined to be clinically significant, the subject will be informed, a 
referral letter will be issued, and the subject will be guided as to where to present for further 
investigation and medical care. Treatment for minor ailments may be provided by study 
clinicians at the study site. Decisions to exclude the subject from enrollment in the trial or to 
withdraw the subject from the trial will be at the discretion of the investigator. 
 
 Assignment of Groups 
Enrollment in the main phase occurs with collection of baseline study samples on study Day -
14. Randomization will occur prior to enrollment, prior to or on study Day -14. Randomization 
of the subjects in Arm 1 and 3a will occur first as these subjects will be enrolled first. 
Randomization of Arm 2 and 3b will occur together later prior to enrollment. If a subject was 
randomized into group 1 or 3a but was not vaccinated, they may be randomized into groups 2 
and 3b if still eligible. 
If a subject withdraws from the study after randomization, they can be replaced by 
another subject at random if withdrawal happens prior to receipt of first vaccination. Once a 
subject has received their first vaccination, they cannot be replaced.  
For the booster phase, enrollment will occur at the receipt of the first dose of 
artemether/lumefantrine prior to vaccination. Enrolled subjects cannot be replaced. 
During the study, the list linking randomization numbers to study product (PfSPZ 
Vaccine or control) will be made available only to the study statistician and associated team 
members, pharmacy team/syringe preparers (at the start of the study), independent safety monitor 
(if needed to review as outlined in Section 11.15.2), and DSMB chair (if needed for closed 
session unblinded review). On vaccination days, the vaccines associated with each 
randomization number will be obtained from the pharmacist. 
To ensure proper identification of study subjects, following subject enrollment all subjects 
will receive an identification card with their photo on it to present at the clinic with each study 
visit. 
 Detailed Study Procedures 
Detailed study procedures are outlined in Appendix A of the protocol. 
 
 

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8 STUDY PROCEDURES/EVALUATIONS 
 Photographs of Rash or Injection Site Reactions 
If a subject develops a rash or injection site reaction, photographs may be taken by the 
investigators. These photographs will not include the subject’s face or any identifying scars, 
marks, or tattoos. 
 Clinical Laboratory Testing 
Using standard techniques, the clinical laboratory will perform the following tests: 
1. Complete blood count (CBC) plus white blood cell (WBC) differential and platelet count 
• The following CBC parameters will be assessed for safety throughout the trial: WBC, 
absolute neutrophil count (ANC)/absolute granulocyte count (AGC), hemoglobin 
(Hb), and platelet count. 
2. Serum creatinine (Cr) 
3. Alanine aminotransferase (ALT) 
4. HBsAg test (can include rapid diagnostics, ELISA, PCR if indicated) (at screening only 
in the main phase. For the booster phase, ONLY if clinically indicated) 
5. HCV test (can include rapid diagnostics, ELISA, PCR if indicated) (at screening only in 
the main phase. For the booster phase, ONLY if clinically indicated) 
6. HIV test (can include rapid diagnostics, ELISA, Western Blot if indicated) (at screening 
only in the main phase. For the booster phase, ONLY if clinically indicated) 
7. Urine dipstick and/or Urinalysis (at screening for the main and booster phases only) 
8. Urine and/or serum pregnancy testing (β-hCG) 
Additional clinical testing includes the following but will be completed retrospectively by 
other laboratories as noted below: 
1. Hemoglobinopathy testing - testing for normal adult hemoglobin (HbAA), hemoglobin c 
trait (HbCC), hemoglobin sickle cell trait (HbAS), hemoglobin sickle cell disease (HbSS)  
 
 Electrocardiogram 
 Electrocardiogram for the Study 
Electrocardiograms (12-lead ECGs) will be performed during screening in the main phase and as 
needed throughout the study and will be read by the study site physician in Mali, a Mali 
cardiologist or NIH study cardiologist or their representative. Subjects with QT interval (QTc) > 
460 ms may be excluded as Coartem may prolong QTc. Subjects with clinically significant 
abnormalities will also be excluded from the study. 
 Malaria Diagnostics 
 Malaria Blood Smears 
The gold standard for malaria diagnosis and evaluation of VE endpoints is the detection of 
malaria parasites on Giemsa-stained thick blood films. Blood films will be prepared at the 
specified time points or when clinically indicated and will be examined by technicians with a 
documented experience in slide reading following the SOP established for malaria slide reading 

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within the MRTC (Guindo et al., 2012), and in consideration of the modifications suggested for 
CHMI trials (Laurens et al., 2012).  Slides are considered positive if at least two unambiguous 
P.falciparum parasites per slide are identified and confirmed by a second microscopist. Positive 
results will be reported promptly to the study Principal Investigator or designee. 
Thick blood smears will be prepared from the blood remaining in the IV cannula, or (at 
time points when no IV blood collection is planned) from a finger prick sample. The smears will 
be examined microscopically. 
Thick blood smears will be used for diagnosis throughout the study. 
 Malaria qPCR 
While detection of parasites on thick blood smears remains the most common primary endpoint 
in human challenge trials, both PCR- and nucleic acid sequence-based amplification (NASBA)- 
based methods have been increasingly used to support blood smear data in malaria vaccine trials 
(M. Walther et al., 2005; M. Walther et al., 2006). These research molecular assays have 
significantly increased sensitivity for detection of P. falciparum blood-stage infection 
approaching 20 parasites/mL, often resulting in diagnosis 2-4 days earlier than by paired thick 
blood smears (Hermsen et al., 2001; Schneider et al., 2004; M. Walther et al., 2005). 
Quantification of parasite density by these methods allows evaluation of parasite growth curves 
for assessing the utility of partially-effective vaccine candidates. LMIV has also developed a 
research qPCR that detects 18s of P. falciparum with a detection limit of at least 20 parasites/mL 
that will be used during the study for comparison to traditional thick blood smears.  
P. falciparum qPCR may be performed from all scheduled visits with a malaria blood smear 
noted (see Appendix A) to capture infections that remain below the detection limit for 
microscopy. For subject convenience, a finger prick sample can be used for both preparation of 
the microscopy slide and for DNA preservation. 
 Unscheduled Blood Smear Positive Visits 
Each time a subjects has detected P falciparum malaria parasites on thick blood smear (whether 
or not they were symptomatic; scheduled or unscheduled visits), he/she will be asked to the 
clinic to provide an additional blood sample within 24 hours of the clinic visit (the next calendar 
day) for the following as seen in Appendix A: 
• 0.5 mL ethylene diamine tetraacetic acid (EDTA) microtainer: for whole blood ex-
vivo assays if sample not obtained within the last two days of the positive blood 
smear .(For the booster phase, only collect if the sample has not been obtained within 
the last 7 days). 
• 4 mL EDTA tube: to obtain RNA and DNA for the study of host and parasite 
transcriptome (RNA) and parasite genotype (DNA) and to obtain plasma for 
proteomics studies if sample not obtained within the last 28 days of the positive blood 
smear  
• 0.5 mL for qPCR if sample not obtained within the last two days of the positive blood 
smear (For the booster phase, NOT required) 
Note: if a blood smear is positive for P.falciparum, documentation in a smear positive 
CRF is required whether these additional samples were collected or not. 

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 Immunologic Laboratories 
As indicated in the objectives, assays will be conducted to assess immunogenicity in addition to 
safety as described above. Laboratory assays to assess immune response to PfSPZ Vaccine will 
be performed at the LMIV, NIAID, NIH, Sanaria Inc, and NIH Center for Human Immunology 
according to standard laboratory procedures. 
These assays include: 
1. Binding ELISA for antibodies to P. falciparum liver stage and blood stage antigens 
(which includes but not limited to: CSP, sporozoite surface protein 2, liver stage 
antigen 1, erythrocyte binding antigen 175, merozoite surface protein 1, merozoite 
surface protein 5, and exported protein 1 [PfCSP, PfLSA-1, PfEBA-175, PfMSP-1, 
PfMSP-5, malaria protein EXP-1] 
2. (IFN-γ) ELISPOT assay and multi-parameter flow cytometry with intracellular 
cytokine staining on peripheral blood mononuclear cells in P. falciparum liver- stage 
antigens (CSP, LSA-1) and PfSPZ  
3. B and T cells studies to analyze immunologic responses  
Sanaria, Inc. will also assess antibodies to whole PfSPZ by immunofluorescence assay (IFA) and 
inhibition of sporozoite invasion assay (ISI) and to asexual erythrocytic stage parasites by IFA as 
described (Epstein et al., 2011; Seder et al., 2013) and also by protein microarrays (Antigen 
Discovery Inc).  
In addition, using plasma, sera, peripheral blood mononuclear cells, or their component 
parts (e.g., purified IgG), Naval Medical Research Center will perform assays of humoral and 
cellular immunity that may be associated with protective activity. 
Laboratory assays to assess immune responses to novel pre-erythrocytic antigens will be 
performed in the PEVA Consortium laboratories at the LMIV, NIAID, and NIH according to 
standard laboratory procedures. The target proteins are novel antigens that confer protection 
against liver stage malaria in rodent malaria models (P. yoelii, P. berghei) according to 
vaccination studies conducted by Seattle BioMed and LMIV. The novel antigens to be used for 
these laboratory assays include PFL1995c, PFE0305w, LISP1 (PF14_0179), SAP1 (PF11_0480), 
MAL7P1.164, PF14_0113, using the identifiers in the PlasmoDB database (www.plasmodb.org). 
These antigens were initially selected on the basis of their gene expression during early liver 
stage development of P. falciparum, and preliminary testing shows that these antigens are 
immunologically recognized by individuals previously exposed to P. falciparum. The potential 
utility of these antigens as pre-erythrocytic vaccines has been supported by animal studies, 
wherein orthologues of these genes incorporated in DNA vaccines induce protective immunity in 
mice that significantly reduces the liver stage development of P. berghei and P. yoelii parasites. 
The assays included in this study can confirm that individuals receiving CVac with PYR develop 
immune responses to pre-erythrocytic antigens and can provide additional data by which to 
assess the potential for these antigens to be developed as subunit vaccines to prevent infection. 
The long-term objective of the PEVA consortium is to identify antigens that individually, or in 
combination with CSP or other antigens, will induce a high level of pre-erythrocytic immunity 
that is protective against P. falciparum. 
 
The assays to be performed include: 
1. Binding ELISA for antibodies to P. falciparum pre-erythrocytic antigens (PFL1995c, 
PFE0305w, LISP1 (PF14_0179), SAP1 (PF11_0480), MAL7P1.164, PF14_0113) 

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2. IFN-γ ELISPOT/Intracellular cytokine staining (ICS) assay on peripheral blood 
mononuclear cells in P. falciparum pre-erythrocytic antigens (PFL1995c, PFE0305w, 
LISP1 (PF14_0179), SAP1 (PF11_0480), MAL7P1.164, PF14_0113)  
 
 Transcriptomic analysis  
Whole genome transcriptional profiling will be performed to explore possible gene expression 
profiles or pathways that predict optimal responses to vaccination. Gene expression profiling 
following vaccination will allow the predictive capacity of eventual protected and unprotected 
vaccinees, and thus will assist in defining the correlates of protection induced by vaccination. 
Transcriptional analyses will be performed on whole blood collected as outlined in Appendix A. 
Blood will be collected via venous puncture and placed in PAXGene tubes to preserve RNA 
integrity until the RNA is extracted. The molecular profiling encompasses the identification of 
RNA transcripts present in all humans, which are induced or repressed after each vaccination. 
This does not represent genetic testing of individuals or their DNA. 
 
9 RESEARCH USE OF STORED HUMAN SPECIMENS 
Intended Use: Samples and data collected under this protocol will be used to study malaria and 
related diseases and possible adverse reactions to vaccination.  
 
Storage: Access to stored research samples will be limited using either a locked room or a 
locked freezer. Temporary storage of samples collected in Mali, prior to shipment to LMIV, may 
occur at the Core Immunology Laboratory or the MRTC CAP laboratory. Samples will be stored 
at the LMIV in Rockville, MD or at LMIV’s designated repository, Thermo Scientific, 
Rockville, MD, with the exception of retention specimens which may be kept at the MRTC in 
Mali for quality control. Samples and data will be stored using codes assigned by the 
investigators or their designees. Data will be kept in password-protected computers. Only 
investigators or their designees will have access to the samples and data.  
 
Tracking: Samples will be tracked using a sample-tracking software program, e.g., 
Freezerworks.  
 
Disposition at the Completion of the Protocol: In the future, other investigators (both at the 
NIH and outside) may wish to study these samples and/or data. In that case, Institutional Review 
Board (IRB) approval must be sought prior to any sharing of samples. Any clinical information 
shared about the sample with or without patient identifiers would similarly require prior IRB 
approval.  
At the completion of the protocol (termination), samples and data will either be destroyed 
or, after IRB approval, transferred to another existing protocol.  
 
Reporting the Loss or Destruction of Samples/Specimens/Data to the IRB: Any loss or 
unanticipated destruction of samples (for example, due to freezer malfunction) or data (for 
example, misplacing a printout of data with identifiers) that meets the definition of Protocol 

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Deviation and/or compromises the scientific integrity of the data collected for the study, will be 
reported to the NIAID IRB. 
Consent to allow long term storage of study samples is a part of the inclusion criteria for this 
study. However, if a subject decides following enrollment not to have their samples stored, the PI 
or designee will destroy all known remaining samples and report this destruction to the subject 
and the NIAID IRB and Faculty of Medicine, Pharmacy and Odonto-Stomatology Ethics 
Committee (FMPOS EC). This decision will not affect the subject’s continued participation in 
this protocol or any other protocols supported by the NIH. 
 
 

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10 DATA SHARING PLAN 
In NIH's view, all data should be considered for data sharing. Data should be made as widely and 
freely available as possible while safeguarding the privacy of subjects, and protecting 
confidential and proprietary data. We recognize that the public dissemination of our scientific 
results can facilitate the creation of collaborative efforts with domestic and international 
collaborators. Furthermore, we recognize that the proposed project may result in novel ideas for 
new methods, technologies, and data that could benefit the entire research community. 
Therefore, final research data will be shared openly and timely in accordance with the most 
recent NIH guidelines (http://grants.nih.gov/grants/policy/data_sharing/) while being mindful 
that the confidentiality and privacy of participants in research must be protected at all times. 
Timelines for distribution of data will vary depending on any required restrictions in accordance 
with federal and/or institutional policies and guidelines. In general, we expect de-identified data 
will be available through NIH-funded or approved public repository, speaking engagements and 
publications, presentations at scientific symposia and seminars. Effort will be made to publish 
our research findings in scientific journals. All final peer-reviewed manuscripts that arise from 
this proposal will be submitted to the digital archive PubMed Central. For tools, reagents, data 
and model organisms generated by the proposed study, pending third parties’ rights, LMIV will 
transfer materials to outside researchers in both the private and public sectors under a Material 
Transfer Agreement or Research Collaboration Agreement.  
 
11 ASSESSMENT OF SAFETY 
 Documenting, Recording, and Reporting Adverse Events 
At each contact with the subject, information regarding adverse events will be elicited by 
appropriate questioning and examinations and will be: 
• immediately documented in the subject’s medical record/source document, 
• recorded on the Adverse Event Case Report Form (AE CRF) or electronic database, 
and 
• reported as outlined below (e.g., IND sponsor, IRB, FDA). 
A study clinician will be available during the study period and will be available to the study 
subjects at all times. Should a subject call a study clinician to report an AE, it will be discussed 
with the PI and documented, recorded, and reported appropriately. 
  Definitions 
Adverse Event (AE): An AE is any untoward or unfavorable medical occurrence in a human 
subject, including any abnormal sign (e.g., abnormal physical exam or laboratory finding), 
symptom, or disease, temporally associated with the subject’s participation in the research, 
whether or not considered related to the research. 
Adverse Reaction (AR): An AR is an adverse event that is caused by an investigational agent 
(drug or biologic). 
 
Suspected Adverse Reaction (SAR): A SAR is an adverse event for which there is a reasonable 
possibility that the investigational agent caused the adverse event. ‘Reasonable possibility’ 
means that there is evidence to suggest a causal relationship between the drug and the adverse 

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event. A suspected adverse reaction implies a lesser degree of certainty about causality than 
adverse reaction which implies a high degree of certainty. 
 
Serious Adverse Event (SAE): A SAE is defined as an AE that results in any of the following 
outcomes: 
• 
death 
• 
life threatening (i.e., an immediate threat to life) 
• 
inpatient hospitalization or prolongation of an existing hospitalization 
• 
persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
• 
congenital anomaly/birth defect 
• 
medically important event 
Medical and scientific judgment will be exercised in deciding whether expedited reporting is 
appropriate in other situations, such as important medical events that may not be immediately 
life threatening or result in death or result in hospitalization but may jeopardize the subject or 
may require intervention to prevent one of the other outcomes listed above.  
 
Unexpected Adverse Event: An AE is considered unexpected if it is not listed in the 
Investigator’s Brochure (IB) or Package Insert (for marketed products) or is not listed at the 
specificity or severity that has been observed. It is the responsibility of the IND sponsor to make 
this determination. 
Serious and Unexpected Suspected Adverse Reaction (SUSAR): A SUSAR is a SAR that is 
both serious and unexpected. 
 
Unanticipated Problem (UP): An UP is any event, incident, experience, or outcome that is 
1. unexpected in terms of nature, severity, or frequency in relation to 
a. the research risks that are described in the IRB-approved research protocol and 
informed consent document, IB, or other study documents; and 
b. the characteristics of the subject population being studied; and 
2. possibly, probably, or definitely related to participation in the research; and 
3. places subjects or others at a greater risk of harm (including physical, psychological, 
economic, or social harm) than was previously known or recognized.  
 
Unanticipated Problem that is not an Adverse Event (UPnonAE): An UPnonAE is an UP 
that does not fit the definition of an adverse event, but which may, in the opinion of the 
investigator, involve risk to the subject, affect others in the research study, or significantly 
impact the integrity of research data. Such events would be considered a non-serious UP. For 
example, we will report occurrences of breaches of confidentiality, accidental destruction of 
study records, or unaccounted-for study drug. 
 
New Onset of Chronic Illness (NOCI): A NOCI is defined as a diagnosis of a new medical 
condition that is chronic in nature, including those potentially controllable by medication (e.g., 
diabetes, asthma). Any NOCI will be recorded in the same manner as unsolicited AEs. 
 
Protocol Deviation: Any change, divergence, or departure from the IRB approved study 
procedures in a research protocol. Protocol deviations are designated as major  or minor. 

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      Major Deviations - Deviations from the IRB approved protocol that have, or may have the 
potential to, negatively impact, the rights, welfare or safety of the subject, or to substantially 
negatively impact the scientific integrity or validity of the study.  
 
      Minor Deviations - Deviations that do not have the potential to negatively impact the rights, 
safety, or welfare of subjects or others, or the scientific integrity or validity of the study. 
 
Noncompliance: Failure of investigator(s) to follow the applicable laws, regulations, or 
institutional policies governing the protection of human subjects in research or the requirements 
or determinations of the IRB, whether intentional or not  
 Investigator Assessment of Adverse Events 
If a diagnosis is clinically evident (or subsequently determined), the diagnosis rather than the 
individual signs and symptoms or lab abnormalities will be recorded as the AE.  
All solicited (see Table 6 below) and unsolicited AEs will be recorded through Day 7 after each 
injection. Injection site reactions will be assessed until Day 7 after injection (PfSPZ Vaccine or 
normal saline) or until resolved.  
 
After the periods specified above only unsolicited AEs, SAEs, UPs, and NOCIs will be recorded. 
 
Table 6: Solicited Adverse Events 
Laboratory adverse events1 
Hemoglobin (decreased hemoglobin) 
Platelet count (thrombocytopenia or 
thrombocytosis) 
WBC (leukopenia or leukocytosis) 
Creatinine (Cr) (increased Cr) 
ANC (neutrophil count decreased) or AGC 
(granulocyte count decreased) 
ALT (increased ALT) 
Local reactogenicity (secondary to PfSPZ Vaccine/normal saline) – through Day 7 post 
injection 
Injection site pain/tenderness 
Injection site induration 
Injection site erythema/redness 
Injection site swelling/edema 
Injection site pruritus 
Injection site bruising 
Systemic reactogenicity (secondary to PfSPZ Vaccine/normal saline ) – through Day 7 
post injection 
Rash 
Urticaria 
Generalized pruritus 
Generalized Edema 
Headache 
Fever or feverish 
Chills 
Malaise/Fatigue 
Myalgia 
Arthralgia 
Sweats 
Diarrhea 
Back Pain 
Chest Pain (non-musculoskeletal) 
Nausea/Vomiting 
Abdominal Pain 
1 Note absolute lymphocyte counts will be capture on CRFs for use for research assessments. If clinically significant 
changes as determined by PI, these may also be reported as AEs as noted below. 
 

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Any laboratory abnormalities (other than those specified as safety labs in the protocol  as defined 
by the values in the toxicity table) should be reported as AEs if they require intervention. 
Interventions include, but are not limited to, discontinuation of treatment, dose reduction/delay, 
additional assessments, or concomitant treatment. In addition, any medically important 
laboratory abnormality may be reported as an adverse event at the discretion of the investigator. 
This could include a laboratory result for which there is no intervention, but the abnormal value 
suggests a disease or organ toxicity. In addition, similar to solicited AEs, all laboratory AEs as 
defined in Appendix C, will be collected and graded for severity through 7 days after each 
vaccination until resolved. 
The Investigator will assess all AEs with respect to Seriousness (criteria listed above), Severity 
(intensity or grade), and Causality (relationship to study agent and relationship to research) 
according to the following sections in the protocol. 
 Severity 
Severity of AEs will be assessed by the investigator as described in Appendix B. AEs not 
included in the Appendices will be graded for severity using the followings definitions as seen in 
Table 7. 
Table 7: AE Severity Grading Definitions 
Severity 
Definition 
Grade 1 (Mild) 
No interference with activity, may use one 
dose of an over the counter medication 
Grade 2 (Moderate) 
Repeated use of non-narcotic pain reliever > 
24 hours or some interference with activity 
Grade 3 (Severe) 
Activities of daily living limited to <50% of 
baseline, medical evaluation/therapy required 
Grade 4 (Life-Threatening) 
Extreme limitation in activity, significant 
assistance required; immediate medical 
intervention or therapy required to prevent 
death 
Grade 5 
Death 
 
 Causality 
Causality (likelihood that the event is related to the study agent) will be assessed considering the 
factors listed under the following categories: 
Definitely Related 
• reasonable temporal relationship 
• follows a known response pattern 
• clear evidence to suggest a causal relationship 
• there is no alternative etiology 
Probably Related 
• reasonable temporal relationship 
• follows a suspected response pattern (based on similar agents) 
• no evidence of a more likely alternative etiology 
Possibly Related 

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• reasonable temporal relationship 
• little evidence for a more likely alternative etiology 
Unlikely Related 
• does not have a reasonable temporal relationship  
 
OR 
• good evidence for a more likely alternative etiology 
Not Related 
• does not have a temporal relationship 
 
OR 
• definitely due to an alternative etiology 
 
Note: Other factors will also be considered for each causality category when appropriate. 
Causality assessment is based on available information at the time of the assessment of the AE. 
The investigator may revise the causality assessment as additional information becomes 
available. 
 
The degree of certainty with which an AE can be attributed to administration of the study 
vaccine will be determined by how well the event can be understood in terms of one or more of 
the following: 
• The event being temporally related with vaccination or reproduced on re-vaccination; 
• A reaction of similar nature having previously been observed with this type of vaccine and/or 
formulation; 
• The event having been reported in the literature for similar types of vaccines; and/or 
• Whether or not there is another identifiable cause. 
 
All local (injection site) reactions will be considered causally related to vaccination. All malaria 
cases will be reported as not related to vaccination unless results indicate otherwise. 
Asymptomatic parasitemia (positive blood smears without related malaria clinical symptoms) 
will not be reported as an AE. Clinical malaria will be reported as an AE. 
Reports will further classify AEs as follows:  
• Related - all AEs that are assessed as definitely, probably, or possibly related. 
• Unrelated - all AEs assessed as unlikely or definitely not related. 
When reporting to regulatory authorities and IRBs is needed, AE relationship will be determined 
as noted above. 
 
 Investigator Reporting Responsibilities to the Sponsor 
 Adverse Events 
Line listings, frequency tables and other summary AE data will be submitted to the IND sponsors 
when needed for periodic safety reviews, review of IND annual reports, review of IND safety 
reports, and preparation of final study reports. 
 Serious Adverse Events 
All SAEs (regardless of relationship and whether or not they are also UPs) will be reported and 
sent to the IND sponsor by fax (SAE fax line: 240-306-0596) or email attachment. Deaths, 

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immediately life threatening and all possibly, probably or definitely related SAEs will be 
communicated by telephone, fax, email or automated report via the data management system by 
the PI within 24 hours of site awareness of occurrence to the IND sponsor. All other SAEs will 
be reported to the IND sponsor within three business days after the site becomes aware of the 
event. The PI must document that the communication is received and acknowledged. 
Sanaria, Inc.  
SAE Fax: 240-306-0596 
 
Individuals: 
1. Stephen L. Hoffman, M.D. 
  Tel: 240-403-2701(office)  
Tel: 240-299 3178 (mobile) 
Email: slhoffman@sanaria.com 
 
  2. Thomas L Richie, M.D., Ph.D. 
  Tel: 240-403-2727 (office) 
  Tel: 301-466-7943 (mobile) 
  Email: trichie@sanaria.com 
 
3. Tooba Murshedkar, MS 
  SAE Fax: 240-306-0596 
Email: tmurshedkar@sanaria.com 
 
In Mali – the clinical site investigator will also notify the LMIV PI and the site medical monitor 
in Mali by email, fax, or telephone within one working day of notification of an SAE occurrence. 
LMIV Contact Information: 
Patrick Duffy, MD 
Office 301 761 5089 
Fax 301 480 1962 
 
 
 
Email: Patrick.Duffy@nih.gov 
 
Independent Safety Monitor: 
Mamadou Dembele, MD 
Service Medicine Interne 
Centre Hospitalo-Universitaire du Point G 
+ 223 2022 5003 or mobile: +223 7604 93 87 
Email: hassiramadydembele@yahoo.fr 
 
 Unanticipated Problems (UPs) 
All UPs that are also adverse events will be reported to the IND sponsor on the NIH Problem 
Report Form sent by fax or email attachment no later than 7 calendar days of site awareness of 
the event.  
UPs that are not AEs will also be reported to the IND sponsor. 

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 Pregnancy 
Pregnancy itself is not an AE. However, complications of pregnancies are AEs and may be 
SAEs. Pertinent obstetrical information for all pregnancies will be reported to the IND sponsor 
and LMIV via fax or email within three business days from the site awareness of the pregnancy.  
Pregnancy outcome data (e.g., delivery outcome, spontaneous, or elective termination of the 
pregnancy) will be reported to the IND sponsor and LMIV within three business days of the 
site’s awareness of the outcome on a protocol-specified form.  
In the event of pregnancy, the following steps will be taken: 
• 
Discontinue the study agent 
• 
Unblind per the site unblinding procedures if the pregnancy occurs within 4 
weeks after the last vaccination.  
Note: If pregnancy occurs more than 4 weeks after the last vaccination, the 
subject should ONLY be unblinded if she meets the criteria for intentional, 
unscheduled unblinding in Section 11.4.  
• 
The subject will be withdrawn from receiving any further investigational products 
but will continue in follow-up for safety, malaria infection evaluation and 
modified immunogenicity assays as outlined in Appendix A. 
• 
Report to FMPOS EC as an informational item 
• 
Report to NIAID IRB as an informational item 
• 
Report to DSMB, Sponsor Medical Monitor, and Site Medical Monitor 
• 
Advise research subject to notify the obstetrician of participation in the study  
 Reporting Procedures to NIAID IRB and FMPOS EC 
 Reporting to the NIAID IRB 
UPs, non-compliance and other reportable events will be reported to the NIH IRB as per 
Policy 801.  
 
 Reporting to the FMPOS EC 
Events reported to the NIAID IRB will simultaneously be reported the the FMPOS EC. 
In addition, SAEs, related or not related to the research will be reported to the FMPOS 
EC  within 72 hours of investigator awareness, regardless of expectedness.  
 
 Additional Investigator Reporting Responsibilities to the Local IRB (NIAID 
IRB and FMPOS EC) 
Investigators are responsible for submitting any IND FDA Safety Reports and UP summaries 
that are received from the IND sponsor to their local IRB/EC. Investigators must also comply 
with all local IRB/EC reporting requirements. 
 Reporting to the Data and Safety Monitoring Board 
As agreed with the Office of Clinical Research Policy and Regulatory Operations (OCRPRO), a 
DSMB chartered by the IND sponsor, Sanaria, Inc. will be used for this study instead of the 
NIAID Intramural DSMB. 
The DSMB will review the study prior to initiation, after completion of the vaccination 
series and at study close (as outlined in Figure 5). Prior to the administration of the booster 

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vaccine, the DSMB will review the data from the main phase and the plans for the booster phase. 
The board may convene additional reviews as necessary, and will issue recommendations 
concerning continuation, modification, or termination of the study. All SAEs will be reported by 
the PI to the sponsor immediately upon becoming aware of them. All SAEs that are possibly, 
probably or definitely related to the study agent, UPs, and safety reports (as available) will be 
reported by the sponsor to the DSMB. 
The DSMB will review the study data to evaluate the safety, efficacy, study progress, and 
conduct of the study. The sponsor will notify the DSMB of any cases of intentional or 
unintentional unblinding as soon as possible. The sponsor will notify the DSMB at the time 
pausing criteria are met and obtain a recommendation concerning continuation, modification, or 
termination of the study. The PI will submit the written DSMB summary reports with 
recommendations to the IRB(s). 
 Follow-up Adverse Events and Serious Adverse Events 
AEs that occur following receipt of a single vaccination are followed until the final outcome is 
known or until the end of the study follow-up period.  
SAEs that have not resolved by the end of the follow-up period will be followed until the 
final outcome is known. If it is not possible to obtain a final outcome for an SAE (e.g., the 
subject is lost to follow-up), the reason a final outcome could not be obtained will be recorded by 
the investigator on the AE CRF (if the CRF is still open) and the SERF.  
SAEs that occur after the study follow-up period (six months following the last 
vaccination) that are reported to and assessed by the Investigator to be possibly, probably, or 
definitely related must be reported to the study IND sponsor as described above. 
 Sponsor’s Reporting Responsibilities 
SUSARs as defined in 21 CFR 312.32 and determined by the IND sponsor will be reported to 
FDA and all participating Investigators of related Sanaria trials as IND Safety Reports.  
The IND sponsor will also submit an IND Annual Report of the progress of the investigation to 
the FDA as defined in 21 CFR 312.33.  
 Pausing Criteria for the Study 
The PI will closely monitor blinded study data as they become available and will make 
determinations regarding the presence and grading of AEs. The AEs will be evaluated with 
regard to the known complications associated with administration of vaccine components. If a 
dose of vaccine is considered unacceptably reactogenic (as described in the following criteria), 
the study will be paused. No new enrollments and no further vaccinations will be administered 
by the investigators until reviewed by the DSMB and study IND sponsor. A report of DSMB 
recommendations will be submitted to the IRBs. The following criteria will be used to define 
unacceptable reactogenicity of the malaria vaccine (AEs that are possibly, probably, or definitely 
related to the vaccine will be considered “Related” and will be summarized as such): 
1. One or more subjects experience an SAE as defined in Section 11.4.2 of this protocol 
that is determined to be possibly, probably, or definitely related to the vaccine or placebo 
or 
2. One or more subjects experience a hypersensitivity reaction (e.g. anaphylaxis, diffuse 
urticaria) that is probably or definitely related to the vaccine or placebo; or 
3. Any severe clinical illness occurs that is not explained by a diagnosis that is unrelated to 
injection; or 

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4. Thirty percent of subjects in any dose arm experience the same Grade 2 or higher 
laboratory abnormality (see Appendix B), or Grade 3 systemic AE that is determined to 
be possibly, probably, or definitely related to the injection (PfSPZ Vaccine or placebo) as 
defined in this protocol or  
5. Ten percent of subjects in any arm experience Grade 3 or higher local reactogenicity; or 
6. Any safety issue that the study PI or IND sponsor determines should pause the study. 
 
The IRBs, the NIAID, the FDA, or other government agencies may discontinue the study at any 
time. Subsequent review of serious, unexpected, and related AEs by the DSMB or IRB, the IND 
sponsor, the FDA, and other regulatory authorities may also result in suspension of further 
administration of vaccine at the clinical site (or, in the case of the DSMB, a recommendation to 
the Sponsor that the study should be suspended). The FDA, other regulatory authorities, and the 
study sponsor(s) retain the authority to suspend additional enrollment and administration of 
vaccine for the entire study as applicable.  
 Reporting of Study Pausing 
If a pausing requirement is met, a description of the event(s) or safety issue will be reported by 
the PI or Site Investigator within one business day to the IND sponsor by fax or email. 
The site investigator will inform the LMIV PI, the ISM, and the local IRB that a pausing rule has 
been met according to their requirements. The LMIV PI will notify the NIAID IRB. The IND 
sponsor will notify the DSMB as well as all sites conducting Sanaria-sponsored studies, or 
studies using Sanaria related products that the study has been paused. 
 Resumption of a Paused Study 
The IND sponsor, in collaboration with the PI and DSMB will determine if it is safe to resume 
the study. The IND sponsor will notify the site investigators of this decision. The conditions for 
resumption of the study will be defined in this notification. The site investigator will notify their 
local IRB(s) of the study pause and of the decision to resume the study. 
 Pausing Criteria for a Subject  
The decision to suspend administration of the study agent(s) for a single subject or for all 
subjects in a specific group requires discontinuation of use of the study agent to any study 
subject(s) until a decision is made whether or not to continue study agent in the study.  
The pausing criteria for a single subject or for the subjects in this study include:  
• A subject experiences an SAE or ≥ 2 or more Grade 3 or greater AE (excluding 
laboratory assays) that is unexpected (as determined by the IND sponsor) and is possibly, 
probably, or definitely related to the study agent;  
OR 
• Any safety issue that the Site Investigator determines should pause administration of the 
study agent to a single subject.  
The IND sponsor, in collaboration with the PI, may also pause for an individual subject if a 
safety concern is identified during routine aggregate data analysis. 
 Reporting of Pausing for a Subject  
If a pausing requirement is met, a description of the AE(s) or safety issue must be reported by the 
site Investigator by fax or email within one business day to the IND sponsor and LMIV PI. The 

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PIs will notify the ISM, and the local IRB (NIAID IRB, FMPOS EC). The IND sponsor will 
report this to the DSMB. 
 Resumption of a Paused Subject  
The IND sponsor in collaboration with the PI and the DSMB will determine if it is safe to 
resume administration of the study agent to the subject. The IND sponsor will notify the Site 
investigators of this decision. The site investigators will notify their local IRB(s) of the decision 
to resume administration of the study agent prior to resumption. 
 Discontinuation of Study  
Sanaria, Inc. as the study sponsor, the NIAID IRB, FMPOS EC, and the FDA may terminate this 
study at any time. Reasons for terminating the study may include, but are not limited to, the 
following: 
• The incidence or severity of an AE in this or other studies indicates a potential health 
hazard to subjects 
• Subject enrollment is unsatisfactory 
• Data recording is inaccurate or incomplete 
• Investigators do not adhere to the protocol or applicable regulatory guidelines in 
conducting the study 
 Withdrawal of an Individual Subject 
A subject will not be considered to have completed the trial if any of the following reasons 
apply: 
1. Research terminated by Sponsor or Investigator – applies to the situation where the entire 
study is terminated by the sponsor or investigator, or other regulatory authority for any 
reason. 
2. Withdrawal of consent – applies to a subject who withdraws consent to participate in the 
study for any reason. 
3. Noncompliant with protocol – applies to a subject who does not comply with protocol-
specific visits or evaluations, on a consistent basis, such that adequate follow-up is not 
possible, and the subject’s safety would be compromised by continuing in the trial. This 
also applies to a subject who is lost to follow-up and is not reachable by telephone or 
other means of communication and cannot be located. 
4. Completed follow up after developing an AE – applies to a subject who is withdrawn 
from study due to an AE, serious or otherwise. Any grade 3 or greater AE that is assessed 
as possibly, probably, or definitely related to vaccination, PfSPZ Vaccine or placebo 
(other than local reactions lasting <72 hours, or systemic reactions lasting <48 hours) will 
result in withdrawal of the subject from further vaccinations. Subjects may also be 
withdrawn for any AE that would cause continued participation in the study to not be in 
the best interest of the subject, as per the investigator’s judgment. Any subject who will 
notreceive any further vaccination  because of an AE related to study agent will be 
followed for safety until at least resolution of that AE and will be encouraged to remain 
in the safety evaluation for the duration of the study. 
5. Other – is used when previous categories do not apply and a written explanation is 
required. 

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If a subject withdraws or is withdrawn prior to completion of the study, the reason for this 
decision will be recorded in the source documents and CRFs. Any subject who has received at 
least one dose of vaccine will be encouraged to remain in the safety evaluation for the duration 
of the study. The subject’s data will be included in the safety and immunogenicity analysis. If a 
subject fails to complete all planned vaccinations because of an AE or SAE, the subject will be 
followed until resolution or stabilization of the event. If a subject withdraws, the investigator will 
make a reasonable effort to determine the reason. 
 Replacement of Withdrawn Subjects 
Subjects who have received at least one vaccination and who withdraw or are terminated from 
the study prior to completion will not be replaced. In the main phase, subjects withdrawn before 
the first vaccination may be replaced. 
  Unblinding for the Study 
Intentional, unscheduled unblinding may occur if a subject experiences a SAE that the treating 
clinician and/or site PI believes warrants unblinding to provide appropriate clinical management 
of the subject. The request for unblinding may be requested by the site PI or designee, sponsor, 
sponsor medical monitor, independent medical monitor, and DSMB. If non-emergent, all parties 
should be notified to discuss prior to unblinding taking place. If unblinding is requested, an 
“Unblinding Report” should be documented per standard operating procedures and submitted to 
the study statistician for formal unblinding.  
If emergency unblinding is required, the PI or designee will contact the study statistician 
or study pharmacist for unblinding. The sponsor will be informed within one business day that 
the unblinding was necessary and a submitted “Unblinding Report” will be provided within 2 
business days.  
Subjects who are unblinded will be encouraged to remain in the study to be followed for 
safety. 
For subjects who do not enroll in the booster phase, scheduled unblinding of the subject by 
the unblinded pharmacist will occur on Study Day 295 (Arms 1 and 3a) and Study Day 211 
(Arms 2 and 3b) at the completion of the subject’s final visit as already outlined in Appendix A 
per site procedures. For subjects enrolled in the booster phase, scheduled unblinding by the 
unblinded pharmacist will occur on Study Day 561 (Arms 1 and 3a) and Study Day 477 (Arms 2 
and 3b). All primary and secondary endpoints will have been completed at this time. Individuals 
directly continuing AE assessment, including study investigators, or performing assays for 
exploratory endpoints will remain blinded to individual randomization until assessment or assays 
are completed.  
 Safety Oversight 
 Sponsor Medical Monitor 
A medical monitor, representing the IND sponsor (Sanaria, Inc) has been appointed for oversight 
of safety in this clinical study. The sponsor medical monitor will be responsible for performing 
safety assessments. 
 Independent Safety Monitor (ISM) in Mali 
An independent safety monitor (ISM) in Mali will review the study prior to initiation and will be 
available to advise the investigators on study-related medical issues and to act as a representative 

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for the welfare of the subjects. The ISM will conduct independent safety monitoring and 
recommend appropriate action regarding adverse events and other safety issues. The ISM is an 
expert in the field of oversight of clinical trials conducted in Mali and internal medicine, 
specifically in the population under study in Mali. The ISM does not have direct involvement in 
the conduct of the study and does not have other interests with any collaborating pharmaceutical 
firms or their competitors.  
All serious adverse events, all UPs, and all FDA IND Safety Reports will be reported by 
the PI to the ISM prior to or at the same time they are submitted to the IRB or IND sponsor. The 
ISM will be notified immediately if any pausing rule is met and the ISM will provide 
recommendation for continuation, modification, or termination of the study. The PI will also 
notify the medical monitor if intentional or unintentional unblinding occurs. 
 Data and Safety Monitoring Board (DSMB) 
As agreed with OCRPRO, for this study a DSMB chartered by the IND sponsor, Sanaria, Inc. 
will be used instead of the NIAID Intramural DSMB. 
The DSMB will review the study prior to initiation and as outlined in Figure 5 and 
Section 11.7. The board may convene additional reviews as necessary, and will issue 
recommendations concerning continuation, modification, or termination of the study. All SAEs, 
UPs, and all IND Safety Reports will be reported by the sponsor to the DSMB.  
The DSMB will review the study data to evaluate the safety, efficacy, study progress, and 
conduct of the study. The sponsor will notify the DSMB at the time pausing criteria are met and 
obtain a recommendation concerning continuation, modification, or termination of the study. The 
PI will submit written DSMB summary reports with recommendations to the IRB(s).  
 
12 CLINICAL MONITORING 
 Site Monitoring Plan 
As per International Conference on Harmonisation (ICH)-GCP 5.18 and FDA 21 CFR 312.50, 
clinical protocols are required to be adequately monitored by the study sponsor. This study 
monitoring will be conducted according to the “NIAID Intramural Clinical Monitoring 
Guidelines.” Monitors under contract to the NIAID/OCRPRO will visit the clinical research site 
to monitor aspects of the study in accordance with the appropriate regulations and the approved 
protocol. The objectives of a monitoring visit will be: 1) to verify the existence of signed 
informed consent documents and documentation of the informed consent process for each 
monitored subject; 2) to verify the prompt and accurate recording of all monitored data points, 
and prompt reporting of all SAEs; 3) to compare abstracted information with individual subjects’ 
records and source documents (subjects’ charts, laboratory analyses and test results, physicians’ 
progress notes, nurses’ notes, and any other relevant original subject information); and 4) to help 
ensure investigators are in compliance with the protocol. The monitors also will inspect the 
clinical site regulatory files to ensure that regulatory requirements: for the Office for Human 
Research Protections (OHRP), FDA, and applicable guidelines (ICH-GCP) are being followed. 
During the monitoring visits, the investigator (and/or designee) and other study personnel will be 
available to discuss the study progress and monitoring visit. 
The investigator (and/or designee) will make study documents (e.g., consent forms) and 
pertinent hospital or clinical records readily available for inspection by the local IRB, the FDA, 

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the IND Sponsor (Sanaria), the site monitors, and the NIAID staff for confirmation of the study 
data.  
A specific protocol monitoring plan will be discussed with the PI and study staff prior to 
enrollment. The plan will outline the frequency of monitoring visits based on such factors as 
study enrollment, data collection status and regulatory obligations. 
 
 

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13 STATISTICAL CONSIDERATIONS 
 Endpoints and Statistical Methods 
 Safety analysis 
Safety will be assessed by line listing and tables at the individual level. Intention-to-treat (ITT) 
group comparisons, between the vaccine arms and the control arm, will be performed in terms of 
the proportions of solicited AE, related AE and SAE. Other concerning trends will be 
investigated as needed or requested by the PI, ISM, IND sponsor, and/or DSMB. 
 Vaccine efficacy analysis 
Primary efficacy analysis will be based on time to infection, which is defined as the time to the 
first positive blood smear. Arms will be compared by logrank test for interval-censored data 
(using the interval package in R). VE will be estimated assuming a Weibull model and allowing 
for interval censoring and stratification by village (survival package in R).  
The proportions of infection will be also compared across arms by the exact binomial 
test, or the Exact Cochran-Mantel-Haenszel test stratifying on village if needed (using the 
mantelhaen.test in R with the exact option set to true, this is a conditional exact test). Subjects 
that are censored prior to the last day of planned follow up will be removed from the analysis and 
censoring will be assumed to be completely at random. A sensitivity analysis may be performed 
where all censored subjects are treated as either cases or non-cases in either arm.  
Under either of these analyses, we will perform an ITT and a per-protocol analysis. 
Under the per-protocol analysis, subjects that drop out prior to receiving the full number of 
vaccinations will not be included in the analysis.  
The same efficacy analyses will be performed at the end of the main phase and the end of 
the booster phase.  
 Immunogenicity analysis 
We will characterize and compare immunogenicity responses between vaccine and placebo arms 
by Wilcoxon rank sum test or two-sample t-test after proper transformation. We will also 
compare the immunogenicity response before and after vaccination by Wilcoxon signed rank test 
or paired t-test after proper transformation. Figures of immune responses in each study arm will 
be provided to depict the pattern of change in immune responses. 
We will explore the impact of PfSPZ Vaccine on the genotype and transcriptome profile 
of parasites isolated from study subjects using a linear regression or a generalized linear 
regression. 
The same immunogenicity analysis will be carried out at the end of the main phase and 
the end of the booster phase.  
 Interim analysis 
An interim analysis on efficacy will be performed after the first peak transmission season, 
approximately in December 2018. The same efficacy analysis methods will be applied to the 
interim analysis in both ITT and per protocol cohorts. The interim analysis will be performed to 
assist regimen selection in future studies. The analysis results will not affect the final analysis of 
the study. The interim analysis will completed by the study statistician. Analysis will be 
reviewed by LMIV senior investigator and PI, MRTC senior investigator, the sponsor and 
DSMB.  Subjects, site clinicians and site personnel conducting clinical assessments and LMIV 

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and MRTC laboratory personnel conducting study related assays will remain blinded until after 
scheduled unblinding at the completion of the study.  
 Sample Size Consideration 
Sample size consideration is primarily based on VE evaluation. Seventy subjects will be enrolled 
in each arm. If the annual drop-out rate is between 15% and 28%, there will be 50 to 60 available 
subjects for efficacy evaluation at one year after study initiation. With 50 samples per arm, the 
study is capable of detecting the protective efficacy of vaccine with 88% power if VE is 45% and 
the background infection rate is 0.7 (see Table 8). With 60 samples per arm, the study has 83% 
power if VE is 45% and background infection rate is 0.6. For safety evaluation, with 70 subjects 
in each arm, there is 90% probability of observing at least one AE in the arm if the adverse event 
rate is no less than 0.033. 
 
Based on data from existing studies, the number of participants in the booster phase will 
be close to that in the main phase. The above sample size consideration should approximately 
apply to the booster phase.  
Table 8: Power for group-wise comparison based on logrank test on time to infection 
Sample Size 
per Arm 
Background 
Infection Rate 
Vaccine 
Efficacy (VE) 
Power 
50 
0.6 
0.45 
76 
50 
0.6 
0.3 
44 
50 
0.6 
0.25 
33 
50 
0.7 
0.45 
88 
50 
0.7 
0.3 
59 
50 
0.7 
0.25 
45 
60 
0.6 
0.45 
83 
60 
0.6 
0.3 
51 
60 
0.6 
0.25 
39 
60 
0.7 
0.45 
93 
60 
0.7 
0.3 
67 
60 
0.7 
0.25 
52 
70 
0.6 
0.45 
89 
70 
0.6 
0.3 
57 
70 
0.6 
0.25 
44 
70 
0.7 
0.45 
96 
70 
0.7 
0.3 
73 
70 
0.7 
0.25 
59 
 
 Randomization and Blinding  
Participants in arms 1 and 3a will be enrolled and randomized before the enrollment and 
randomization of participants in arms 2 and 3b. The study will be randomized with block 
randomization and stratified by village. To accomplish this, a list of all enrolled subjects will be 
given to the study statistician at least 2 days prior to the desired time for the first randomization. 
To prevent dropout before first vaccination, randomization and first administration of 
vaccination or placebo should occur as close in time as possible.  

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14 HUMAN SUBJECT PROTECTIONS AND ETHICAL 
OBLIGATIONS 
This research will be conducted in compliance with the protocol, GCPs, and all applicable 
regulatory requirements. 
 Institutional Review Board 
A copy of the protocol, informed consent forms (ICFs), and other study related information to be 
completed by subjects, such as questionnaires, diary cards, medical history forms, and any 
proposed advertising/recruitment materials or letters to the subjects will be submitted to the 
reviewing IRBs for written approval. The investigator must submit and obtain approval from the 
IRBs for all subsequent amendments to the protocol, informed consent documents, and other 
study documentation referenced above. The investigator will be responsible for obtaining IRB 
approval of the annual Continuing Review throughout the duration of the study. The 
investigators will notify the reviewing IRBs of protocol violations and SAEs as specified in the 
relevant sections of the protocol. The results of the study will be shared with the IRBs. 
 Informed Consent Process 
Informed consent is a process where information is presented to enable persons to voluntarily 
decide whether or not to participate as a research subject. It is an on-going conversation between 
the human research subject and the researchers which begins before consent is given and 
continues until the end of the subject's involvement in the research. Discussions about the 
research will provide essential information about the study and include: purpose, duration, 
experimental procedures, alternatives, risks and benefits. Subjects will be given the opportunity 
to ask questions and have them answered.  
Consent forms will be approved by all participating IRBs. The subjects will sign the informed 
consent document prior to undergoing any research procedures. The subjects may withdraw 
consent at any time throughout the course of the trial. The informed consent process will be 
documented in the subject’s research chart, as required by 21 CFR 312.62. The ICF will be 
signed (or fingerprinted) and personally dated by the subject and the person who conducted the 
informed consent discussion. The original signed ICF will be retained in the subject’s chart and a 
signed and dated copy will be provided to the subject. The rights and welfare of the subjects will 
be protected by emphasizing to them that the quality of their medical care will not be adversely 
affected if they decline to participate in this study.  
 Community Permission in Mali 
Community permission will be obtained from village elders, family heads, and other community 
members after explanation and discussion of the study (Diallo et al., 2005). The community 
permission process goes through the following steps: 
• Study investigators/personnel explain the study to village leaders, including the village 
chief, family heads, women association, and elders. 
 
• The village leaders then discuss the study with family heads and community members 
and relay any additional questions or concerns they may have to study personnel. 
 

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• The study and the informed consent process are explained in detail to heads of families 
by study investigators/personnel.   
At the time of community permission, the need for both husband and wife to agree to avoid 
pregnancy for the specified period if a wife chooses to volunteer will also be addressed. 
The individual informed consent process and form will be translated into French. The study team 
conducts careful word-for-word review of the study consent form, and will translate the consent 
orally into local languages, as the majority of potential study subjects do not read or speak 
French. Verification that the oral translations are accurate and that the potential subjects 
understand the contents of the informed consent form will be done by an independent witness 
who is not a member of the study team.  
 Individual Informed Consent in Mali 
Local households and families will be invited to come to the study clinic for review of the 
informed consent, and if the subject agrees to participate, the subject will sign or fingerprint the 
consent form.  
At the consenting visit, the subject will read the consent form, or have it explained in 
cases of illiteracy. Individuals in each family will be separately consented and not all individuals 
from a household need to participate.  
Subjects will be encouraged to ask questions, and then take a multiple-choice 
questionnaire (true/false) to evaluate consent comprehension. All incorrect responses will be 
reviewed with the subject, and he or she must verbalize understanding of all incorrect responses. 
A score of ≥80% correct is required for enrollment. For subjects scoring less than 80%, study 
staff may choose to review study details again with subject and reassess comprehension with a 
repeat Malaria Comprehension Exam. At the discretion of the investigator, any subject whose 
comprehension is questionable, regardless of score, may be excluded from enrollment.  
The Malaria Comprehension Exam will be translated into French and administered orally 
in the native dialect in the case of potential subjects who cannot read. Study staff will use 
incorrect answers from the questionnaire to identify those areas of the study procedures that need 
further review with subject. This will help ensure that the subject has sufficient understanding of 
the study before enrollment. Subjects unable to read will place a fingerprint in the place of a 
signature. In addition, an independent witness will sign the consent form to attest that the consent 
was fully explained and all questions were answered. 
 Subject Confidentiality 
Subjects will not be identified in any publicly released reports of this study. All records will be 
kept confidential to the extent provided by federal, state, and local law. The study monitors and 
other authorized representatives of the sponsor may inspect all documents and records required 
to be maintained by the Investigator. The investigator will inform the subjects that the above-
named representatives will review their study-related records without violating the 
confidentiality of the subjects. All laboratory specimens, evaluation forms, reports, and other 
records that leave the site will be identified only by a coded number in order to maintain subject 
confidentiality. All records will be kept locked and all computer entry and networking programs 
will be done with coded numbers only. Clinical information will not be released without written 
permission of the subject, except as necessary for monitoring by IRB, FDA, NIAID, OHRP, or 
the sponsor’s designee. 
 

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15 POTENTIAL RISKS AND BENEFITS 
For any clinical trial, the risk for potential subjects should be weighed against the benefit. As no 
direct benefit to trial subjects is likely, benefits are considered in the context of possible public 
health gains that might occur as a result of this study. 
Risks to the subjects are associated with venipuncture, immunization, or drug administration.  
These risks are outlined below: 
 Venipuncture 
Risks occasionally associated with venipuncture include pain, bruising, bleeding, and infection at 
the site of venipuncture, lightheadedness, and rarely, syncope. 
The total amount of blood collected are well within the American Association of Blood Banks 
recommendations, and the current NIH guidelines, and will not compromise these otherwise 
healthy subjects (Howie, 2011). Any minor bruising, local tenderness or pre-syncopal symptoms, 
or rarely, infection associated with venepuncture, will be documented as AEs.  
 DVI Immunizations (either PfSPZ Vaccine or Normal Saline) 
Possible local injection reactions resulting from DVI include pain, swelling, erythema, 
induration, limitation of limb movement for several days, lymphadenopathy, bruising, or pruritus 
at the injection site. Systemic reactions such as fever, chills, headache, fatigue, malaise, myalgia, 
and joint pain may also occur, and may range from mild to severe. These side effects will be 
monitored but are generally mild and self-limiting. 
As with any investigational product, immediate hypersensitivity reactions including urticaria, 
anaphylaxis, or other IgE-mediated responses are possible. There is a theoretical possibility of 
risks about which we have no present knowledge. Subjects will be informed of any such risks 
should further data become available. 
Subjects may be asked to defer routine immunization until 14 – 28 days following vaccination.  
 PfSPZ Vaccine 
Based on vaccinations administered thus far, the most frequent AEs reported have been headache 
and malaise, with the majority mild to moderate in nature. Laboratory abnormalities seen include 
mild, transient, and asymptomatic change in liver enzymes (ALT and/or aspartate 
aminotransferase [AST]), WBC (leukopenia), and absolute granulocyte counts.  
Possible local reactions include pain, swelling, erythema, induration, limitation of 
limb movement for several days, lymphadenopathy, or pruritus at the injection site. 
Systemic reactions such as fever, chills, headache, fatigue, malaise, myalgia, and joint 
pain may also possibly occur, with some reactions moderate or severe. 
Other than mild and transient local (site of administration) reactions, the listed 
adverse reactions remain theoretical.  
In Equatorial Guinea two serious adverse events possibly related to PfSPZ Vaccine have 
been described. One volunteer who received PfSPZ Vaccine had a miscarriage at 10 weeks after 
getting pregnant while participating in a PfSPZ Vaccine trial. On vaccination day, the subject 
had a negative urine pregnancy test. She was started on contraceptive measures on the same day 
she received the vaccine and was advised to additionally use a barrier method. 
Miscarriages frequently occur without known causes and although it is unlikely the 
vaccine caused the miscarriage, the temporal relationship meant this was a possibility. All 
women of child-bearing age are required to take birth control measures as specified within the 

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protocol and/or consent form to avoid getting pregnant while participating in trials of PfSPZ-
based products. In this protocol, volunteers must use two forms of contraception and must have 
started a hormonal method at least 21 days prior to receipt of Sanaria® PfSPZ Vaccine injection.  
Another volunteer, a 15-year-old boy who received PfSPZ Vaccine, had a generalized 
seizure 3 ½ hours after receiving his third dose. The boy fully recovered from the seizure. The 
EEG showed that he was predisposed to having seizures. It is unlikely the vaccine 
caused the seizure, but like all vaccines, PfSPZ Vaccine causes an immune response in the body 
which may increase the chance that those individuals predisposed to seizures experience a 
seizure. 
As with any infusion, immediate hypersensitivity reactions including urticaria, 
anaphylaxis, or other IgE-mediated responses are possible. There is a theoretical possibility of 
risks about which we have no present knowledge. Subjects will be informed of any such risks 
should further data become available. 
Subjects may be asked to defer routine immunization (such as influenza) until 14 – 28 days 
following vaccination.  
 Normal Saline 
The amount of normal saline used in this study is small (< 1 mL) and has been well tolerated, 
including in previous PfSPZ Vaccine studies. Overall, most AEs reported with the use of normal 
saline have been reactions that may have occurred because the technique of administration and 
have been local injection reactions as noted above in Section 15.2.  
 Antimalarial Medication 
Subjects will be treated with a registered, oral, proven, and highly efficacious treatment during 
the course of this study. 
All antimalarials considered for this trial have an excellent safety profile and are 
generally well tolerated in the dosing regimens to be used, although common side effects (e.g., 
nausea, vomiting, diarrhea, headaches) are anticipated to occur in some subjects. Subjects in the 
study will be closely monitored for adverse drug reactions and where possible, attempts will be 
made to minimize anticipated side effects. Specific toxicities for Coartem are noted below and 
further outlined in the IB and the package insert for each drug 
Potential subjects with known sensitivity or contraindications to the antimalarial 
administered in this study are excluded from participation. The most common / important side 
effects are listed below for each drug. A more comprehensive list of possible side effects is 
provided in the associated Package Insert. 
 Coartem® (Artemether/Lumefantrine) 
For artemether/lumefantrine the most commonly reported side effects in adults are: headache, 
anorexia, dizziness, asthenia, arthralgia and myalgia. Generally, these effects do not require 
discontinuation of the drug. 
Artemether/lumefantrine has an acceptable safety profile. Individuals who may have any 
contraindication for the use of this drug (e.g. prolonged QTc or taking other medications that can 
prolong QTc, history of myocardial infarction) will be excluded at screening. The most common 
side effects (i.e., >30%) in adults are: headache, anorexia, dizziness, asthenia, arthralgia, and 
myalgia. Discontinuation of artemether/lumefantrine due to AE is rare (0.2%) in adults. Rare but 

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serious hypersensitivity reactions (urticarial and angioedema) and skin reactions (bullous 
eruption) have been reported post marketing.  
Artemether/lumefantrine is a Category C pregnancy drug. Thus, all female participants 
will undergo pregnancy testing prior to receipt of the investigational dose of 
artemether/lumefantrine at the start of the study. Also, per the package insert, 
artemether/lumefantrine may decrease the efficacy of hormonal birth control, so female 
volunteers who are on hormonal birth control will be counseled about back up pregnancy 
prevention methods.  
For complete artemether/lumefantrine safety information, including less commonly 
reported side effects, please refer to the Package Insert for Coartem that is provided. 
 Cardiac Abnormalities 
There is no specific known cardiac risk for healthy subjects associated with experimental malaria 
challenge/infection or the antimalarial drugs at the proposed dosing used in this study. Likewise, 
cardiac abnormalities in uncomplicated clinical malaria are extremely rare and routine cardiac 
monitoring of subjects with severe malaria is not required even in subjects receiving treatment 
with antimalarials with known effects on cardiac electrical conduction (Bethell et al., 1996; 
Bregani, Tien, Cabibbe, Figini, & Manenti, 2004; Ehrhardt et al., 2005). 
A CHMI subject participating in a malaria vaccine trial in the Netherlands had an 
unexplained cardiac event following receipt of an investigational vaccine, malaria challenge, 
infection and treatment with artemether/lumefantrine (Nieman et al., 2009). It is thought the 
temporal association of the event to malaria challenge was likely circumstantial (Lyke et al., 
2010). The definitive etiology of the event remains unknown and the subject recovered without 
sequelae. 
A second cardiac event in a malaria vaccine trial participant in the Netherlands was 
reported (van Meer et al., 2014). The trial subject received a different test malaria vaccine than 
the subject reported in 2009. The subject was observed on day 13, after CHMI, to have changes 
in a blood test suggesting a heart muscle problem. Later that day the subject experienced chest 
pain and reported a heavy feeling in his left arm. After further evaluation the subject was 
diagnosed with myocarditis. It is not known whether this illness was related to malaria infection, 
the test vaccine that the subject received, the medicine used to treat malaria, a viral infection 
unrelated to the study or something else. Myocarditis resolved without treatment. 
Cardiac events, such as coronary vasospasm or myocarditis, are not associated with 
uncomplicated natural P. falciparum infection or experimental infection in the cumulative 
experience in over 1300 volunteers at three centers worldwide (Ehrhardt et al., 2005). However, 
in order to minimize the potential risk for cardiac abnormalities during the study, cardiac risk 
assessment will be conducted as part of the screening process based on screening ECG (subjects 
with clinically significant abnormalities on ECG will be excluded from the study) and targeted 
cardiac medical and family history questioning at screening. 
 Pregnancy 
Malaria infection can have adverse effects on both the pregnant mother and fetus. Women who 
are pregnant, nursing or plan to become pregnant during the study are excluded from the study. 
Pregnancy testing is performed during screening and throughout the study, including prior to 
each PfSPZ Vaccine or Placebo vaccine via DVI and prior to artemether/lumefantrine dosing. If 
clinical history indicates recent sexual activity that may lead to pregnancy, a serum β-HCG test 
will be performed and results reviewed by a study investigator prior to the subject continuing in 

Two Regimens of PfSPZ Vaccine in Mali, Africa 
 
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72 
the study. Pregnancy prevention counseling and compliance is reinforced at every clinic visit 
(see Appendix A) throughout the main study. 
If a subject becomes pregnant during the Study, the subject will not be withdrawn from 
the study but no further investigational products will be administered. The Sponsor and NIAID 
IRB/FMPOS EC will be notified of the pregnancy. We will confirm the pregnancy by urine (or 
serum) pregnancy test. The subject will be advised to follow up for antenatal care per Mali 
Ministry of Health guidelines, this may include receipt of intermittent preventive treatment for 
prevention of malaria in pregnancy. 
The subject will then be provided with an alternative study schedule which will include 
only obtaining samples for malaria infection evaluation and smaller amount of blood sample for 
immunogenicity assessment at their scheduled visits and the option to provide a 4mL sample for 
parasite purification if blood smear positive as outlined in Appendix A.. This study schedule 
may be altered at the investigator’s discretion if any concern that the blood draws would impact 
the expecting the health of the mother or the fetus.  
Pregnant subjects who develop clinical malaria will be treated following Mali National 
Policy on Malaria Control guidelines. Uncomplicated malaria in the 1st trimester is treated with 
quinine and during 2nd and 3rd trimesters, treatment is with Coartem® [artemether/lumefantrine.] 
Complicated malaria in pregnancy is treated similarly to non-pregnant patients.  
 Risk to the Community  
PfSPZ Vaccine is not known to cause any risk to the community. 
 Benefits 
Subjects will not receive any direct benefit from participation in this study unless the 
immunization provides long term anti-malarial immunity, which is unknown at this time. It is 
hoped that information gained in this study will contribute to the development of a safe and 
effective malaria vaccine. 
 
16 COMPENSATION 
Subjects will be given in kind (such as rice and/or millet) or cash equivalent, that can be given in 
multiple installments as outlined in Table 9, to compensate for the time taken to come to the 
study clinic for study-related visits. Preferred compensation will be decided in consultation with 
village elders, but case-by-case exceptions to receive the cash equivalent may be acceptable. The 
Mali EC recommends compensating the study subject for their time lost for study procedures. 
The amount is equivalent to USD $6 for each scheduled visit with blood drawn and equivalent to 
USD $3 for each scheduled visit without blood drawn. For unscheduled visits that request 
research labs to be drawn at that time, such as positive blood smear visits during the malaria 
transmission season, subjects will be compensated USD $6.  
Table 9: Estimated Compensation for the Study 
Disbursements to subjects of compensation will be made periodically throughout the trial. 
Study Group(s) 
Study Activity 
US Dollar Equivalent in 
Rice or Millet Dispensed 
(Local Currency [CFA] 

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1, 2, 3a, 3b 
Screening & Enrollment 
$12 = 6,500 F CFA 
1, 3a 
Completion of Vaccination #1 & #2 
$81 = 43,600 F CFA 
 2, 3b 
Completion of Vaccination #1 & #2 
$33 = 17,700 F CFA  
1, 2, 3a, 3b 
Completion of Vaccination #3 & follow up 
$90 = 48,400 F CFA 
1, 2, 3a, 3b 
AL dosing before vaccination #3 
$6 = 3,200 F CFA 
1, 2, 3a, 3b 
Screening & Pre-Injection #4 visits 
$24 = 13,000 F CFA 
1, 2, 3a, 3b 
Completion of Injection #4 & follow up 
$90 = 48,400 F CFA 
*Assuming currency exchange rate of USD $1= 538 CFA 
 
 

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17 DATA HANDLING AND RECORD KEEPING 
 Data Capture and Management 
In Mali, the study data will be collected on paper CRFs and then put into a study specific 
DataFax electronic database or entered directly into DataFax electronic database. Data from 
CRFs will be collected directly from subjects during study visits and telephone calls. CRFs 
(paper or electronic) will be used as source. Any type of corrections to paper CRFs must be 
initialed and dated by the person making the correction. Any type of corrections to electronic 
CRFs will be tracked electronically with time, date, individual making the correction, and what 
was changed. All CRFs should be reviewed by the Investigator or designee and signed as 
required with written or electronic signature. 
Data entry will be performed by authorized individuals. Corrections to the electronic data 
systems will be tracked electronically (password protected or through an audit trail) with time, 
date, individual making the correction, and what was changed. The investigator is responsible for 
assuring that the data collected are complete, accurate, and recorded in a timely manner. 
 Types of Data 
Source documents include all recordings of observations or notations of clinical activities and all 
reports and records necessary to confirm the data abstracted for this study. Complete source 
documentation (laboratory test reports, hospital or medical records, progress notes, observations, 
etc.) is required for every study subject for the duration of the study. Source documentation will 
be made available for review or audit by the Sponsors, or their designees and any applicable 
Federal authorities. 
 Retention of Study Records 
The investigator is responsible for retaining all essential documents listed in the ICH GCP 
Guideline. Study records will be maintained by the PI for a minimum of three years and in 
compliance with institutional, IRB, state, and federal medical records retention requirements, 
whichever is longest. All stored records will be kept confidential to the extent required by 
federal, state, and local law. 
Should the investigator wish to assign the study records to another party and/or move them to 
another location, the investigator will provide written notification of such intent to 
OCRPRO/NIAID and Sanaria, Inc with the name of the person who will accept responsibility for 
the transferred records and/or their new location. Destruction or relocation of research records 
will not proceed without written permission from NIAID/OCRPRO or Sanaria, Inc. 
 Protocol Revisions 
No revisions to this protocol will be permitted without documented approval from the IRBs that 
granted the original approval for the study. Any change to the protocol will be submitted to the 
sponsor for review and then to the participating IRBs as a protocol amendment; changes not 
affecting risk to subjects may request an expedited review. In the event of a medical emergency, 
the investigator shall perform any medical procedures that are deemed medically appropriate and 
will notify the IND sponsor of all such occurrences. 

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75 
18 APPENDICES 
Appendix A: Study Schedule 
 
2
4
5
6
7
8
9
10
Clinic visits 
1
2
3
4
5
6
7
8
9
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Unscheduled 
-- Blood 
Smear 
Study Day 
-56
-14
1
2
4
8
15
29
43
57
58
60
64
71
85
99
113
114
116
120
127
141
155
169
183
197
211
225
239
253
267
295
N/A
Days post-
PfSPZ Vaccine
-56
-14
0
1
3
7
14
28
42
0
1
3
7
14
28
42
0
1
3
7
14
28
42
56
70
84
98
112
126
140
154
182
N/A
Weeks post-
PfSPZ Vac #1
-8
-2
0
1
2
4
6
8
9
10
12
14
16
17
18
20
22
24
26
28
30
32
34
36
38
42
N/A
Visit windows 
(days)
"-7"       
"+14"
±2
0
±1
±2
±3
±5
-5
±14
0
±1
±2
±3
±5
-7
±14
0
±1
±2
±3
±3
±3
±3
±3
±3
±3
±3
±3
±3
±3
+42
Screen
Enroll 
PfSPZ Vac 
#1
Safety 
F/U
Safety 
F/U
Safety 
F/U
Safety 
F/U
Safety 
F/U
Safety 
F/U; Pre-
Vac
PfSPZ Vac 
#2
Safety 
F/U
Safety 
F/U
Safety 
F/U
Safety 
F/U
Safety 
F/U
Pre-Vac; 
AL
PfSPZ Vac 
#3
Safety 
F/U
Safety 
F/U
Safety 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Unblinding 
visit
Unscheduled 
Visit Positive 
BS
CLINICAL PROCEDURES
Complete medical 
history/ physical
X
Informed consent
X
X2
Malaria 
Comprehension 
Exam
X
Pre-test/Post-test 
HIV counseling
X
Pregnancy 
Prevention 
Counseling
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Interim clinical 
evaluation
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
AE/SAE assessment
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Conmed review
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
AL dose
X
PfSPZ Vaccine (Arm 
1 only)1
X
X
X
LABORATORY 
PROCEDURES
Designated 
Laboratory
Tube Type
Screening/Safety 
Labs and procedures
CBC with differential
MRTC CAP 
lab/UB/LPD
EDTA
2
2
2
2
2
2
2
2
2
2
2
2
2
ALT, Cr
SST
3
3
3
3
3
3
3
3
3
3
3
3
3
Hepatitis B, C, HIV 
testing; sickle cell 
screening
SST
5
Urine dipstick or UA
Urine 
Container
X
Urine/Serum 
Pregnancy Test 
(females only)
Urine 
Container or 
Lithium Hep
X
X
X
X
X
X
ECG
NIH/Mali 
Cardio
N/A
X
Malaria Infection 
Assays
qPCR
MRTC CAP 
lab/LMIV 
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Peripheral Blood Smear
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Research Assays
Humoral Assays
MRTC/ 
LMIV
SST
10
2.5
5
5
2.5
2.5
2.5
Cellular Assays
NaHep
10
10
10
10
10
10
10
10
Ex Vivo Assays
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Parasite Purification (CF11)
EDTA
4
Transcriptional Assays
PaxGENE
1
1
1
1
1
1
Daily total
10
27.5
1
0
6
5.5
1
0.5
0.5
1
0
5.5
5.5
14
0.5
22.5
6
0
6
12.5
21.5
15
6
1
1
19
1
1
1
20
1
0
5
Study cumulative total
10
37.5
38.5
38.5
44.5
50
51
51.5
52
53
53
58.5
64
78
78.5
101
107
107
113
125.5
147
162
168
169
170
189
190
191
192
212
213
213
1 Arm 3a receives Normal Saline DVI
2 Booster phase informed consent
Appendix A: Clinic and Laboratory Procedures For Arm 1 and 3a

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Clinic visits 
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
Unscheduled --
Blood Smear 
Positive
Study Day 
-56
-14
1
2
4
8
9
11
15
22
29
30
32
36
43
57
71
85
99
113
127
141
155
169
183
211
N/A
Days post-PfSPZ 
Vaccine
-56
-14
0
1
3
0
1
3
7
14
0
1
3
7
14
28
42
56
70
84
98
112
126
140
154
182
N/A
Weeks post-
PfSPZ Vac #1
-8
-2
 
1
2
4
6
8
10
14
18
22
26
30
N/A
Visit windows 
(days)
"-7"       
"+14"
±2
0
±1
±1
0
±1
±2
±3
±2
0
±1
±2
±3
±3
±3
±3
±3
±3
±3
±3
±3
±3
±3
+42
Screen
Enroll 
PfSPZ Vac 
#1
Safety 
F/U
Safety 
F/U; Pre-
Vac
PfSPZ Vac 
#2
Safety 
F/U
Safety 
F/U
AL
Pre-vac
PfSPZ Vac 
#3
Safety 
F/U
Safety 
F/U
Safety 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
Malaria 
F/U
 Final & 
Unblinding/ 
Clinic   visit
Unscheduled 
Visit Positive 
BS
CLINICAL PROCEDURES
Complete medical history/ 
physical
X
Informed consent
X
X2
Malaria Comprehension 
Exam
X
Pre-test/Post-test HIV 
counseling
X
Pregnancy Prevention 
Counseling
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Interim clinical evaluation
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
AE/SAE assessment
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Conmed review
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
AL dose
X
X
PfSPZ Vaccine (Arm 2 
only)1
X
X
X
LABORATORY 
PROCEDURES
Designated 
Laboratory
Tube Type
Screening/Safety Labs and 
procedures
CBC with differential
MRTC CAP 
lab/UB/LPD
EDTA
2
2
2
2
2
2
2
2
2
2
ALT, Cr
SST
3
3
3
3
3
3
3
3
3
3
Hepatitis B, C, HIV testing; 
sickle cell screening
SST
5
Urine dipstick or UA
Urine Container
X
Urine/Serum Pregnancy 
Test (females only)
Urine Container 
or Lithium Hep
X
X
X
X
X
X
ECG
NIH/Mali 
Cardio
N/A
X
Malaria Infection Assays
qPCR
MRTC CAP 
lab/LMIV 
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Peripheral Blood Smear
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Research Assays
Humoral Assays
MRTC/ LMIV
SST
10
5
5
2.5
2.5
2.5
Cellular Assays
NaHep
10
10
10
10
10
10
10
Ex Vivo Assays
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Parasite Purification (CF11)
EDTA
4
Transcriptional Assays
PaxGENE
1
1
1
1
1
Daily total
10
27.5
1
0
6
1
0
1
22.5
0
6
0
6
11.5
21.5
15
0
1
1
19
1
1
1
20
1
1
5
Study cumulative total
10
37.5
38.5
38.5
44.5
45.5
45.5
46.5
69
69
75
75
81
92.5
114
129
129
130
131
150
151
152
153
173
174
175
1 Arm 3b receives Normal Saline DVI
2 Booster phase informed consent
Appendix A: Clinic and Laboratory Procedures For Arm 2 and 3b

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Two Regimens of PfSPZ Vaccine in Mali, Africa 
 
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Appendix B: Toxicity Table 
Local Reactogenicity Grading 
Local Reaction to 
Injectable Product 
Mild  
(Grade 1) 
Moderate (Grade 2) Severe  
(Grade 3) 
Potentially Life 
Threatening 
(Grade 4) 
Pain/Tenderness/Pruritus 
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 
Emergency room 
(ER) visit or 
hospitalization 
Erythema/Redness/Bruising1 2.5 – 5 cm 
5.1 – 10 cm 
> 10 cm 
Necrosis or 
exfoliative 
dermatitis 
Induration/Swelling2  
2.5 – 5 cm 
and does not 
interfere 
with activity 
5.1 – 10 cm or 
interferes with 
activity 
> 10 cm or 
prevents daily 
activity 
Necrosis 
1 In addition to grading the measured local reaction at the greatest single diameter, the measurement should be 
recorded as a continuous variable.  
2 Induration/Swelling should be evaluated and graded using the functional scale as well as the actual measurement. 
Vital Sign AE Grading 
Vital Signs1  
Mild  
(Grade 1) 
Moderate 
(Grade 2) 
Severe  
(Grade 3) 
Potentially Life Threatening 
(Grade 4) 
Fever2 (°C) 
              (°F) 
38.0 – 38.4 
100.4 – 101.1 
38.5 – 38.9 
101.2 – 102.0 
39.0 – 40 
102.1 – 104 
> 40 
> 104 
Tachycardia - 
bpm 
101 – 115 
116 – 130 
> 130 
ER visit or hospitalization for 
arrhythmia 
Bradycardia - 
bpm3 
50 – 54 
45 – 49 
< 45 
ER visit or hospitalization for 
arrhythmia 
Hypertension 
(systolic) - 
mm Hg 
141 – 150 
151 – 155 
> 155 
ER visit or hospitalization for 
malignant hypertension 
Hypertension 
(diastolic) - 
mm Hg 
91 – 95 
96 – 100 
> 100 
ER visit or hospitalization for 
malignant hypertension 
Hypotension 
(systolic) – 
mm Hg 
85 – 89 
80 – 84 
< 80 
ER visit or hospitalization for 
hypotensive shock 
1 Subject should be at rest for all vital sign measurements.  
2Oral temperature; no recent hot or cold beverages or smoking.  
3When resting heart rate is between 60 – 100 beats per minute. Use clinical judgment when characterizing  
bradycardia among some healthy subject populations, for example, conditioned athletes. 
 
 

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Systemic AE Grading 
Systemic adverse 
events1 
Mild  
(Grade 1) 
Moderate 
(Grade 2) 
Severe  
(Grade 3) 
Potentially Life 
Threatening 
(Grade 4) 
Feverish 
No interference 
with 
activity 
Some interference 
with activity not 
requiring medical 
intervention or use of 
1-2 doses of 
antipyretics 
Prevents daily activity or 
use of >2 doses of 
antipyretics in 24 hours 
ER visit or 
hospitalization  
Chills/Rigors 
No interference 
with activity or 1 
– 2 
episodes/24 hours 
Some interference 
with activity or > 2 
episodes/24 hours 
Prevents daily 
activity 
 
ER visit or 
hospitalization 
for 
hypotensive 
shock 
Sweats 
No interference 
with 
activity 
Some interference 
with activity not 
requiring medical 
intervention 
Prevents daily activity  
ER visit or 
hospitalization  
Diarrhea 
2 – 3 loose stools 
or 
< 400 gms/24 
hours 
4 – 5 stools or 
400 – 800 gms/24 
hours 
6 or more watery stools or 
> 800gms/24 hours 
or requires outpatient IV 
hydration 
ER visit or 
hospitalization 
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/ 
Malaise 
No interference 
with 
activity 
Some interference 
with activity not 
requiring medical 
intervention 
Prevents daily activity 
ER visit or 
hospitalization 
Back Pain 
No interference 
with 
activity 
Some interference 
with activity; use of 
1-2 doses of 
medication 
Prevents daily activity   
ER visit or 
hospitalization  
Chest Pain (non-
musculoskeletal) 
Transient (< 24 
hours) or 
intermittent chest 
pain with no or 
minimal 
interference 
 
 
Persistent chest pain 
resulting in greater 
than minimal 
interference with 
usual activities  
Persistent chest pain 
resulting in inability to 
perform usual activities 
secondary to chest pain 
ER visit or 
hospitalization  
Myalgia 
No interference 
with 
activity 
Repeated use of non- 
narcotic pain 
reliever > 24 hours or 
some interference 
with activity 
Any use of narcotic 
pain reliever or 
prevents daily 
activity 
ER visit or 
hospitalization 

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Systemic adverse 
events1 
Mild  
(Grade 1) 
Moderate 
(Grade 2) 
Severe  
(Grade 3) 
Potentially Life 
Threatening 
(Grade 4) 
Arthralgia 
No interference 
with 
activity 
Repeated use of non- 
narcotic pain 
reliever > 24 hours or 
some interference 
with activity 
Any use of narcotic 
pain reliever or 
prevents daily 
activity 
ER visit or 
hospitalization 
Nausea/ 
Vomiting 
No interference 
with activity or 1 
– 2 
episodes/24 hours 
Some interference 
with activity or > 2 
episodes/24 hours 
Prevents daily 
activity, requires 
outpatient IV 
hydration 
ER visit or 
hospitalization 
for 
hypotensive 
shock 
Abdominal Pain 
No interference 
with 
activity 
Repeated use of non- 
narcotic pain 
reliever > 24 hours or 
some interference 
with activity 
Any use of narcotic 
pain reliever or 
prevents daily 
activity 
ER visit or 
hospitalization 
Urticaria/Rash 
No interference 
with 
activity 
Requiring PO or 
topical treatment  > 
24 hours or IV 
medications or 
steroids for ≤24 hours 
Requiring IV medication 
or steroids for >24 hours 
ER visit or 
hospitalization 
Edema 
No interference 
with 
activity 
Some interference 
with activity not 
requiring medical 
intervention 
Prevents daily activity   
ER visit or 
hospitalization 
Pruritus  
No interference 
with 
activity 
Requiring PO or 
topical treatment  > 
24 hours or IV 
medications or 
steroids for ≤24 hours 
Requiring IV medication 
or steroids for >24 hours 
ER visit or 
hospitalization 
1 For other symptoms not listed, they should be graded as outlined in Section 11.3.1 
***Adapted from Guidance for Industry: Toxicity Grading Scale for Healthy Adult and Adolescent Volunteers Enrolled in 
Preventative Vaccine clinical Trials. 
 

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Mali Laboratory AE Grading 
Hematology/Chemistry 
 
Hematology and 
Biochemistry 
values1, 2 
Mild 
(Grade 1) 
Moderate 
(Grade 2) 
Severe 
(Grade 3) 
Potentially Life 
Threatening 
(Grade 4) 
Hemoglobin (Male) 
- gm/dL  
9.5 – 10.3 
8.0 – 9.4 
6.5 – 7.9 
< 6.5 and / or 
requiring 
transfusion 
Hemoglobin 
(Female)  
gm/dL  
8.0 – 9.0 
7.0 – 7.9 
6.0 – 6.9 
< 6 and /or 
requiring 
transfusion 
WBC Increase – 
103/µL 
11.5 – 15.0 
15.1 – 20.0 
20.1 – 25.0 
> 25.0 
WBC Decrease - 
103/µL 
2.5 – 3.3 
1.5 – 2.4 
1.0 – 1.4 
< 1.0 with fever 
Granulocyte or 
Neutrophil 
Decrease - 103/µL 
0.8 – 1.0 
0.5 – 0.7 
< 0.5 
< 0.5 with fever 
Platelets Decreased 
– 103/µL 
100 – 110 
70 – 99 
25 – 69 
< 25 
Creatinine (Male) 
µmol/L 
124.00 – 
150.99 
151.00 – 176.99 
177.00 – 
221.00 
> 221.00 and 
requires dialysis 
Creatinine 
(Female) µmol/L 
107.00 – 
132.99 
133.00 – 159.99 
160.00 – 
215.99 
> 216.00 and 
requires dialysis 
Liver Function 
Tests –ALT U/L 
75.0 – 150.9 
151.0 – 300.9 
301.0 – 600.0 
> 600.0 
1The laboratory values provided in the tables serve as guidelines and are dependent upon institutional normal parameters. 
Institutional normal reference ranges should be provided to demonstrate that they are appropriate.  
2The clinical signs or symptoms associated with laboratory abnormalities might result in characterization of the laboratory 
abnormalities as Potentially Life Threatening (Grade 4). For example, a low sodium value that falls within a grade 3 parameter 
should be recorded as a grade 4 hyponatremia event if the subject had a new seizure associated with the low sodium value.  
 
Mali Adult Normals 
Chemistry 
Serum1 
Reference Range 
Creatinine (Female) 
- µmol/L 
< 72 
 
Creatinine (Male) -
µmol/L 
48 – 98 
 
ALT – U/L 
 
< 41 
1The laboratory values provided in the table are based on Bancoumana, Malian adults (age 18-45 years old) 
 
 

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Hematology 
Hematology1 
Reference Range 
Hemoglobin 
(Female) - gm/dL 
9.1 – 13.8 
Hemoglobin 
(Male) - gm/dL 
10.8 – 15.8 
WBC – 103/µL 
3.6 – 9.0 
Absolute 
Granulocyte or 
Neutrophil 
Count - 103/µL 
1.3 – 4.4 
Absolute 
Lymphocyte 
Count - 103/µL 
1.3 – 4.4 
Platelet Count 
(Female)- 
103/µL 
144 – 413 
Platelet Count 
(Male)- 103/µL 
114 – 335 
1The laboratory values provided in the table are based on Bancoumana, Malian adults (age 18-45 years old) 
 
Urine Dip/Urinalysis 
Urine1 
Reference Ranges 
Protein 
None 
Blood 
(microscopic) – 
red blood cells per 
high power field 
(RBC/HPF) 
None or Trace 
 
< 1 
1The laboratory values provided in the table are based on Bancoumana, Malian adults (age 18-45 years old) 
 
 
 

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