A Phase I/IIa Clinical Trial to Assess the Safety, Immunogenicity and Efficacy of the Blood-stage Plasmodium Falciparum Malaria Vaccine Candidate RH5.1/AS01
Phase: PHASE1
Conditions: Malaria
Sponsor: University of Oxford

CONFIDENTIAL 
 
VAC063 v9.0 
 
10th October  2018 
 
 
Study Reference: VAC063 
 
A Phase I/IIa clinical trial to assess the safety, immunogenicity and efficacy of the blood-
stage Plasmodium falciparum malaria vaccine candidate RH5.1/AS01 
 
 
Sponsor: University of Oxford 
 
Chief Investigator: Dr Angela M. Minassian 
 

VAC063 Protocol v9.0 
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2 
Modification History 
Version 
Date 
Modifications 
Author(s) 
1.0 
2nd June 2016 
N/A 
Ruth Payne, Simon Draper, 
Johan 
Vekemans, 
David 
Pattinson 
2.0 
15th September 2016 
Addition of information regarding the use of 
the informed consent questionnaire 
Correction of Table 4: Schedule of attendances 
for Group 3 to reflect actions carried out on 
day of third vaccination (day 182) which had 
been incorrectly listed in day 56. Similar 
correction on page 11, dose section 
Addition of wording to clarify that stated 
vaccine and adjuvant doses are nominal and 
may vary slightly due to dilution, mixing and 
administration techniques. 
Blood volumes for Groups 1-4 corrected to 
include 3 mL Tempus tubes on vaccination 
days and 1 day post-vaccination visits. 
Sentence added that an ECG will be done as 
part of Group 5-6 screening. (correction, as 
information is already in PIS G5-6) 
Change in wording of exclusion criterion  
regarding prior receipt of an investigational 
malaria vaccine  
“History of splenectomy” removed as a 
separate exclusion criterion 
Ruth Payne 
Angela Minassian 
3.0 
29th May 2017 
Selection of dose of RH5.1/AS01 (10 µg) for 
Group 5 in the Phase IIa study 
Guy’s and St. Thomas’ NIHR CRF to continue  
as a recruitment and vaccination site for the 
Phase IIa study 
Removal of Cardiovascular Risk Score and 
checking of cholesterol levels from the 
protocol 
Correction of blood volumes in schedule of 
attendances for Groups 5 and 6 (Tables 5 & 6) 
and in groups 1-6 in Table 14 
Clarification of vaccination of 2 back-up 
volunteers in Group 5 (as already explained in 
the PIS) 
Clarification of challenge at 2 weeks post final 
vaccination 
Blinding of all Investigators (except the 
Principal Laboratory Investigator) to the 
malaria qPCR results during the post-challenge 
phase 
Angela Minassian 
Simon Draper 
4.0 
11th September 2017 
Modification of bleed schedule for Groups 5 
and 6. 
Removal of cholesterol measurement from 
footer of table 6  
Details of biochemistry added to footer of table 
Simon Draper 
Angela Minassian 

VAC063 Protocol v9.0 
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5 
5.0 
23rd November 2017 
Addition of conflicts of interests for Dr AM 
Minassian and Prof SJ Draper on page 8  
Correction of 2 minor typographical errors 
(and subsequent cumulative volumes) in the 
bleeding schedule tables for groups 5 and 6 
(Tables 5 & 6), and in Table 14 (Groups 5-6) 
Angela Minassian 
6.0 
23rd January 2018 
Addition of 3 new groups to assess the 
durability of the vaccine-induced reduction in 
PMR (Group 7 = Phase IIa malaria-exposed 
vaccinees; Group 8 = Phase IIa malaria-
exposed controls; Group 9 = newly recruited 
malaria-naïve controls) 
Removal of microscopy as a diagnostic tool in 
the second homologous CHMI, and adjustment 
of 
the 
qPCR 
diagnostic 
criteria 
for 
commencing anti-malarials  
Addition of 2 new exclusion criteria (Groups 5-
9): 
G6PD 
deficiency 
and 
abnormal 
haemoglobinopathy screen 
Clarification of 2 exclusion criteria (relating to 
Hepatitis C serology and contraindications 
relating to use of malarone and riamet) 
Angela Minassian 
Simon Draper 
7.0 
7th February 2018 
Clarification of scientific rationale for re-
challenge of healthy volunteers (requested by 
the MHRA) 
Angela Minassian 
8.0 
(not 
MHRA 
approved) 
12th July 2018 
Addition of further CHMI for groups 8 and 9 to 
assess immunological response to secondary 
(Group 9) and tertiary (Group 8) homologous 
CHMI, and addition of new malaria naïve 
group (Group 10) as comparative controls 
undergoing primary challenge. 
Updates to study group sizes and addition of 
figure to demonstrate volunteer flow through 
first, second and third CHMI (Figure 5) 
Addition of last visit for all vaccinated 
volunteers (Groups 1-4, 5 and 7) to assess 
durability of immune responses 1-2 years since 
their final vaccination.  
Yrene Themistocleous 
Angela Minassian 
9.0 
10th October 2018 
Removal of all aspects added as part of SA008 
(not MHRA approved) relating to further 
CHMI for groups 8 and 9 to assess 
immunological response to secondary (Group 
9) and tertiary (Group 8) homologous CHMI, 
and addition of new malaria naïve group 
(Group 10) as comparative controls undergoing 
primary challenge and related changes to study 
group sizes and figure to demonstrate volunteer 
flow through first, second and third CHMI. 
Extension of period for additional last visit for 
all vaccination volunteers (Groups 1-5 and 7) 
to 1-2.5 years and changes relating to tests 
performed at this visit (removal of all tests 
except for blood draw for immunological 
analysis, with urine pregnancy testing replaced 
by requirement of female volunteers to self-
Yrene Themistocleous 
Angela Minassian 

VAC063 Protocol v9.0 
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report pregnancy status at this visit only). 
Addition of contact to GP to inform them of 
the participation in this additional visit (with 
participant consent). 

VAC063 Protocol v9.0 
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A Phase I/IIa clinical trial to assess the safety, immunogenicity and efficacy of the blood-stage 
Plasmodium falciparum malaria vaccine candidate RH5.1/AS01 
Study Code:  VAC063 
EudraCT Number: 2016-001718-31 
IRAS project ID: 206835 
NRES Committee South Central - Oxford A Reference number: 16/SC/0345 
Chief Investigator: 
 
 
 
 
 
Dr Angela M. Minassian 
Centre for Clinical Vaccinology and Tropical Medicine 
Churchill Hospital, Old Road, Headington 
Oxford, OX3 7LE 
Tel: 01865 611425 
Fax: 01865 289694 
Email: angela.minassian@ndm.ox.ac.uk 
Senior Laboratory Investigator: 
Prof Simon J. Draper 
The Jenner Institute, University of Oxford 
Old Road Campus Research Building 
Roosevelt Drive 
Oxford, OX3 7DQ 
Tel: 01865 617624 
Email: simon.draper@ndm.ox.ac.uk 
Principal Investigator (Southampton): 
 
 
 
 
 
Prof Saul N. Faust   
NIHR Wellcome Trust Clinical Research Facility  
C Level, West Wing, Mailpoint 218 
University Hospital Southampton NHS Foundation Trust 
Tremona Road, Southampton, SO16 6YD 
Tel: 023 8079 6883 
Fax: 023 8079 5023  
Email: s.faust@soton.ac.uk 
Principal Investigator  
(Guys and St Thomas’): 
Dr Anna L. Goodman 
Guys and St Thomas' NHS Foundation Trust 
Department of Infection 
5th Floor North Wing 
St Thomas Hospital, Westminster Bridge Road 
London, SE1 7EN 
Tel: 0207188 3093 
Email: Anna.Goodman@gstt.nhs.uk 
Trial Centres: 
 
 
 
Centre for Clinical Vaccinology and Tropical Medicine 
Churchill Hospital,  
Old Road, Headington 
Oxford, OX3 7LE 
Tel: 01865 611417   
Fax: 01865 289694 
PI at site: Dr Angela M. Minassian  
 
NIHR Wellcome Trust Clinical Research Facility (NIHR 
WTCRF) 
University Hospital Southampton NHS Foundation Trust 
Southampton, SO16 6YD 
Tel: 023 8079 4989 
PI at Site: Prof Saul N. Faust 

VAC063 Protocol v9.0 
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Guys and St Thomas’ NIHR Clinical Research Facility 
4th Floor North Wing 
St Thomas Hospital, Westminster Bridge Road 
London, SE1 7EN 
Tel: 02071883127 
PI at site: Dr Anna L. Goodman 
 
Sponsoring Institution: 
 
 
 
University of Oxford 
Clinical Trials Research Governance 
Joint Research Office 
University of Oxford 
Boundary Brook House 
Churchill Drive 
Headington 
OXON, OX3 7GBTel: 01865 616480 
Fax: 01865 572228 
Email: ctrg@admin.ox.ac.uk 
Local Safety Monitor (Chairman of Local 
Safety Committee): 
Dr Brian Angus 
Centre for Clinical Vaccinology and Tropical Medicine 
Churchill Hospital, Old Road, Headington 
Oxford, OX3 7LE 
Tel: 01865 553 20289 
Email: brian.angus@ndm.ox.ac.uk 
 
External Monitor: 
Clinical Trials Research Governance 
Joint Research Office 
University of Oxford 
Boundary Brook House 
Churchill Drive 
Headington 
OXON, OX3 7GB 
Tel: 01865 616480 
Fax: 01865 572228 
Email: ctrg@admin.ox.ac.uk 
 

VAC063 Protocol v9.0 
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Investigator Agreement 
“I have read this protocol and agree to abide by all provisions set forth therein. 
I agree to comply with the principles of the International Conference on Harmonisation Tripartite Guideline 
on Good Clinical Practice.” 
 
Chief Investigator 
Dr Angela M. Minassian 
 
 
Investigator 
Signature
 
 
Date 26/10/18 
 
“I have read this protocol and agree to abide by all provisions set forth therein. 
I agree to comply with the principles of the International Conference on Harmonisation Tripartite Guideline 
on Good Clinical Practice.” 
 
Senior Laboratory Investigator 
Prof Simon J. Draper 
 
 
Investigator 
Signature
 
 
Date 26/10/18 
 
“I have read this protocol and agree to abide by all provisions set forth therein. 
I agree to comply with the principles of the International Conference on Harmonisation Tripartite Guideline 
on Good Clinical Practice.” 
 
 
Principal Investigator- Guys and St 
Thomas 
Dr Anna L. Goodman 
 
 
Investigator 
Signature
 
 
Date 26/10/18 
 
“I have read this protocol and agree to abide by all provisions set forth therein. 
I agree to comply with the principles of the International Conference on Harmonisation Tripartite Guideline 
on Good Clinical Practice.” 
 
 
Principal Investigator- Southampton 
Prof Saul N. Faust 
 
 
Investigator 
Signature
 
 
Date 26/10/18 
 
 

VAC063 Protocol v9.0 
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8 
 
 
Confidentiality Statement 
This document contains confidential information that must not be disclosed to anyone other than the 
Sponsor, the Investigator Team, the Regulatory Authority and members of the Independent Ethics 
Committee. This information cannot be used for any purpose other than the evaluation or conduct of the 
clinical investigation without the prior written consent of Dr Angela Minassian or Professor Simon Draper. 
 

VAC063 Protocol v9.0 
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9 
Conflict of Interest 
1. “According to the Declaration of Helsinki, 2008, I have read this protocol, and declare the following  
conflict of interest” 
Details: I have a family member who is an inventor on patents for RH5-based vaccines. 
 
Chief Investigator 
Dr Angela M. Minassian 
 
 
Investigator 
Signature
 
 
Date 26/10/18 
2. “According to the Declaration of Helsinki, 2008, I have read this protocol, and declare the following  
conflict of interest” 
Details: I am a named inventor on patents relating to RH5-based vaccines. 
 
 
Principal Investigator 
Professor Simon J. Draper 
 
Investigator 
Signature
 
 
Date 26/10/18 
3.  “According to the Declaration of Helsinki, 2008, I have read this protocol, and declare no conflict of 
interest” 
Details:_________________________________________________________________________ 
 
 
Principal Investigator 
Professor Saul N. Faust 
 
Investigator 
Signature
 
 
Date 26/10/18 
 
4. “According to the Declaration of Helsinki, 2008, I have read this protocol, and declare no conflict of 
interest” 
Details:_________________________________________________________________________ 
 
 
 
 
 
 
 
 
Principal Investigator 
Dr Anna L. Goodman 
 
Investigator 
Signature
 
 
Date 26/10/18 
 

VAC063 Protocol v9.0 
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Table of Contents 
1 
Synopsis ................................................................................................................................................... 13 
2 
Abbreviations ........................................................................................................................................... 15 
3 
Background and Rationale ....................................................................................................................... 17 
 
The need for a vaccine against Plasmodium falciparum malaria .................................................... 17 
3.1
 
Lifecycle of the Plasmodium falciparum malaria parasite .............................................................. 18 
3.2
 
Rationale for a blood-stage vaccine against Plasmodium falciparum malaria................................ 18 
3.3
 
RH5 as an antigen ............................................................................................................................ 19 
3.4
 
Rationale for blood-stage controlled human malaria infection ...................................................... 20 
3.5
4 
Overview of Previous Research ............................................................................................................... 21 
 
Clinical trials ..................................................................................................................................... 21 
4.1
 
Pre-clinical studies ........................................................................................................................... 21 
4.2
 
Potential immunity conferred by a previous malaria challenge and safety data to support a re-
4.3
challenge of healthy volunteers .................................................................................................................. 22 
5 
Controlled Human Malaria Infection Studies .......................................................................................... 24 
 
Microbial Challenge Studies of Human Volunteers ......................................................................... 24 
5.1
 
Controlled Human Malaria Infection (Challenge)............................................................................ 24 
5.2
 
Experimentally-induced blood-stage malaria infection (IBSM) ....................................................... 27 
5.3
 
Clinical Presentation Post-CHMI ...................................................................................................... 29 
5.4
 
Ethical Considerations of CHMI trials .............................................................................................. 29 
5.5
6 
Investigational Products .......................................................................................................................... 30 
 
The RH5.1 Protein (also see Investigator’s Brochure [IB]) .............................................................. 30 
6.1
 
The Adjuvant: AS01 (also see IB) ..................................................................................................... 30 
6.2
 
Storage of Vaccines ......................................................................................................................... 32 
6.3
 
Administration of Vaccines .............................................................................................................. 32 
6.4
 
Vaccine Supply ................................................................................................................................. 32 
6.5
7 
Objectives and Endpoints ........................................................................................................................ 33 
 
Primary objectives ........................................................................................................................... 33 
7.1
 
Primary Outcome Measures ............................................................................................................ 33 
7.2
 
Primary efficacy endpoint (Phase IIa stage of the trial, Groups 5 and 6): ....................................... 33 
7.3
 
Secondary objectives ....................................................................................................................... 33 
7.4
 
Secondary Outcome Measures ....................................................................................................... 33 
7.5
 
Secondary efficacy analysis: ............................................................................................................ 34 
7.6
 
Secondary efficacy endpoint (Groups 7-9): ..................................................................................... 34 
7.7
 
Protocol pre-specified analyses for immunological correlates of efficacy (Groups 5 and 6): ......... 34 
7.8
8 
Recruitment and Withdrawal of Trial Volunteers ................................................................................... 35 
 
Volunteers ....................................................................................................................................... 35 
8.1

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Informed consent ............................................................................................................................ 36 
8.2
 
Inclusion and exclusion criteria ....................................................................................................... 37 
8.3
 
Withdrawal of Volunteers ............................................................................................................... 40 
8.4
 
Pregnancy ........................................................................................................................................ 40 
8.5
 
Safety Stopping/ Holding Rules ....................................................................................................... 41 
8.6
9 
Study Overview ........................................................................................................................................ 43 
 
Study Groups ................................................................................................................................... 43 
9.1
 
Potential Risks for volunteers .......................................................................................................... 48 
9.2
 
Known Potential Benefits ................................................................................................................ 51 
9.3
10 
Experimentally Induced Blood-Stage Malaria Infection Inoculum ...................................................... 52 
 
Storage conditions ........................................................................................................................... 52 
10.1
 
Administration of the inoculum ...................................................................................................... 52 
10.2
11 
Treatment of Trial Volunteers ............................................................................................................. 53 
 
Trial Sites ......................................................................................................................................... 53 
11.1
 
Study procedures ............................................................................................................................. 53 
11.2
 
Study visits ....................................................................................................................................... 54 
11.3
12 
Assessment of Safety ........................................................................................................................... 71 
 
Interim Safety Review ...................................................................................................................... 71 
12.1
 
Definitions ....................................................................................................................................... 71 
12.2
 
Foreseeable Adverse Reactions: ...................................................................................................... 72 
12.3
 
Other Foreseeable Medical Occurrences ........................................................................................ 72 
12.4
 
Expected Serious Adverse Events .................................................................................................... 72 
12.5
 
Causality Assessment ...................................................................................................................... 72 
12.6
 
Reporting Procedures for All Adverse Events .................................................................................. 73 
12.7
 
Volunteers to whom an IMP has not been administered ............................................................... 74 
12.8
 
Adverse Events of Special Interest .................................................................................................. 74 
12.9
 
Assessment of Severity ................................................................................................................ 75 
12.10
 
Procedures to be followed in the event of abnormal findings .................................................... 76 
12.11
 
Local Safety Committee ............................................................................................................... 76 
12.12
13 
Statistics ............................................................................................................................................... 77 
 
Sample Size Selection for Groups 1 - 4 ............................................................................................ 77 
13.1
 
Description of Power Calculations for Groups 5 and 6 ................................................................... 77 
13.2
 
Sample Size Selection for Groups 7, 8, 9 and 10 ............................................................................. 79 
13.3
14 
Quality Control and Assurance Procedures ......................................................................................... 80 
15 
Ethics.................................................................................................................................................... 82 
 
Declaration of Helsinki ..................................................................................................................... 82 
15.1

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ICH Guidelines for Good Clinical Practice ........................................................................................ 82 
15.2
 
Informed Consent ............................................................................................................................ 82 
15.3
 
Research Ethics Committee (REC) ................................................................................................... 82 
15.4
 
Volunteer Confidentiality ................................................................................................................ 82 
15.5
16 
Data Handling and Record Keeping ..................................................................................................... 83 
 
Data Handling .................................................................................................................................. 83 
16.1
 
Record Keeping ................................................................................................................................ 83 
16.2
 
Source Data and Case Report Forms (CRFs) .................................................................................... 83 
16.3
 
Data Protection................................................................................................................................ 83 
16.4
17 
Financing and Insurance ...................................................................................................................... 84 
 
Financing .......................................................................................................................................... 84 
17.1
 
Insurance ......................................................................................................................................... 84 
17.2
18 
Compensation ...................................................................................................................................... 85 
19 
References ........................................................................................................................................... 86 
20 
Appendix A: Laboratory Values for Exclusion ...................................................................................... 91 
 

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1 
SYNOPSIS 
Title 
A Phase I/IIa clinical trial to assess the safety, immunogenicity and efficacy of the 
blood-stage Plasmodium falciparum malaria vaccine candidate RH5.1/AS01  
Trial Centres 
Centre for Clinical Vaccinology and Tropical Medicine (CCVTM) 
Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK 
NIHR Wellcome Trust Clinical Research Facility (NIHR WTCRF) 
University Hospital Southampton NHS Foundation Trust Southampton, SO16 6YD 
Guys and St Thomas’ NIHR Clinical Research Facility 
St Thomas Hospital, Westminster Bridge Road, London, SE1 7EN 
Clinical Phase  I/IIa  
Design 
Open-label, multi-centre, first-in-human, dose escalation Phase I/IIa blood-stage P. 
falciparum malaria vaccine trial. 
Population 
Healthy, malaria naïve males and non-pregnant females aged 18 – 45 years 
Sample Size 
Phase I Stage 
Group 1: 6 - 12 volunteers 
Group 2: 6 -12 volunteers 
Group 3: 12 volunteers 
Group 4: 12 volunteers 
Phase IIa Stage 
Group 5: 15 volunteers 
Group 6: 15 volunteers 
Group 7: 5-15 (previously Group 5) 
volunteers 
Group 8: 5-15 (previously Group 6) 
volunteers 
Group 9: 5-6 volunteers 
Total: 74 - 84 volunteers  
Follow-up 
duration 
Volunteers will be followed up for a total of approximately 8 months in Groups 1, 2 
and 4 and 1 year in Group 3. Follow- up duration will be approximately 8 months for 
Group 5, 3 months for Group 6, and 3 months for Group 9. Volunteers in Groups 1,2, 
3, 4 or 5 who elect to attend for a visit 1-2.5 years after their last vaccination dose will 
be followed for a further 6 months  2 years. Those Group 5 and 6 volunteers who 
transition to Groups 7 and 8 will be followed up for approximately a further 6 and 3 
months respectively. Volunteers in Group 7 who elect to attend for a visit 1-2.5 years 
after their last vaccination dose will be followed for a further 9 months – 2 years and 3 
months 
Planned Trial 
Period 
Approximately 3.5 years, from the Oxford site initiation visit (SIV).  
Primary 
Objectives 
To assess the safety of the RH5.1/AS01 vaccine in healthy volunteers at different 
doses. 
To establish whether the RH5.1/AS01 vaccine can demonstrate a reduced parasite 
multiplication rate in vaccinated subjects compared to infectivity controls in a blood-
stage controlled human malaria infection model. 
Secondary 
Objectives 
To assess the humoral and cellular immunogenicity of RH5.1/AS01 when administered 
to healthy volunteers at different doses. 
To assess immunological readouts for association with a reduced parasite 
multiplication rate. 
To assess the durability of any reduction in parasite multiplication rate (PMR) in 
vaccinated (Group 5) subjects by subjecting them to a re-challenge with 3D7 clone 
parasites approximately 4 months after the primary challenge (Group 7), and 
comparing the PMR with 1) that of previously challenged Group 6 controls receiving a 
second challenge (Group 8); and 2) that of newly recruited malaria-naïve controls 

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(Group 9) receiving a primary challenge. 
 
Investigational 
Product 
RH5.1 
AS01 
Form 
The RH5.1 is a recombinant protein vaccine in liquid form stored between –70°C and –
90°C. It is allowed to thaw to room temperature and then administered within an 
hour of thawing. It will be mixed with the GSK Adjuvant System AS01 (stored at +2 to 
+8°C) immediately prior to administration. 
Dose 
Group 1: 3 doses of 2µg RH5.1 in 0.5mL AS01 at days 0, 28 and 56 
Group 2: 3 doses of 10µg RH5.1 in 0.5mL AS01 at days 0, 28 and 56 
Group 3: 2 doses of 50µg RH5.1 in 0.5mL AS01 at days 0 and 28, followed by 10µg 
RH5.1 in 0.5mL AS01 at day 182 
Group 4: 3 doses of 50µg RH5.1 in 0.5mL AS01 at days 0, 28 and 56 
Group 5: 3 doses of 10 µg RH5.1 in 0.5mL AS01 at days 0, 28 and 56 
Group 7: Group 5 participants receiving 1 further dose of 10 µg RH5.1 in 0.5 mL AS01 
approximately 4 months after the last immunisation 
Groups 6, 8, 9: Infectivity controls 
Route 
Intramuscular (IM) injection in the deltoid region of the non-dominant arm 

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2 
ABBREVIATIONS 
AE 
Adverse event 
ADR 
Adverse drug reaction 
AID 
Autoimmune Disease 
AMA1 
Apical membrane antigen 1 
AR 
Adverse reaction 
AS01 
Adjuvant system 01 
CBF 
Clinical Bio-manufacturing Facility 
CCVTM 
Centre for Clinical Vaccinology and Tropical Medicine 
ChAd63 
Chimpanzee adenovirus 63 
ChAd63 RH5 
Recombinant chimpanzee adenovirus 63 encoding the Plasmodium 
falciparum reticulocyte-binding protein homologue 5 
CHMI 
Controlled human malaria infection 
CRF 
 
Case Report Form or Clinical Research Facility 
CS/CSP 
 
Circumsporozoite protein 
CTRG 
 
Clinical Trials Research Governance 
DSUR 
 
Development safety update report 
ECG 
 
Electrocardiogram 
ELISA 
 
Enzyme-linked immunosorbent assay 
ELISPOT 
Enzyme-linked immunospot 
FBC 
Full blood count 
FDA 
United States Food and Drug Administration 
GCP 
Good Clinical Practice 
GP 
General Practitioner  
GSK 
GlaxoSmithKline 
HCG 
Human Chorionic Gonadotrophin 
HLA 
Human leukocyte antigen 
IB 
Investigators’ Brochure 
ICH 
International Conference on Harmonisation of Technical Requirements for 
Registration of Pharmaceuticals for Human Use 
IMP 
Investigational Medicinal Product 
IMP-D 
Investigational Medicinal Product Dossier 
LSC 
Local safety committee 
LSM 
Local safety monitor 
µg 
microgram 
MHRA 
Medicines and Healthcare products Regulatory Agency 
MPL 
Monophosphoryl lipid A 
MSP1 
Merozoite surface protein 1 
MVA 
Modified vaccinia virus Ankara 
MVA RH5 
Recombinant modified vaccinia virus Ankara encoding the P. falciparum 
reticulocyte-binding protein homologue 5  
NHS 
National Health Service 
NIHR 
National Institute for Health Research 
pfu 
plaque-forming units 

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PCR 
Polymerase chain reaction 
PMR 
Parasite Multiplication Rate 
QA 
Quality assurance 
QIMR 
Queensland Institute of Medical Research 
QP 
Qualified person 
qPCR 
Quantitative polymerase chain reaction 
QS21 
Quillaja saponaria saponin molecule fraction 21 
REC 
Research Ethics Committee 
RH5 
Reticulocyte-binding protein homologue 5 
RUNMC 
Radboud University Nijmegen Medical Centre 
SAE 
Serious adverse event 
SAR 
Serious Adverse Reaction 
SD 
Standard deviation 
SmPC 
Summary of Product Characteristics 
SOP 
Standard Operating Procedure 
SUSAR 
Suspected unexpected serious adverse reaction 
TMF 
Trial master file 
USAID 
United States Agency for International Development  
vp 
viral particle 
WHO 
World Health Organisation 
WTCRF 
Wellcome Trust Clinical Research Facility 

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3 
BACKGROUND AND RATIONALE 
 
The need for a vaccine against Plasmodium falciparum malaria 
3.1
Malaria in humans is caused by five species – Plasmodium falciparum, Plasmodium vivax, Plasmodium 
ovale, Plasmodium malariae and Plasmodium knowlesi. P. falciparum causes the most morbidity and 
mortality of the Plasmodium species, accounting for an estimated 187 million cases of malaria and 438,000 
deaths worldwide in 2015. Globally, there are thought to be around 3.2 billion people at risk of malaria, 
with sub-Saharan African populations at highest risk of acquiring malaria: approximately 90% of deaths are 
estimated to occur in the World Health Organisation (WHO) African Region. Children under five years of 
age are the most severely affected, accounting for 70% of deaths from this infection 1. 
Since 2000 massive efforts have been made to increase distribution of commodities to prevent malaria 
across Africa, with a significant reduction in malaria deaths. It is estimated that an estimated 663 (542 – 
753) million cases have been averted in Africa since the introduction of control measures in 2000, the most 
effective of which has been the widespread use of insecticide treated nets (ITNs) which is thought to 
account for 68 (62 – 73)% of the averted cases 2. However, challenges to the success of current strategies to 
combat malaria (such as insecticide-treated nets, indoor residual spraying, and antimalarial drugs) include: 
the development of resistance of Anopheles mosquitoes to certain insecticides; the development of 
resistance of malaria parasites to chemotherapeutic agents 3; the absence of a gametocidal drug suitable 
for mass administration 4; and the risk of re-importation of malaria into geographic regions previously 
cleared of malaria using environmental elimination measures.  
The Roll Back Malaria (RBM) Partnership was launched in 1998 by the WHO, the United Nations Children’s 
Fund (UNICEF), the United Nations Development Programme (UNDP) and the World Bank. A major goal of 
the RBM Partnership is to support the development of a vaccine against malaria as a key future strategy for 
reducing mortality from malaria. The development of an effective vaccine may indeed be necessary for the 
greater goal of global eradication of malaria 5. The recently updated Malaria vaccine technology roadmap 
calls for the development of a vaccine against P. falciparum and P. vivax by 2030, that will have protective 
efficacy of at least 75 percent against clinical malaria, suitable for administration to appropriate at-risk 
groups and development of vaccines to reduce malaria transmission suitable for administration in mass 
campaigns 6.  
 

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Lifecycle of the Plasmodium falciparum malaria parasite 
3.2
 
Figure 1: Lifecycle of Plasmodium falciparum.  
 
In the pre-erythrocytic stage of human infection, the bite of infected female Anopheles mosquitoes 
transmits malaria sporozoites to the human host where they travel via the bloodstream to the liver and 
invade hepatocytes (liver-stage). Here they mature into merozoites for 6 to 7 days, after which the 
hepatocytes rupture releasing thousands of merozoites into the bloodstream. Merozoites then invade 
erythrocytes where they multiply and after 2 days cause the erythrocyte to rupture, releasing progeny 
merozoites that in turn invade new erythrocytes (blood-stage). A small percentage of merozoites 
differentiate into male and female gametocytes. These are ingested by a mosquito when it takes a blood 
meal and they unite within the mosquito’s midgut to form a zygote. The zygote matures and releases 
sporozoites which migrate to the mosquito’s salivary glands and are injected into the human when the 
mosquito feeds. Infection by sporozoites and the liver-stage of malaria is asymptomatic.  It is the blood-
stage of infection that is associated with symptoms and potentially severe or fatal complications. 
 
Rationale for a blood-stage vaccine against Plasmodium falciparum malaria 
3.3
Immunity to malaria develops naturally over time following frequent exposure. No single overriding 
correlate of protection has been described, however the cumulative acquisition of protective antibodies 
against blood-stage antigens is well documented and arguably essential for natural immunity 7. The 
immunity that develops confers protection against severe disease such as cerebral malaria, hypoglycaemia, 
metabolic acidosis and renal failure. However, this immunity is dependent on repeated boosting by regular 
infection and is therefore present in adults but not children who remain at risk of severe and often fatal 
disease 7. A vaccine targeting the blood-stage of malaria is an attractive proposition as it could generate an 
immune response which mimics the already proven protective natural immunity seen in adults, or could 
control parasitaemia by alternative mechanisms but also allowing for induction of other naturally-acquired 
immune mechanisms in parallel. Ideally a blood-stage vaccine would therefore lead to a reduction in 
disease severity whilst still allowing exposure to parasites so the opportunity for the host’s natural 
immunity to develop is preserved 8. This process would not occur with pre-erythrocytic vaccines, meaning 
that if the effects of the vaccine waned or control measures failed, individuals living in malaria endemic 
regions would be at risk of rebound of severe malaria disease 9. 
There are several lines of evidence supporting the feasibility of a blood-stage vaccine, including: 

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 
Induction of protective immunity with defined antigens in animal models 10,11; 
 
The ability of adoptively transferred B cells from immune donors to B cell-deficient mice to clear 
parasitaemia 11; 
 
Age-related acquisition of immunity against severe clinical malaria in endemic regions 12,13; 
 
The ability of passively transferred antibodies from immune adults to protect against natural and 
challenge infections with P. falciparum 14-16.  
Natural immunity to malaria targets multiple blood-stage antigens and is slowly acquired. PfEMP1 is a 
potential target antigen but is highly polymorphic and immunity is variant specific 12. Field studies have 
shown that more conserved merozoite surface antigens such as merozoite surface protein 1 (MSP1) and 
apical membrane antigen 1 (AMA1) are also targets of naturally-occurring protective blood-stage immunity 
17,18. However, both of these antigens have been tested in both protein-in-adjuvant formulations and in 
viral vectored vaccines, with little success. A Phase IIa efficacy trial using mosquito bite controlled human 
malaria infection (CHMI) in malaria-naïve adults for the viral vectored vaccines developed in Oxford 
(ChAd63/MVA-AMA1 and ChAd63/MVA-MSP1) showed that the induction of strong cellular immunity did 
not impact on parasite growth rates 19. The demonstration of a significant reduction in parasite replication 
in the blood is deemed essential for a blood-stage vaccine to effectively prevent illness when pre-
erythrocytic control measures have failed 8. The main challenges for blood-stage malaria vaccine 
development have been the expression of conformationally correct large antigens, insufficient antibody 
responses and the extensive polymorphism of many candidate blood-stage antigens 20. 
The most promising P. falciparum blood-stage antigen to date is reticulocyte-binding protein homologue 5 
(PfRH5), as it overcomes two major difficulties for blood-stage vaccination: 
- 
Antibodies can block erythrocyte invasion to high efficiency (requiring lower antibody 
concentrations than previous studied targets – MSP1 and AMA1)21,22. 
- 
Antibodies cross-inhibit in vitro all P. falciparum lines and field isolates tested to date 23. 
 
RH5 as an antigen 
3.4
Plasmodium merozoite invasion of erythrocytes is a complex process. The merozoite reorients after an 
initial interaction with the erythrocyte, so that its apical end faces the surface of the cell. A tight junction is 
formed between the merozoite and erythrocyte when the micronemes and rhoptries of the merozoite 
discharge their contents. The erythrocyte membrane subsequently encases the merozoite, creating a 
vacuole around the invading parasite 24. The micronemal parasite ligands (Duffy-binding proteins, DBPs, or 
erythrocyte binding antigens, EBAs) and rhoptry ligands (reticulocyte-binding proteins, RBPs and their 
homologues) are two families of antigens that are functionally conserved across Plasmodium species and 
are thought to be involved in the tight committed attachment step between the parasite and new host red 
blood cell. 
P. falciparum reticulocyte-binding protein homologue 5 (PfRH5) is one of the reticulocyte binding-like (RBL 
or P. falciparum RBP homologue (PfRH)) proteins which are involved in parasite invasion of red blood cells. 
It is expressed in merozoites and localises to the apical complex. PfRH5 is expressed in all P. falciparum 
strains tested so far, and is essential for parasite survival given two reports that the gene cannot be 
knocked out 25,26. PfRH5 binds to its receptor basigin, the Ok blood group antigen, and this interaction 
mediates an essential interaction required for red blood cell invasion by all tested strains of P. falciparum 
27. Low-level antibodies to PfRH5 can be found in the pooled serum of humans from malaria-endemic 
countries, but not from pooled malaria-non-exposed immune sera 28,29. More recently these responses 
have been associated with clinical protection in an endemic setting, supporting the theory that these 
antibodies may play a part in controlling malaria infection 30. Importantly, although antibodies have been 
found, it appears that PfRH5 does not come under significant immune pressure. This may account for the 
limited polymorphism in PfRH5 which was reported from the malaria whole genome sequencing project 31 

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20 
(using >220 field isolates from Africa, Asia and Oceania) where only 12 single nucleotide polymorphisms 
were identified in this 526 amino acid antigen, and of these only 7 showed a frequency of >5% 21. The 
basigin binding site on PfRH5 may also be functionally constrained, thus limiting polymorphism, given few 
amino acid substitutions have been reported to affect basigin recognition and host red blood cell tropism 
26,32,33. Blocking of the PfRH5-basigin interaction has also been shown to be an important contributor of 
anti-PfRH5 antibody action 34. 
Polyclonal antibodies induced by PfRH5 vaccination (or by natural infection) overcome two of the major 
difficulties for blood-stage vaccination: firstly, antibodies can block erythrocyte invasion to high efficiency 
(requiring lower antibody concentrations than previously studied targets, such as PfAMA1 and PfMSP1) 30, 
and secondly, and even more importantly, these antibodies cross-inhibit in vitro all P. falciparum lines and 
field isolates tested to date 21,23,35,36. Importantly, high-level efficacy induced by PfRH5 vaccination against 
heterologous strain challenge in an in vivo Aotus monkey P. falciparum challenge model has also been 
demonstrated 37. In summary, the full-length PfRH5 antigen is now the highest priority target identified in 
the blood-stage malaria vaccine field for over a decade 23. 
RH5 has entered clinical testing in a Phase Ia trial in Oxford and Southampton (VAC057) using the viral 
vectored vaccines ChAd63 RH5 and MVA RH5. This trial demonstrated that antigen-specific T cells and IgG 
were successfully induced by vaccination, and there were no safety concerns. The antibodies induced by 
vaccination were able to inhibit parasite growth in an assay of growth inhibitory activity (GIA), and 
demonstrated functional activity across a number of laboratory and field strains. The level of antibodies 
induced by viral vectored vaccines is typically lower than with protein-in-adjuvant vaccines, so it is 
anticipated that RH5 given as a soluble protein with a powerful adjuvant will induce higher levels of 
antibody than the viral vectored vaccines. 
 
Rationale for blood-stage controlled human malaria infection 
3.5
The blood-stage controlled human malaria infection (CHMI) model, in which volunteers are inoculated with 
red blood cells infected with 3D7 clone blood-stage parasites, has been used successfully to test drugs 38. In 
2014 a Phase I/IIa trial of the AMA1 vaccine FMP2.1/AS01B was carried out in Oxford to develop the blood-
stage CHMI model for testing blood-stage malaria vaccines. The study was powered to detect a 33% 
decrease in parasite multiplication rate (PMR) with ≥80% power as the primary efficacy endpoint. Although 
the vaccine demonstrated no efficacy in this trial it did demonstrate the reproducibility of the blood-stage 
CHMI model. There was no difference in the mean PMRs between the vaccinees (Group 1) and controls 
(Group 2). The mean PMR for Group 1 was 10.32 (95% confidence interval (CI) 8.97-11.67) and for Group 2 
was 10.31 (95% CI 9.00-11.62), P=0.99 using unpaired t test39.. As part of the analyses in this trial, the PMRs 
in the fifteen infectivity controls were compared to historical data from twenty one unvaccinated infectivity 
control volunteers from four previous CHMI trials, in which volunteers were exposed to the bites of five 
mosquitoes infected with the 3D7 clone of P. falciparum 40-42. PMRs were modelled from these datasets and 
the pooled data showed a similar mean PMR of 10.23 per 48 h, but a significantly larger spread (SD=4.67; 
P=0.008, F test). These data indicate that the blood-stage model provides better power to observe partial 
vaccine efficacy against blood-stage parasite growth rates and, moreover, showed that each individual PMR 
can be modelled from the qPCR data with greater confidence (Payne RO et al., submitted). The blood-stage 
CHMI model is therefore preferable as a means of assessing blood-stage malaria vaccine efficacy as it will 
allow for the detection of partial efficacy more conclusively than with sporozoite CHMI. 

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4 
OVERVIEW OF PREVIOUS RESEARCH 
 
Clinical trials 
4.1
This is a first-in-human study of the soluble protein RH5.1 vaccine with the GSK adjuvant system AS01. The 
RH5 antigen has previously been administered to healthy volunteers in the viral vectored vaccines ChAd63 
RH5 and MVA RH5 in the Phase Ia clinical trial VAC057 (ClinicalTrials.gov identifier: NCT02181088), with no 
safety concerns. This trial demonstrated that RH5-specific antibodies and T cells can be induced by 
vaccination, and that the IgG antibodies are able to inhibit growth of all tested P. falciparum strains in vitro, 
including laboratory lines and recently culture-adapted field isolates43. These data confirmed the RH5 
antigen is immunogenic when administered as a vaccine in healthy UK adults. It is anticipated that the 
RH5.1/AS01 formulation will elicit higher levels of RH5-specific IgG antibodies than the ChAd63-MVA 
formulation, given previous experience with other antigens such as AMA1 and MSP1 that have also been 
tested in humans using both subunit vaccine delivery strategies 42,44-46. 
 
Pre-clinical studies 
4.2
RH5.1 has been administered to BALB/c mice with the AS01 adjuvant, and was shown to elicit high-levels of 
growth inhibitory antibodies. Similar (but not identical) RH5-based protein/adjuvant vaccines have been 
administered to mice, rats, rabbits and Aotus nancymaae monkeys and in all cases have been shown to 
elicit high-levels of strain-transcending neutralising antibodies 35-37,47-49. 
In the recent pre-clinical study conducted in Oxford with RH5.1/AS01 in BALB/c mice, mice were immunised 
with three doses of RH5.1 - either 2 µg, 10 µg or 50 µg in 50 µL AS01 at 4 week intervals (6 mice per group). 
A group of mice were also vaccinated with three doses of 50 µg RH5.1 in PBS (n=6), and another 6 mice 
received 50µg RH5.1 in the Addavax adjuvant for comparison (an oil-in-water emulsion similar to MF59 or 
AS03 adjuvant). Vaccinations were administered intramuscularly and blood was collected at 4, 8 and 10 
weeks. Similar levels of anti-RH5 IgG were induced by all doses of RH5.1 in AS01 (Figure 2). Purified IgG 
from serum demonstrated inhibition of P. falciparum growth in a GIA assay, with the lower doses (2 µg and 
10 µg) demonstrating the highest levels of inhibition (lowest EC50s) (Figure 3). 
 
 
Figure 2: Anti-RH5 IgG induced by vaccination of BALB/c mice at 0, 4 and 8 weeks. ELISA responses are 
shown at the peak (week 10). 
 
A n ti-P fR H 5  Ig G  (A U )
A d d a v a x  +  R H 5  5 0  u g
A S 0 1  +  R H 5  5 0  u g
A S 0 1  +  R H 5  1 0  u g
A S 0 1  +  R H 5  2  u g
P B S  +  R H 5  5 0  u g
1 0 2
1 0 3
1 0 4
1 0 5
1 0 6

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Figure 3: In vitro GIA of purified IgG from mice vaccinated with RH5.1 in Addavax, AS01 and PBS. 
 
 
Potential immunity conferred by a previous malaria challenge and safety data to support a re-
4.3
challenge of healthy volunteers 
There is no precedent in the modern CHMI era for re-challenge of volunteers who were not sterilely 
protected and reached thick smear positive on the primary infection. The old neurosyphilis P. vivax malaria 
data 51 showed a reduction in fever episodes and a log reduction in the maximum mean parasite count after 
a homologous P. vivax and P. falciparum re-challenge, lending support to the concept of conferred 
protection from a prior challenge, but with little experience in human blood-stage re-challenge in the 
modern era, the effect in blood-stage P. falciparum remains unknown. Only one previous study has 
administered a second intravenous P. falciparum challenge in humans to date52. Five malaria naïve 
volunteers were repeatedly inoculated with infected erythrocytes at low doses, followed by administration 
of anti-malarials before development of clinical infection. Three of the four volunteers who completed the 
study were protected from infection after three rounds of low dose blood-stage challenge and cure, with 
no demonstrable DNA by qPCR after the fourth inoculation. However, with very small numbers, lack of a 
control group and detection of residual atovaquone, which may have caused this protective effect, the 
interpretation of these results is difficult.52,53  
 
The reason for the lack of experience of re-challenge in a blood-stage P. falciparum challenge model is that 
until this study, there has never been any protective efficacy shown with a blood-stage vaccine, so there 
has never been any reason to re-challenge volunteers. Ours is the first study to show any efficacy of a 
blood-stage vaccine in over 40 years, which is why it is of immense scientific importance to take this further 
to assess the durability of any vaccine-induced protection, and at the same time answer the fascinating 
question of whether exposure to a previous challenge (with or without a prior vaccination) may confer 
immunity against a second challenge.   
In the natural exposure setting (i.e., in endemic countries) it is well known that prior exposure to malaria 
can confer immunity to subsequent exposures, such that individuals can go on to develop asymptomatic 
infections where they are able to tolerate much higher levels of parasitaemia without symptoms or clinical 
signs of malaria7. Safety of re-challenge is indicated by the natural history of induced protection from 
previous malaria exposure in endemic areas, as well as the wealth of data from repeated infection 
administered as malariotherapy, which strongly indicates that exposing a previously malaria-exposed 
volunteer to a second or third challenge would not confer any additional risk over that of a first challenge. 
Indeed, it is highly possible that this may in fact confer some protective immunity (and so could result in a 
Ig G  C o n c e n tra tio n  (u g /m l)
G IA  (% )
1 0
1 0 0
1 0 0 0
-2 0
0
2 0
4 0
6 0
8 0
1 0 0
A d d a va x +  R H 5  5 0  u g
P B S  +  R H 5  5 0  u g
A S 0 1  +  R H 5  5 0  u g
A S 0 1  +  R H 5  1 0  u g
A S 0 1  +  R H 5  2  u g
A S 0 1  O n ly

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23 
milder infection and delay the time to diagnosis). Alternatively, if there is no immunity from the previous 
challenge or challenges, then this repeat would be like the prior challenge, with no change in risk.  
 
 
It is also important (and of particular relevance to a study of healthy volunteers) to clarify that hundreds of 
healthy volunteers (i.e. not those in endemic countries) in other malaria vaccine trials worldwide, have in 
fact been re-challenged with P. falciparum malaria as part of a controlled human infection model using 
either the mosquito bite40,54-56 or injected sporozoite57,58 routes of challenge (and the same 3D7 strain of P. 
falciparum as used here for blood-stage challenge). These include volunteers in the UK, the Netherlands 
and the USA40,54-58. There have been no safety concerns in any of these trials as result of a re-challenge so 
there is evidence for safety of a re-challenge, both in the experimental and natural settings, and it is well 
known that the safety of the blood-stage model is no different from that of the mosquito or sporozoite 
models. While most of these studies did not re-challenge control volunteers (only vaccinees who had either 
been sterilely protected or not protected) it is important to highlight that interpreting the effects of a re-
challenge in a vaccinated group, without a parallel control group can be very difficult, and we believe our 
study design is ideal to assess this.  
 
We are therefore confident that: 
 
 1) We have a strong scientific rationale for re-challenge, with incorporation of crucial control groups 
(malaria exposed and malaria naïve); 
 2) There is no additional concern re volunteer safety, given the wealth of safety data on P. falciparum re-
challenge from both experimental and natural settings; and 
 3) The scientific output of the study will be greatly enhanced by including these control groups. 

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5 
CONTROLLED HUMAN MALARIA INFECTION STUDIES 
 
Microbial Challenge Studies of Human Volunteers 
5.1
The deliberate infection of human volunteers with micro-organisms has contributed uniquely to our 
understanding of the pathogenesis, immune responses and the treatment and prevention of numerous 
microbial diseases including influenza, cholera, typhoid and hepatitis 59,60. A review by the UK Academy of 
Medical Sciences on microbial challenge studies recognised that such studies are desirable for providing 
proof of concept for prophylactic and therapeutic interventions and can significantly accelerate progress to 
Phase III studies 59. 
 
Controlled Human Malaria Infection (Challenge) 
5.2
Plasmodium falciparum malaria is a microbe particularly well suited to challenge studies. It has a relatively 
short asymptomatic period, a well-established diagnostic laboratory test (thick film microscopy), and no 
long term sequelae or infectious state following appropriate and timely treatment. Studies involving 
controlled human malaria infection (CHMI) are a powerful tool for investigating malaria vaccine and 
prophylactic drug efficacy 61. With an increasing number of candidate malaria vaccines being developed, 
the number of centres conducting CHMI studies is expanding 61.  
Deliberate infection of humans with malaria was first performed in 1917 by Wagner von Jauregg, primarily 
as a therapy for patients with neurosyphilis 62. Thousands of patients underwent the treatment (the 
objective of which was to induce a febrile illness that was thought beneficial for the progress of the 
disease), administered by the bites of infectious mosquitoes or by intravenous or subcutaneous inoculation 
of dissected Plasmodium sporozoites suspended in media. The practice stopped with the advent of 
antibiotics effective against syphilis. 
Following the development of protocols for the continuous culture of asexual P. falciparum in 1976 63 and 
for the generation of mature P. falciparum gametocytes in vitro in 1981 64, it became possible to produce 
laboratory-reared infectious mosquitoes, meaning that CHMI trials could be performed more routinely 65. 
The first well-documented CHMI study with laboratory-reared infectious mosquitoes was carried out in 
1986 at the US Walter Reed Army Institute of Research (WRAIR), the US Naval Medical Research Institute 
(NMRI) and the US National Institutes of Health (NIH). Six volunteers were infected with P. falciparum 
sporozoites by the bites of infectious Anopheles freeborni and Anopheles stephensi mosquitoes 66. The 
following year, the efficacies of the first recombinant protein and synthetic peptide P. falciparum vaccines 
were tested in experimentally infected volunteers 67,68.  
CHMI has now become established as a key tool to assess the efficacy of novel malaria vaccines and drugs 
61. As CHMI trials are carried out in a controlled environment, they allow detailed evaluation of parasite 
growth and immunological responses, providing key information for vaccine and drug development 61.  
Since the late 1980s, the number of institutions carrying out CHMI with P. falciparum has been growing. In 
2007, data were published from a total of 532 volunteers 69. Unpublished analysis shows that a total of 
1,343 volunteers were experimentally infected with P. falciparum between 1985 and 2009 70. 
Having been stopped in the 1980s due to ethical and safety concerns, experimentally induced blood-stage 
malaria infection (IBSM) was reintroduced in the 1990s. Human challenge with Plasmodium falciparum 
malaria-infected erythrocytes to enable assessment of blood-stage vaccines, drugs and further investigate 
early events in blood stage infection has been undertaken in over 100 volunteers since 1997 71,72. All of 
these volunteers have been challenged with aliquots of infected erythrocytes taken from a single donor, 
and the number of infected erythrocytes has varied from 30 to 6000 71. Malaria challenge using this method 
has always resulted in parasitaemia as detected by PCR 71. 

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There are several advantages of blood-stage challenge over sporozoite challenge. The ability to give a 
uniform dose of P. falciparum-infected erythrocytes results in much more consistent growth curves 38 with 
a longer pre-patent period, enabling blood-stage vaccines with partial efficacy to be assessed (Figure 4). 
The method also ensures the timing and dose of parasites into the circulation as it eliminates the variability 
of the size of liver-to-blood inoculum seen with sporozoite challenge 71,73. The number of parasites 
inoculated is approximately 100 times lower than the number released from the liver following sporozoite 
challenge, and this enables the blood-stage to be followed for approximately 4-6 more days (2-3 replication 
cycles) 61. The relative consistency of the course of infection allows blood tests to assess immunogenicity to 
be taken at similar stages of blood-stage infection, resulting in data with can be treated with a greater 
degree of confidence. This allows the numbers of participants required to be reduced, making early direct 
comparisons of potential vaccine candidates more affordable 71. 
 
 
Figure 4: Schematic of parasite growth after blood-stage and sporozoite challenge with effect of a 
theoretical blood-stage vaccine reducing parasite multiplication by 30%. Starting levels of parasites are as 
used in the Oxford pilot study 73. An 18-fold 48-hour multiplication is assumed (a typical value in vaccine-
naïve subjects under both blood-stage and sporozoite challenge). 
Oxford’s Experience Conducting CHMI Trials 
The University of Oxford has been conducting CHMI studies for the last 12 years. To date, more than 400 
volunteers have undergone CHMI in studies conducted by the University of Oxford, including over 120 
unvaccinated control volunteers (Table 1). A recent meta-analysis has shown that the symptoms of malaria 
experienced by volunteers undergoing sporozoite challenge by mosquito bite in Oxford are broadly similar 
to those experienced by volunteers challenged by mosquito bite at RUNMC and the United States Military 
Malaria Vaccine Program (USMMVP) 74.  
In Oxford, four volunteers have required admission to hospital for observation following challenge (SAE 
related to CHMI). 
 
Patient 1: VAC013: Vaccinated Volunteer: Admitted for 48 hours due to vomiting and received 
intra-venous fluids and anti-emetics as additional therapy. 
 
Patient 2: VAC022: Vaccinated Volunteer: Admitted for 12 hours following the development of mild 
eyelid oedema following chloroquine treatment. This resolved spontaneously and was considered 
related to the treatment with chloroquine. 
 
Patient 3: VAC039: Unvaccinated Control volunteer: Admitted to hospital for 24 hours for 
intravenous fluid rehydration and observation following a pre-syncopal episode and moderately 
severe symptoms of uncomplicated malaria. 

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 
Patient 4: VAC045: Vaccinated Volunteer: Admitted to hospital with lassitude and vomiting due to 
malaria and malarone treatment. Treated with anti-emetics, intravenous fluid rehydration, 
cessation of malarone, and antimalarial treatment with Riamet. Discharged from hospital the 
following day.   
Trial 
(Reference) 
Year 
Type of Challenge  
No. Vaccinees 
Challenged 
No. Controls 
Challenged 
No. SAEs Related to 
Challenge 
VAC004 
2000 
Sporozoite 
12 
6 
0 
VAC007 
2000 
Sporozoite 
9 
5 
0 
VAC013 
2001 
Sporozoite 
14 
11 
1 
VAC015 75 
2001/3 
Sporozoite 
16 
5 
0 
VAC017 75 
2002 
Sporozoite 
16 
4 
0 
VAC018 54 
2002/3 
Sporozoite 
5 
5 
0 
VAC021 76 
2003/4 
Sporozoite 
16 
6 
0 
VAC022 77 
2003 
Sporozoite 
11 
6 
1 
VAC023 78 
2003/4 
Sporozoite 
15 
6 
0 
BSV 1 
2005 
Blood 
0 
6 
0 
VAC030 
2005/6 
Sporozoite 
24 
6 
0 
VAC027 79,80 
2006/7 
Sporozoite 
15 
6 
0 
MAL034 & 
VAC037 45 
2009/10 
Sporozoite 
43 
12 
0 
VAC035 81 
2010 
Blood 
5 
3 
0 
VAC039 42 
2010 
Sporozoite 
36 
6 
1 
VAC049 82 
2011 
PfSPZ Challenge  
0 
18 
0 
VAC04541 
2012 
Sporozoite 
30 
6 
1 
VAC052 
2013 
Sporozoite 
27 
6 
0 
VAC055 
2013 
Sporozoite 
33 
6 
0 
VAC054 
2014 
Blood 
12 
15 
0 
VAC055 
rechallenge 
2014 
Sporozoite 
14 
5 
0 
VAC059 
2015 
Sporozoite 
36 
4 
0 
TOTAL 
 
 
389 
153 
4 
 
Table 1: CHMI trials conducted to date by the University of Oxford at CCVTM. Sporozoite = mosquito bite. 
Blood = Blood stage challenge. PfSPZ Challenge = aseptic, cryopreserved P. falciparum administered by 
injection. Control = unvaccinated infectivity controls.  
 
In a Phase I/IIa sporozoite challenge study assessing the efficacy of viral vectored malaria vaccines in Oxford 
(VAC039; Clinical trials.gov reference: NCT01142765) 42, one volunteer who underwent sporozoite 
challenge on 1st October 2010 failed to attend his next scheduled study visit on 7th October 2010. The 
police were immediately informed and began a nationwide search for the individual. All volunteers had 
been informed at screening that the police would be notified should they go missing following CHMI if they 
had not completed a full course of an appropriate anti-malarial treatment. The volunteer was found in The 
Netherlands by the local police 17 days following CHMI. He then had very mild malaria symptoms. He was 
admitted to a local hospital where he received appropriate treatment for P. falciparum. He had no signs of 
severe malaria but showed an altered mental state considered unrelated to malaria with apparent memory 
loss and suicidal ideation. He was therefore transferred for in-patient psychiatric assessment and 
discharged a few days later to his GP’s care. He has subsequently been reportedly diagnosed as 
schizophrenic. 

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It emerged that from 2nd October 2010, the day after CHMI, the volunteer had experienced an alteration in 
his expected behaviour following his arrest the previous evening by the police relating to their investigation 
of a serious crime. This arrest appeared to trigger his leaving home and disappearance and appears 
relevant to the subsequent finding of memory loss and suicidal ideation. It emerged on subsequent 
investigation that the volunteer actually had a history of some psychiatric morbidity pre-dating his 
involvement in the study by many years, which was not disclosed at screening by the volunteer or his GP. 
Of note, the volunteer had attended 9 clinic visits prior to challenge and appeared a reliable and 
appropriate volunteer.  
This event was extensively discussed with investigators, colleagues and appropriate authorities and non-
study related causality agreed. Given the exceptional circumstances relating to this case, it seems unlikely 
that a similar event would happen again in the future. Management of the event was extensively reviewed 
by the trial’s Sponsor, the MHRA and ethics committee who felt that appropriate and timely action was 
taken. Follow-up procedures following CHMI have been reviewed locally, and it has been decided that for 
sporozoite challenge studies volunteers are contacted daily on days 1-5 post-challenge in order to make 
sure they are contactable and well. The blood-stage challenge model volunteers are seen from Day 1 post-
challenge and therefore followed even more closely initially. 
 
Experimentally-induced blood-stage malaria infection (IBSM) 
5.3
The samples we propose to use as infectious inocula were produced by Drs Gregor Lawrence, Allan Saul 
and colleagues at QIMR in Brisbane, Australia in 1994 83. The protocol for the study was reviewed and 
approved by the QIMR Ethics Committee and the Healthy Volunteer Studies Research Ethics Subcommittee, 
Lothian Health Board (Edinburgh). Procedures were designed to minimise the risk of other infectious agents 
in the cryopreserved samples.  
Collection and cryopreservation of inoculum 
Laboratory-reared Anopheles stephensi mosquitoes were infected with the P. falciparum clone 3D7 (a 
chloroquine-sensitive strain) by membrane feeding on a blood meal containing gametocytes. Ten and 
fourteen days later, the mosquitoes were fed on two volunteers. Parasitaemia in the volunteers was 
followed by daily microscopy from day 4 after infection. Blood was taken and frozen in aliquots from the 
volunteers 6 hours after they developed fever, when both were microscopically parasite positive. The 
volunteers were treated with chloroquine soon after blood was drawn with complete recovery. 
Initial development of the blood inoculum to be used in this study and its use in five volunteers is described 
by Cheng et al. 1997 83. The inoculum used for all volunteers comes from one of the donors described 
above. This is because the second donor (whose blood has not been used) had a much lower parasitaemia 
71. Blood was collected at the Australian Red Cross Blood Bank in an aseptic manner using standard blood 
bank equipment. The leukocytes were removed with a leukocytic filter. The thawing and washing of the 
cells reduced the amount of serum transferred with the red cells by a factor of 1000, compared to injecting 
the same volume of blood. The volume of inoculum to be given to each volunteer contains a very small 
volume of red blood cells, equivalent to only 1.5 to 4 microlitres of blood.  
The red cells were cryopreserved using a protocol from the American Association of Blood Banks Technical 
Manual that is normally employed for freezing blood from patients and donors with rare blood groups. 
Blood from both volunteers was group O and Rhesus negative.  
Viability of the inoculum was confirmed by culture in a trial in Nijmegen in 2011 84, and may be reconfirmed 
prior to initiation of the study. Viability up to the time expected to be required for inoculations (4 hours) 
may also be confirmed at that time. For each vial of inoculum used a small amount will be cultured after 
inoculations are complete to confirm viability and the estimated number of parasitised red blood cells 
inoculated. 

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Previous Studies 
In the study conducted by Cheng et al. 83, two volunteers infected with the inoculum were treated based on 
positive qPCR prior to development of symptoms; the other three were treated when symptomatic. All 
recovered fully with rapid decline of parasitaemia after treatment with chloroquine.  
Oxford University has previously undertaken three CHMI studies of healthy human volunteers using this 
inoculum. The first was a pilot study, approved in 2003 by the Oxfordshire Research Ethics Committee (ref. 
C03.061) in which 5 volunteers received the inoculum. As expected, the results showed less variation in 
rate of rise of parasitaemia than is typically experienced with a liver-stage (or sporozoite) malaria challenge. 
The trial was successful, with all volunteers being diagnosed with malaria between the morning of day 7 
and the morning of day 9 after inoculation. The symptoms of malaria experienced by volunteers at and 
around the point of diagnosis were as expected. No SAEs were reported. All volunteers were clinically well 
after antimalarial treatment when reviewed in clinic at day 42 after inoculation. During the trial one 
volunteer became mildly anaemic but this was transient, with a normal haemoglobin on repeat testing one 
week later; and one volunteer had a raised bilirubin of 35 µmol/L on two occasions. All volunteers 
successfully completed follow-up 73. 
Following this a Phase IIa study of the Safety, Immunogenicity and Parasite Growth Inhibitory Activity of 
AMA1-C1/Alhydrogel® + CPG 7909 was conducted (VAC035). This involved 8 healthy volunteers (5 vaccinees 
and 3 controls) receiving the blood-stage CHMI with the same inoculum. All individuals challenged 
developed malaria (confirmed by positive blood film and positive qPCR), although only 2 of the 8 subjects 
developed clinical malaria symptoms pre-diagnosis 81. A significant inverse relationship between vaccine-
induced growth inhibitory activity (GIA) and PMR was seen in vaccinated subjects, but no impact on overall 
PMRs was observed across the vaccinated and control groups. However, the sample size in this study was 
very small, limiting the statistical power to assess differences in PMR between the groups 81. 
The most recent blood-stage CHMI trial conducted in Oxford was VAC054, which looked at the safety, 
immunogenicity and efficacy of the AMA1 vaccine candidate FMP2.1 given with the AS01 Adjuvant System. 
In this trial 12 vaccinated volunteers and 15 infectivity controls received the blood-stage CHMI inoculum, 
which was homologous to the vaccine. The vaccine induced functional antibodies which were able to inhibit 
growth in vitro in a growth inhibition activity (GIA) assay, but demonstrated no efficacy with all vaccinees 
and controls developing blood-stage malaria. There was no effect on PMR in vaccinees compared with the 
infectivity control group. However, this trial demonstrated the reproducibility of the blood-stage CHMI 
model, with much larger group sizes than used in previous studies. The study also demonstrated its utility 
for measuring modest reductions in PMR in comparison to mosquito-bite CHMI where analysis of historical 
data showed a higher dispersion of data in the infectivity controls 39. 
The main reason for the small sample size in VAC035 was the requirement for volunteers to be both 
Epstein Barr virus (EBV) and cytomegalovirus (CMV) seropositive. This resulted in the exclusion of 52 of 75 
volunteers screened. Seropositivity was thought necessary as a precaution because the donor of the 
infected erythrocytes was EBV and CMV seropositive, and there was therefore thought to be a risk to 
participants of infection with these viruses. However, both of these herpes viruses are leukocyte-associated 
and the donor blood was leukodepleted and washed before freezing, as well as being extensively washed 
during preparation of the inoculum. Leukodepletion has been shown to be effective in preventing 
transmission of both EBV and CMV 85. PCR analysis of the donor blood for the IBSM has been negative for 
both EBV and CMV since this technology became available (Prof James McCarthy, QIMR, personal 
communication) 71. Following a risk assessment, QIMR (Australia) no longer consider seropositivity to either 
of these viruses to be necessary for volunteers receiving blood-stage challenge. In the latest Oxford trial 
(VAC054) EBV and CMV serostatus were checked prior to CHMI but were not used to exclude volunteers. 
63% of volunteers were seronegative for CMV and 11% were seronegative for EBV. There were no cases of 
seroconversion in this trial. We therefore believe it is unnecessary to require potential volunteers to be 

VAC063 Protocol v9.0 
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seropositive for EBV and/or CMV, and will not check serostatus in this trial. We will, however, inform 
volunteers that the risk of transmission of infection cannot be completely excluded and this will be 
mentioned on the consent form volunteers are asked to sign prior to enrolment. 
 
Clinical Presentation Post-CHMI 
5.4
Individuals who have received the malaria-infected erythrocyte inoculum are typically expected to develop 
clinical malaria over the next 7-10 days 72. The most common symptoms are fatigue and headache, and 
severe symptoms can include headache, fatigue, malaise, chills, myalgia, rigors, nausea and vomiting. 
Clinical symptoms generally coincide with the detection of blood-stage parasites at densities of 10–20 
parasites per μL of blood by microscopy of thick film smears. This corresponds to a parasitaemia of 
approximately 0.0004% 61,86. Severe malaria is generally diagnosed when parasitaemia is 3 logs greater than 
the peak parasitaemia in challenge trials. After the start of malaria treatment, symptoms can temporarily 
increase in severity but subside quickly with an average duration of approximately 2-3 days 61. There has 
been a suggestion of decreased symptomatology with blood-stage challenge compared with sporozoite 
challenge, independent of peak parasitaemia, parasite multiplication rate or parasite density at diagnosis 72. 
This was also apparent in the recent VAC054 study. 
Immediate treatment of volunteers at the earliest phase of microscopically detectable blood-stage 
infection or at a conservative parasitaemia qPCR cut-off ensures that the potential risks of complications 
associated with severe malaria are minimised to the greatest extent possible.  
Human malaria sporozoite challenge infections have been conducted in over 1,340 volunteers challenged 
with Plasmodium falciparum so far 69,86,87. Recently, safety concerns were raised in a young volunteer who 
suffered a cardiac event shortly after treatment for diagnosed malaria.  This was diagnosed as probable 
myopericarditis, although ischaemia could not be ruled out. Although a definite relationship between the 
cardiac event, which resolved fully and rapidly, and the experimental malaria infection was not established 
88, it has been generally agreed that volunteers with an increased risk of cardiac disease should be excluded 
from such trials 70. A further case of myopericarditis has since been identified in a recent CHMI study, also 
at the Nijmegen, Netherlands centre, but in this case the individual was also diagnosed with an intercurrent 
rhinovirus infection so that the relation to malaria infection is again uncertain. There was a brief episode of 
clinical chest pain and the volunteer made a full recovery. 
 
Ethical Considerations of CHMI trials 
5.5
Participants in CHMI trials are healthy volunteers who do not obtain direct health benefit from 
participation. Challenge trial investigators must exercise all possible safeguards for volunteer safety to 
ensure that trial participation is of minimal risk. Investigators must also ensure that maximal scientific 
benefit accrues from each challenge trial. 

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6 
INVESTIGATIONAL PRODUCTS 
 
The RH5.1 Protein (also see Investigator’s Brochure [IB]) 
6.1
RH5.1 was manufactured under Good Manufacturing Practice (GMP) by the Clinical Biomanufacturing 
Facility (CBF) in Oxford in 2015. The doses to be used in this study are 2 µg, 10 µg and 50 µg. These are 
nominal doses as the actual dose may vary slightly dependent on dilution, mixing and administration. 
The Quality Control Standards and Requirements for the vaccine are described in separate Quality 
Assurance documents (e.g. certificate of analysis) and the required approvals have been obtained. The 
vaccines are QP certified, labelled and packed according to applicable regulatory requirements at the CBF. 
In summary the RH5.1 protein consists of the entire full-length ectodomain of the PfRH5 antigen (amino 
acids E26 – Q526) with the sequence based on the 3D7 clone of P. falciparum. The vaccine was produced 
from a stable Drosophila S2 cell line, and also contained an N-terminal 18 αα BiP insect signal peptide 
(MKLCILLAVVAFVGLSLG) which is cleaved off as the protein is secreted from the cell, and a C-terminal four 
amino acid (E-P-E-A) “C-tag” used for affinity purification. The cell line system called ExpreS2 was provided 
by ExpreS2ion Biotechnologies in Denmark. The rationale for this vaccine design was based on previous 
experience with PfRH5 vaccines developed in other systems. All four putative N-linked glycosylation 
sequons (N-X-S/T) were mutated Thr to Ala – as performed for a previous PfRH5 protein vaccine produced 
in mammalian HEK293 cells and tested in rabbits23 and Aotus monkeys 37. 
 
The Adjuvant: AS01 (also see IB) 
6.2
Adjuvants have been known to increase the immune response against a given antigen for over 80 years 89. 
The AS01 adjuvant system has been developed and manufactured by GlaxoSmithKline (GSK) Biologicals and 
is presented as a liquid solution in a monodose glass vial. AS01 is a liposome-based Adjuvant System with a 
specific aim to improve cell-mediated immunity 89. The adjuvant system contains 3-0-desacyl-4’ 
monophosphoryl lipid A (MPL), a TLR4 (toll-like receptor 4) ligand derived from the cell wall 
lipopolysaccharide (LPS) of the Gram negative Salmonella minnesota R595 strain. The LPS is detoxified by 
hydrolytic treatment and purification to provide a powerful adjuvant without the toxic effects of the parent 
molecule 89. The AS01 adjuvant system also contains QS21, a highly purified saponin extract (triterpene 
glycoside) from the bark of the South American tree Quillaja saponaria. QS21 has been shown to impact 
antigen presentation to antigen presenting cells (APCs) and favours the induction of cytotoxic T 
lymphocytes 89. The 0.5 mL final dose of AS01 contains 50 µg of MPL and 50 µg of QS21 46. The AS01E 
adjuvant contains 25 micrograms of MPL and 25 micrograms of Stimulon QS21 in a 0.5mL dose. 
AS01 is closely related to AS02 which contains the same immunostimulants MPL and QS21 as AS01. AS02 is 
an oil-in-water formulation, while AS01 contains liposomes. AS01B, AS02A and AS01E, AS02D are the adult 
and paediatric formulations of AS01 and AS02, respectively. The clinical evaluation of GSK’s leading malaria 
vaccine candidate antigen RTS,S started with AS02.  
In parallel to the continued evaluation of RTS,S/AS02 in endemic countries, the RTS,S antigen was 
combined with AS01 in a sporozoite challenge trial. Safety and reactogenicity of RTS,S/AS01 was found to 
be comparable to that of RTS,S/AS02 90. Injection site pain was the most frequently reported solicited local 
adverse event (AE) in both the RTS,S/AS01 and RTS,S/AS02 groups, occurring with a similar frequency in 
both vaccine groups (following 81.0% and 82.1% of doses, respectively). Grade 3 pain was reported more 
frequently in recipients of RTS,S/AS02 than of RTS,S/AS01 (following 9.0% and 2.8% of doses, respectively). 
Fatigue and headache were the most frequently reported solicited general AEs after vaccination in both 
groups, occurring with a similar frequency in both the RTS,S/AS01 and RTS,S/AS02 groups (fatigue: 
following 44% and 36% of doses; headache: following 33% and 35% of doses, respectively). Grade 3 
solicited general AEs considered to be related to study vaccine were infrequent (following ≤4.2% of doses). 

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31 
The frequency of causally related unsolicited AEs was similar in the RTS,S/AS01 and RTS,S/AS02 groups 
(following 19.7% and 15.2% of doses, respectively). Three serious adverse events (SAEs) were reported (2 in 
RTS,S/AS01 group, 1 in challenge control group); none were considered to be related to vaccination. 
A trend towards improved vaccine efficacy (VE) against infection with RTS,S/AS01 compared to RTS,S/AS02 
was observed (50.5% [95% CI: 32.9, 67.1] vs 31.8% [95% CI: 17.6, 47.6]). VE against infection was significant 
in both the RTS,S/AS01 and RTS,S/AS02 groups compared to infectivity controls (P0.001). In infected 
subjects, the mean pre-patent period (PPP) was similar in the RTS,S/AS01 (14.4 days) and RTS,S/AS02 (13.6 
days) groups. The shortest mean time to infection was in the infectivity control group (10.8 days). 
The comparable reactogenicity and safety profile of RTS,S/AS01 and RTS,S/AS02 was confirmed in semi-
immune adults 91. Unadjusted VE against infection over 16 weeks in the RTS,S/AS01 and RTS,S/AS02 groups 
was 29.5% (95% CI: -15.4, 56.9, p=0.164) and 31.7% (95% CI: -11.6, 58.2, p=0.128) respectively. Significantly 
higher anti-CS antibody geometric mean titres (GMTs) were observed in recipients of RTS,S/AS01 than of 
RTS,S/AS02 at each post-vaccination time point.  
Malaria-048 was a small study of 36 subjects (12 subjects in each of the RTS,S/AS02, RTS,S/AS01 and 
RTS,S/Saline groups), designed to characterise the immune responses elicited by RTS,S/AS01 and 
RTS,S/AS02 vaccine formulations in healthy malaria naïve adults as compared to non-adjuvanted RTS,S 
vaccine, with the aim of demonstrating superiority of the anti-CS antibody responses elicited by RTS,S 
adjuvanted with either AS01 or AS02 as compared to non-adjuvanted antigen.  
Local and general solicited AEs were reported more frequently in the adjuvanted vaccine groups as 
compared to the non-adjuvanted control, but overall the safety data were assessed as favorable for both 
adjuvanted vaccine formulations. Both RTS,S/AS02 and RTS,S/AS01 elicited significantly higher anti-CS 
antibody response than RTS,S/Saline. The primary endpoint of the trial was demonstrated, with the 
RTS,S/AS01 induced anti-CS response being higher than the RTS,S/AS02 response 92.  
The evaluation of RTS,S/AS01E continued in children living in conditions of natural malaria exposure. In 
total, safety data for the RTS,S/AS01E malaria vaccine candidate have been evaluated following the 
administration of 19,598 doses to 6756 children aged 5 months to 4 years, and of 13,740 doses to 4698 
infants aged 6 to 12 weeks living in malaria-endemic countries. Results from the Phase III pivotal study in 
children aged 5-17 months showed that in children aged 5-17 months, RTS,S/AS01E reduces clinical 
episodes of malaria and severe malaria by approximately half during the 12 months after vaccination. The 
rate of generalised convulsive seizures after RTS,S/AS01 vaccination in children aged 5-17 months, was 1.04 
per 1000 doses (95% CI: 0.62, 1.64). RTS,S/AS01E given in co-administration with DTPwHepB/Hib vaccine at 
6, 10, 14 weeks of age reduced the risk of malaria by approximately one third. Long term effects on a 
number of endpoints of public health interest, and the effect of a booster dose at study Month 20 have 
been characterized. In the older age category, but not in the younger age category, cases of meningitis 
reported as SAEs were more frequently reported in children vaccinated with RTS,S/AS01 as compared with 
the control vaccine. Meningitis etiologies were heterogeneous and there was no cluster in post-vaccination 
time-to-event 93. EMA evaluation of the risk-benefit balance led to a positive recommendations for 
RTS,S/AS01E vaccination 94. WHO recommended pilot introduction studies of RTS,S/AS01E according to a 
four dose regimen in high and middle endemicity countries in 5-17 months old children 95.  
In addition to malaria candidate vaccines, the AS01 adjuvant system has been used in formulation of other 
candidate vaccines, including HIV and tuberculosis vaccines. No specific safety concern has emerged from 
the review of safety data from AS01 adjuvanted vaccine candidates in adults. Suspected cases of 
neuroinflammatory conditions (for example: multiple sclerosis, optic neuritis, and myelitis) and potentially 
autoimmune adverse events (for example: rheumatoid arthritis, Crohn's disease, thyroiditis, type 1 
diabetes mellitus and systemic erythematosis) have been reported with other MPL-containing 
investigational products. A causal relationship between the products or adjuvant components and these 
events has not been identified at this time. Evaluation of these and similar events continues. 

VAC063 Protocol v9.0 
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32 
 
Storage of Vaccines 
6.3
The RH5.1 vaccine will be stored between –70°C and –90°C. All movements of the study vaccines will be 
documented. Vaccine accountability, storage, shipment and handling will be in accordance with local SOPs.  
AS01 will be stored between +2 and +8°C in a locked fridge. 
The storage conditions will be under the responsibility of the Sponsor. 
Any temperature deviation outside the ranges specified above must be reported to the Sponsor as soon as 
detected. Following an exposure to such a temperature deviation, vaccines will not be used until Sponsor 
approval has been given.  
 
Administration of Vaccines 
6.4
The antigen and adjuvant will be mixed in the clinic prior to use to create the RH5.1/AS01 vaccine. This will 
be carried out as per the Standard Operating Procedure (SOP) MC031. 
All vaccines will be administered according to SOP VC002 Vaccination. The vaccine will be administered 
intramuscularly for all groups in the deltoid muscle of the non-dominant arm preferentially. The vaccinating 
Investigator will wear gloves. During administration of the vaccines, Advanced Life Support drugs and 
resuscitation equipment will be immediately available for the management of anaphylaxis. On vaccination 
day, vaccines will be allowed to thaw to room temperature and administered within 1 hour. Depending on 
dose and concentration, one or more vials of vaccine may be used. 
The injection site will be covered with a sterile dressing and the volunteer will stay in the CCVTM, 
Southampton NIHR WTCRF or Guys and St Thomas CRF for observation, in case of immediate adverse 
events. Observations will be taken 30 minutes after vaccination (+/- 5 minutes) and the sterile dressing 
removed and injection site inspected. Observations will also be taken at 60 minutes (+/- 10 minutes) before 
the volunteer leaves. 
 
Vaccine Supply 
6.5
RH5.1 was manufactured at the CBF in Oxford. 
AS01 adjuvant system is manufactured by GSK. AS01 is available as a 0.5 ml extractable liquid in a mono-
dose glass vial and stored at +2 to +8°C before use. The vaccine and adjuvant doses are nominal and may 
vary slightly due to dilution, mixing and administration techniques. 
 AS01 will be supplied to the CBF in Oxford in a refrigerated container with a temperature logger to ensure 
a cold chain of +2 to +8°C. 
The vaccine and adjuvant will be labelled for investigational use only in trial VAC063 by the CBF, who will 
then transfer the vaccine and adjuvant to the clinical sites. RH5.1 and AS01 will be certified for release for 
use in this trial by a qualified person (QP) at the CBF in Oxford. 
All movements of the study vaccines will be documented. Vaccine accountability, storage, shipment and 
handling will be in accordance with local SOPs. 
The final product for administration will be prepared by mixing of the RH5.1 liquid vaccine with the liquid 
adjuvant as per SOP MC031.  

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7 
OBJECTIVES AND ENDPOINTS 
 
Primary objectives  
7.1
To assess the safety of RH5.1/AS01 in healthy malaria-naïve adults in the UK. 
To assess the in vitro growth inhibition activity (GIA) against 3D7 clone P. falciparum parasites of IgG 
purified from the serum of vaccinees. 
To assess efficacy of the RH5.1/AS01 vaccine by establishing if the vaccine can demonstrate a reduced 
parasite multiplication rate (PMR) in vaccinated subjects compared to infectivity controls against 3D7 clone 
parasites in a Phase IIa blood-stage controlled human malaria infection (CHMI) model. 
 
Primary Outcome Measures 
7.2
The specific endpoints for safety and reactogenicity will be actively and passively collected data on adverse 
events. 
The specific endpoints for GIA in vitro will be assessed from a titration of the purified IgG in the assay. 
 
Primary efficacy endpoint (Phase IIa stage of the trial, Groups 5 and 6): 
7.3
PCR-derived parasite multiplication rate (PMR) will be the primary efficacy endpoint for the Phase IIa stage 
of the trial, and comparison of the endpoint between the Groups 5 and 6 will constitute the primary 
analysis for efficacy. 
The arithmetic mean of the three replicate PCR results obtained for each individual at each timepoint will 
be used for model-fitting. Negative individual replicates will be handled as specified in the Jenner Institute 
qPCR SOP. qPCR data points which, based upon the mean of the three replicates, are negative or below the 
limit of quantification will be handled as specified in the Jenner Institute qPCR SOP . PMR will be calculated 
using a linear model fitted to log10-transformed qPCR data 96. As previously, fitted lines will be constrained 
to pass through the known starting parasitaemia, calculated from the results of a limiting-dilution-based 
assay of the number of viable parasites in the inoculum 81 and a weight-based estimate of each volunteer’s 
blood volume (70mL/kg) 42. 
The distribution of PMRs will be assessed for deviation from normality visually and using a d’Agostino-
Pearson test. Standard ladder-of-power transformations may be applied to achieve normality. Equality of 
variance will be tested with an F test. In the event of deviation from normality, PMRs will be compared by 
two-tailed Mann-Whitney test; otherwise a two-tailed two-sample t-test will be used, with Welch’s 
correction if variances are non-equal as assessed by F-test. 
 
Secondary objectives 
7.4
To assess the humoral and cellular immunogenicity of RH5.1/AS01 using different vaccine doses and 
vaccination regimens. 
To assess the durability of any reduction in parasite multiplication rate (PMR) in vaccinated Group 5) 
subjects by subjecting them to a re-challenge with 3D7 clone parasites approximately 4 months after the 
primary challenge (Group 7), and comparing the PMR with 1) that of previously challenged Group 6 controls 
receiving a second challenge (Group 8); and 2) that of newly recruited malaria-naïve controls (Group 9) 
receiving a primary challenge. This is using the same Phase IIa blood-stage controlled human malaria 
infection (CHMI) model. 
 
Secondary Outcome Measures 
7.5
P. falciparum RH5-specific immunogenicity will be assessed by a variety of immunological assays.  

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Other exploratory immunology may be carried out in collaboration with other specialist laboratories, 
including laboratories outside of Europe. This would involve transfer of serum/plasma and/or peripheral 
blood mononuclear cells (PBMC), but samples would be anonymised. Volunteers will be consented for this. 
 
Secondary efficacy analysis:  
7.6
 
Time to microscopic patency will be compared between Groups 5 and 6 by Mann-Whitney test. 
 
A test of the hypothesis that there is a relationship between in vitro GIA induced by the RH5.1 
vaccine and PMR. 
 
A test of the hypothesis that there is a relationship between anti-RH5 antibody responses induced 
by the RH5.1 vaccine and PMR. 
 
Secondary efficacy endpoint (Groups 7-9): 
7.7
PCR-derived parasite multiplication rate (PMR) will also be the efficacy endpoint for assessing the durability 
of the vaccine-reduction in PMR. Comparison of this PMR endpoint between Groups 7, 8 and 9 will 
constitute this secondary analysis for efficacy. PMRs will be calculated from the qPCR data exactly as above 
(for Groups 5 and 6). The distribution of PMRs will be assessed for deviation from normality visually and 
using a d’Agostino-Pearson test. PMRs across the 3 groups will be compared by two-tailed Kruskall-Wallis 
test with Dunn’s multiple comparison post-test; PMRs between Groups 7 and 8 will also be compared by 
two-tailed Mann-Whitney test. Non-parametric analysis is used given the relatively small groups sizes in the 
re-challenge arm of this trial.  
 
Protocol pre-specified analyses for immunological correlates of efficacy (Groups 5 and 6): 
7.8
An analysis will be conducted to test for association between 'GIA50 titre' (defined as the dilution factor 
from the serum/plasma IgG concentration to the IgG concentration achieving 50% GIA against 3D7 clone P. 
falciparum parasites using the single-cycle standardised assay SOP at the PATH-MVI GIA Reference Center 
Laboratory at NIH) and PMR within the RH5-vaccinated group. The relationship between GIA50 and PMR will 
be assessed by Spearman rank correlation. Samples which do not achieve 50% GIA at the highest tested 
concentration will be ranked based upon the percentage GIA achieved at this highest concentration. 
Samples achieving <20% GIA at this highest concentration will be treated as tied, on the basis that it is 
highly unlikely that such weak GIA would achieve an effect upon PMR. The PMRs of volunteers with PMR 
greater than the control group mean will be treated as tied, on the basis that differences between their 
PMRs are likely to represent biological noise and are not informative with respect to the relationship 
between GIA and PMR. GIA and PMR data will be visually inspected. Standard ladder-of-power 
transformations may be applied if these result in a linear relationship. If a linear relationship appears 
plausible before or after transformation, a Pearson correlation coefficient will be calculated. If the 
relationship between GIA and PMR appears non-linear despite transformation, a Spearman rank correlation 
coefficient and P value will be calculated. 
A similar analysis will be undertaken to test for association between anti-RH5 antibody response and PMR 
within the RH5-vaccinated group. 
All other analyses will be reported as not pre-specified in the trial protocol. Other analyses may be detailed 
in the VAC063 laboratory plan. Some assays will be duplicated at different sites. Some of these will involve 
analysis of frozen samples, and others analysis of fresh samples. Recruitment and Withdrawal of Trial 
Volunteers 
 

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8 
RECRUITMENT AND WITHDRAWAL OF TRIAL VOLUNTEERS 
 
Volunteers 
8.1
Volunteers may be recruited by use of an advertisement +/- registration form formally approved by the 
ethics committee and distributed or posted in the following places: 
 
In public places, including buses and trains, with the agreement of the owner / proprietor. 
 
In newspapers or other literature for circulation. 
 
On radio via announcements. 
 
On a website or social media site operated by our group or with the agreement of the owner or 
operator (including on-line recruitment through our web-site).  
 
By e-mail distribution to a group or list only with the express agreement of the network 
administrator or with equivalent authorisation. 
 
By email distribution to individuals who have already expressed an interest in taking part in any 
clinical trial at the Oxford Vaccine Centre, the Guys and St Thomas NIHR CRF or the Southampton 
NIHR WTCRF. 
 
On stalls or stands at exhibitions or fairs. 
 
Via presentations (e.g. presentations at lectures or invited seminars). 
 
Direct mail-out: This will involve obtaining names and addresses of adults via the most recent 
Electoral Roll. The contact details of individuals who have indicated that they do not wish to receive 
postal mail-shots would be removed prior to the investigators being given this information. The 
company providing this service is registered under the Data Protection Act 1998. Investigators 
would not be given dates of birth or ages of individuals but the list supplied would only contain 
names of those aged between 18 - 45 years (as per the inclusion criteria). 
 
Oxford Vaccine Centre databases: We may contact individuals registered on the Oxford Vaccine 
Centre database who have previously expressed an interest in receiving information about future 
studies for which they may be eligible. 
 
Southampton NIHR WTCRF Database of Healthy Volunteers: We may contact individuals from this 
database who have previously expressed an interest in receiving information about future studies 
for which they may be eligible. 
 
Recruitment to Groups 7 and 8 
Volunteers enrolled in Group 5/6 will be asked at one of their follow up visits whether they would be 
interested in a re-challenge. Those who are will be re-consented, and attend a re-screening visit after their 
C+90 follow-up appointment.  
 
 
 
Recruitment to Group 9 for primary challenge 
Volunteers originally screened, eligible, but not enrolled into groups 5 or 6 (e.g., those unable to commit to 
the schedule or those volunteers who were “back-ups” but were not enrolled), but who agree to remain on 
the volunteer email distribution list (database), will be contacted to see if they would like to be screened as 
new controls for a re-challenge study (Groups 9).If this does not result in sufficient volunteers being re-
recruited into Group 9, we will formally re-advertise the study as detailed above.   

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Invitation to visit 1-2.5 years post-final vaccination (Groups 1-5 and 7) 
Participants who have received at least three doses of RH5.1/AS01 will be contacted to ask if they would be 
interested in attending for a further visit which will take place 1-2.5 years after their last dose of 
vaccination. If interested, a visit will be scheduled and new consent obtained to proceed with the visit and 
blood tests.  
 
 
Informed consent 
8.2
All volunteers will sign and date the informed consent form before any study specific procedures are 
performed. The information sheet will be made available to the volunteer at least 24 hours prior to the 
screening visit. At the screening visit, the volunteer will be fully informed of all aspects of the trial, the 
potential risks and their obligations. The following general principles will be emphasised: 
 
Participation in the study is entirely voluntary 
 
Refusal to participate involves no penalty or loss of medical benefits 
 
The volunteer may withdraw from the study at any time 
 
The volunteer is free to ask questions at any time to allow him or her to understand the purpose of 
the study and the procedures involved 
 
The study involves research of an investigational vaccine 
 
There is no direct benefit from participating 
 
The volunteer’s GP will be contacted to corroborate their medical history 
 
Samples are given as a gift to the University of Oxford and volunteers will not gain any personal 
direct benefit from this, even if used in the future for commercial purposes (e.g. monoclonal 
antibody production). 
 
The volunteer’s blood samples taken as part of the study will be stored indefinitely either as part of 
an ongoing ethically approved study or in a human tissue authority (HTA) licensed biobank.  
 
Samples may be sent outside of the UK and Europe to laboratories in collaboration with the 
University of Oxford. These will be anonymised. 
The aims of the study and all tests to be carried out will be explained. The volunteer will be given the 
opportunity to ask about details of the trial, and will then have time to consider whether or not to 
participate. If they do decide to participate, they will sign and date two copies of the consent form, one for 
them to take away and keep, and one to be stored in the case report form (CRF) – this is a paper or 
electronic document used to collect data relating to a particular volunteer. These forms will also be signed 
and dated by the Investigator. 
Volunteers for Groups 5-9 will be asked to complete a questionnaire testing their understanding of the trial 
as part of the consent process. This helps to ensure that individuals understand the trial sufficiently to give 
informed consent. Provided the volunteer answers all questions in the questionnaire correctly, they will be 
asked to sign and date two copies of the consent form, as detailed above. Volunteers who fail to answer all 
questions correctly on their first attempt will be allowed to re-take the same questionnaire following 
further discussion with the investigator. Provided they subsequently answer all questions in the 
questionnaire correctly they may then complete the consent form and be screened for the trial. 
 
Volunteers in Groups 5 and 6 will be re-consented to take part in Groups 7 and 8, respectively, if they 
choose to participate. At a time-point after the C+90 visit for the preceding challenge, volunteers in Groups 

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37 
8 and 9 who wish to take place in a further challenge (either tertiary or secondary, respectively) will be re-
consented at a re-screening visit for this phase of the study.  
For volunteers in Groups 1-5 and 7 who wish to attend for a visit 1-2.5 years after their final vaccination, 
informed consent to proceed with the visit procedures will be obtained at the start of the visit. 
 
Inclusion and exclusion criteria 
8.3
This study will be conducted in healthy adults, who meet the following inclusion and exclusion criteria: 
Inclusion Criteria 
The volunteer must satisfy all the following criteria to be eligible for the study: 
 
Healthy adults aged 18 to 45 years.  
 
Able and willing (in the Investigator’s opinion) to comply with all study requirements. 
 
Willing to allow the Investigators to discuss the volunteer’s medical history with their General 
Practitioner (GP). 
 
For females only, willingness to practice continuous effective contraception (see below) during the 
study and a negative pregnancy test on the day(s) of screening and vaccination, and on the day 
prior to blood-stage CHMI, and prior to the start of antimalarial treatment for Groups 5-9 
volunteers. 
 
Agreement to refrain from blood donation during the course of the study. 
 
Provide written informed consent. 
Additional Inclusion Criteria for Groups 5 - 9 
 
Agreement to permanently refrain from blood donation, as per current UK Blood Transfusion and 
Tissue Transplantation Services guidelines 97.  
 
Reachable (24 hours a day) by mobile phone during the period between CHMI and completion of 
antimalarial treatment. 
 
Willingness to take a curative anti-malaria regimen following CHMI. 
 
Answer all questions on the informed consent questionnaire correctly. 
 
For Groups 7-9: completion of primary challenge, curative anti-malarials and follow-up (up until at 
least the C+28 visit) 
Exclusion Criteria 
The volunteer may not enter the study if any of the following apply: 
 
Participation in another research study involving receipt of an investigational product in the 30 days 
preceding enrolment, or planned use during the study period.  
 
Prior receipt of an investigational vaccine likely to impact on interpretation of the trial data, as 
assessed by the investigator. For Group 7 volunteers undergoing re-challenge, this exclusion 
criterion does not extend to the RH5.1/AS01 vaccine previously received. 
 
Any medical condition that in the judgment of the investigator would make intramuscular (IM) 
injection unsafe. 
 
Administration of immunoglobulins and/or any blood products within the three months preceding 
the planned administration of the vaccine candidate. 
 
Any confirmed or suspected immunosuppressive or immunodeficient state, including HIV infection; 
asplenia; recurrent, severe infections and chronic (more than 14 days) immunosuppressant 

VAC063 Protocol v9.0 
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38 
medication during the period starting six months prior to the first vaccine dose. For corticosteroids, 
this will mean prednisone 20 mg/day (for adult subjects), or equivalent. Inhaled and topical steroids 
are allowed.  
 
Administration of long-acting immune-modifying drugs at any time during the study period (e.g. 
infliximab).  
 
Chronic use of antibiotics with antimalarial effects (e.g. tetracyclines for dermatologic patients, 
sulfa for recurrent urinary tract infections, etc.). 
 
History of malaria chemoprophylaxis within 60 days prior to vaccination  
 
History of allergic disease or reactions likely to be exacerbated by any component of the vaccine. 
 
Any history of anaphylaxis in relation to vaccination. 
 
Pregnancy, lactation or willingness/intention to become pregnant during the study.  
 
History of cancer (except basal cell carcinoma of the skin and cervical carcinoma in situ). 
 
History of serious psychiatric condition likely to affect participation in the study. 
 
Any other serious chronic illness requiring hospital specialist supervision. 
 
Suspected or known current alcohol abuse as defined by an alcohol intake of greater than 42 units 
every week. 
 
Suspected or known injecting drug abuse in the 5 years preceding enrolment. 
 
Seropositive for hepatitis B surface antigen (HBsAg). 
 
Seropositive for hepatitis C virus (antibodies to HCV) at screening (unless has taken part in a prior 
hepatitis C vaccine study with confirmed negative HCV antibodies prior to participation in that 
study, and negative HCV RNA PCR at screening for this study). 
 
History of clinical malaria (any species (Not applicable to prior challenge for Groups 7,8 and 9). 
 
Travel to a malaria endemic region during the study period or within the previous six months.  
 
Any clinically significant abnormal finding on screening biochemistry or haematology blood tests or 
urinalysis. 
 
Any other significant disease, disorder or finding which may significantly increase the risk to the 
volunteer because of participation in the study, affect the ability of the volunteer to participate in 
the study or impair interpretation of the study data.  
 
Inability of the study team to contact the volunteer’s GP to confirm medical history and safety to 
participate. 
 
 
Additional exclusion criteria for Groups 5 - 9 
 
Use of systemic antibiotics with known antimalarial activity within 30 days of CHMI (e.g. 
trimethoprim-sulfamethoxazole, 
doxycycline, 
tetracycline, 
clindamycin, 
erythromycin, 
fluoroquinolones and azithromycin).  
 
History of sickle cell anaemia, sickle cell trait, thalassaemia or thalassaemia trait or any 
haematological condition that could affect susceptibility to malaria infection. 
 
Laboratory evidence of G6PD deficiency at screening 
 
Laboratory evidence of haemoglobinopathy at screening 
 
Use of medications known to cause prolongation of the QT interval and existing contraindication to 
the use of Malarone. 

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39 
 
Use of medications known to have a potentially clinically significant interaction with Riamet and 
Malarone. 
 
Contraindications to the use of both Riamet and Malarone. 
 
Any clinical condition known to prolong the QT interval. 
 
Family history of congenital QT prolongation or sudden death. 
 
Positive family history in both 1st and 2nd degree relatives < 50 years old for cardiac disease. 
 
History of cardiac arrhythmia, including clinically relevant bradycardia. 
 
Volunteer unable to be closely followed for social, geographic or psychological reasons. 
Effective contraception for female volunteers 
Female volunteers are required to use an effective form of contraception during the course of the study. As 
this is a Phase I, first-in-human, study there is no information about the effect of these vaccines on a foetus.  
Acceptable forms of contraception for female volunteers include: 
 
Established use of oral, injected on implanted hormonal methods of contraception. 
 
Placement of an intrauterine device (IUD) or intrauterine system (IUS). 
 
Barrier methods of contraception (condom or occlusive cap with spermicide). 
 
Male sterilisation, if the vasectomised partner is the sole partner for the subject. 
 
True abstinence, when this is in line with the preferred and usual lifestyle of the subject (periodic 
abstinence and withdrawal are not acceptable methods of contraception). 
NB: Women in Groups 5-9 using hormonal contraceptives during CHMI and treated with the antimalarial 
Riamet will be advised to also use a barrier method of contraception whilst on Riamet treatment, and until 
the start of the next menstruation after treatment. 
Prevention of ‘Over Volunteering’ 
Volunteers will be excluded from the study if they are concurrently involved in another trial. In order to 
check this, volunteers will be asked to provide their National Insurance or Passport number (if they are not 
entitled to a NI number) and will be registered on a national database of participants in clinical trials 
(www.tops.org.uk). 
Re-vaccination exclusion criteria  
The following adverse events associated with vaccine immunisation constitute absolute contraindications 
to further administration of vaccine. If any of these events occur during the study, the subject must be 
withdrawn and followed until resolution of the event, as with any adverse event: 
 
Anaphylactic reaction following administration of vaccine 
 
Pregnancy 
The following adverse events constitute contraindications to administration of vaccine at that point in time; 
if any one of these adverse events occurs at the time scheduled for vaccination, the subject may be 
vaccinated at a later date, or withdrawn at the discretion of the Investigator. The subject must be followed 
until resolution of the event as with any adverse event: 
 
Acute disease at the time of vaccination. (Acute disease is defined as the presence of a moderate or 
severe illness with or without fever). All vaccines can be administered to persons with a minor 
illness such as diarrhoea, mild upper respiratory infection with or without low-grade febrile illness, 
i.e. temperature of ≤37.5°C/99.5°F. 

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 
Temperature of >37.5°C (99.5°F) at the time of vaccination. 
 
Withdrawal of Volunteers 
8.4
In accordance with the principles of the current revision of the Declaration of Helsinki and any other 
applicable regulations, a volunteer has the right to withdraw from the study at any time and for any reason, 
and is not obliged to give his or her reasons for doing so. The Investigator may withdraw the volunteer at 
any time in the interests of the volunteer’s health and well-being. In addition the volunteer may 
withdraw/be withdrawn for any of the following reasons: 
 
Administrative decision by the Investigator. 
 
Ineligibility (either arising during the study or retrospectively, having been overlooked at 
screening). 
 
Significant protocol deviation. 
 
Volunteer non-compliance with study requirements. 
 
An AE, which requires discontinuation of the study involvement or results in inability to continue to 
comply with study procedures. 
The reason for withdrawal will be recorded in the CRF. If withdrawal is due to an AE, appropriate follow-up 
visits or medical care will be arranged, with the agreement of the volunteer, until the AE has resolved, 
stabilised or a non-trial related causality has been assigned. Any volunteer who is withdrawn from the 
study may be replaced, if that is possible within the specified time frame. The Local Safety Monitor (LSM) 
may recommend withdrawal of volunteers.  
Any volunteer who fails to attend for two or more follow-up visits during the study will be deemed to have 
withdrawn from the study. If a volunteer withdraws/is withdrawn from the study after CHMI but before 
reaching the criterion for malaria diagnosis, an appropriate, curative course of anti-malarial therapy must 
be completed. The importance of this will be emphasised to volunteers at screening. If a volunteer refuses 
to take anti-malarial therapy after malaria diagnosis, a rapid assessment of mental state and capacity will 
be undertaken, with the involvement of NHS psychiatric and infectious diseases services. If necessary the 
volunteer may be detained under section 4 of the UK Mental Health Act until this assessment can be 
carried out. 
If a volunteer withdraws from the study, blood samples collected before their withdrawal from the trial will 
be used/stored unless the volunteer specifically requests otherwise. Data from volunteers withdrawn from 
the study after they have had a qPCR result of ≥500 parasites/mL will be included in the analysis of results 
relating to the study’s objectives. 
In all cases of subject withdrawal, excepting those of complete consent withdrawal, long-term safety data 
collection will continue as appropriate if subjects have received one or more vaccine doses or undergone 
CHMI.  
 
 
Pregnancy 
8.5
Should a volunteer become pregnant during the trial, she will be followed up as other volunteers and in 
addition will be followed until pregnancy outcome, with the volunteer’s permission. We will not routinely 
perform venepuncture on such volunteers. The management of any volunteers found to be pregnant at any 
time after the blood-stage challenge up to the point of diagnosis with malaria by thick blood smear/ PCR 
will be discussed with the on-call infectious diseases consultant at the Oxford University Hospitals’ NHS 
Trust. 

VAC063 Protocol v9.0 
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41 
 
Safety Stopping/ Holding Rules 
8.6
Safety holding rules have been developed considering the fact that this is a first-in-human dose escalation 
study. Safety reviews will take place prior to each dose escalation. In order for a safety review to take place 
at least 6/12 volunteers in each group must have received the first two vaccinations. 
‘Solicited adverse events’ are those listed as foreseeable adverse reactions in section 12.3 of the protocol, 
occurring within the first 7 days after vaccination (day of vaccination and six subsequent days). ‘Unsolicited 
adverse events’ are adverse events other than the foreseeable ARs occurring within the first 7 days, or any 
AEs occurring after the first 7 days after vaccination. 
Group holding rules (applies to Groups 1 – 5 and Group 7) 
The following holding rules will apply to study Groups 1 – 5 and Group 7 (i.e. vaccinees). If a holding rule is 
activated, then further vaccinations in any Group will not occur until an internal safety review has been 
conducted and it is deemed appropriate to restart dosing. The regulatory authority must be informed and a 
request to restart dosing with pertinent data must be submitted as a request for a substantial amendment. 
The internal safety review will consider:  
 
The relationship of the AE or SAE to the vaccine. 
 
The relationship of the AE or SAE to the vaccine dose, or other possible causes of the event. 
 
If appropriate, additional screening or laboratory testing for other volunteers to identify those who 
may develop similar symptoms, and alterations to the current Participant Information Sheet (PIS) 
are discussed. 
 
New, relevant safety information from ongoing research programmes on the various components 
of the vaccine (i.e. the AS01 adjuvant). 
The local ethics committee and Adjuvant System manufacturers (GSK) will also be notified if a holding rule 
is activated or released.  
All vaccinated volunteers will be followed for safety until resolution or stabilisation (if determined to be 
chronic sequelae) of their AEs. 
The group holding rules are as follows: 
 
Solicited local adverse events: 
o If more than 25% of doses of a vaccine are followed by the same Grade 3 solicited local adverse 
event beginning within 2 days after vaccination (day of vaccination and one subsequent day) 
and persisting at Grade 3 for > 72 hrs. 
 
Solicited systemic adverse events:  
o If more than 25% of doses of a vaccine are followed by the same Grade 3 solicited systemic 
adverse event beginning within 2 days after vaccination (day of vaccination and one 
subsequent day) and persisting at Grade 3 for > 48 hrs.  
 
Unsolicited adverse events: 
o If more than 25% of volunteers develop the same Grade 3 unsolicited adverse event (including 
the same laboratory adverse event) that is considered possibly, probably or definitely related 
to vaccination and persists at Grade 3 for > 48 hrs.  
 
A serious adverse event considered possibly, probably or definitely related to vaccination occurs 
 
Individual stopping rules 

VAC063 Protocol v9.0 
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42 
In addition to the above stated group holding rules, stopping rules for individual volunteers will apply (i.e., 
indications to withdraw individuals from further vaccinations). 
 
Local reactions: Injection site ulceration, abscess or necrosis. 
 
Laboratory AEs: 
o The volunteer develops a Grade 3 laboratory adverse event considered possibly, probably or 
definitely related within 7 days after vaccination and persisting continuously at Grade 3 for 
>72hrs. 
 
Solicited systemic adverse events:  
o The volunteer develops a Grade 3 systemic solicited adverse event considered possibly, 
probably or definitely related within 2 days after vaccination (day of vaccination and one 
subsequent day) and persisting continuously at Grade 3 for >72hrs.  
 
Unsolicited adverse events:  
o The volunteer has a Grade 3 adverse event, considered possibly, probably or definitely related 
to vaccination, persisting continuously at Grade 3 for >72hrs.  
o The volunteer has a serious adverse event considered possibly, probably or definitely related to 
vaccination. 
o The volunteer has an acute allergic reaction or anaphylactic shock following the administration 
of the vaccine investigational product. 
If a volunteer has an acute illness (moderate or severe illness with or without fever) or a fever (oral 
temperature greater than 37.5°C) at the scheduled time of administration of investigational product, the 
volunteer will not receive the vaccine at that time. The vaccine may be administered to that volunteer at a 
later date within the time window specified in the protocol (see Tables 3 - 5) or they may be withdrawn 
from the study at the discretion of the Investigator.  
All vaccinated volunteers will be followed for safety until the end of their planned participation in the study 
or until resolution or stabilisation (if determined to be chronic sequelae) of their AEs, providing they 
consent to this.  
In addition to these pre-defined criteria, the study can be put on hold upon advice of the Local Safety 
Monitor, Chief Investigator, Study Sponsor, regulatory authority, Research Ethics Committee (REC) or Local 
Safety Committee (LSC), for any single event or combination of multiple events which, in their professional 
opinion, jeopardise the safety of the volunteers or the reliability of the data. 

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9 
STUDY OVERVIEW 
 
Study Groups 
9.1
This is an open-label, multi-centre Phase I/IIa dose escalation blood-stage malaria CHMI trial to assess the 
safety, immunogenicity and efficacy of the candidate malaria vaccine RH5.1/AS01. All volunteers recruited 
will be healthy, malaria naïve adults aged between 18 and 45 years.  
Volunteers will be recruited and vaccinated at the CCVTM, Oxford; Guys and St Thomas’ NIHR CRF, London; 
and the NIHR WTCRF, Southampton for the Phase Ia part of the trial. Volunteers will be recruited and 
vaccinated at the CCVTM, Oxford, and at Guy’s and St Thomas’ NIHR CRF, London, for the Phase IIa stage. 
Volunteers in Group 9 will only be recruited in Oxford. Vaccine efficacy will be assessed using blood-stage 
CHMI by injection of parasitised red blood cells, as described in section 10.2.  
There will be 9 study groups across two phases of the trial, with a total of 84 volunteers (see Table 2). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

CONFIDENTIAL 
 
VAC063 v9.0 
 
10th October  2018 
 
Phase Ia 
Group 
Group size 
Day 0 
Day 28 
Day 56 
Day 182 
 
 
1 
6 – 12 
2µg RH5.1/ 0.5mL 
AS01 
2µg RH5.1/ 0.5mL 
AS01 
2µg RH5.1/ 0.5mL 
AS01 
 
2 
6 – 12 
10µg RH5.1/ 
0.5mL AS01 
10µg RH5.1/ 0.5mL 
AS01 
10µg RH5.1/ 
0.5mL AS01 
 
3 
12 
50µg RH5.1/ 
0.5mL AS01 
50µg RH5.1/ 0.5mL 
AS01 
 
10µg RH5.1/ 
0.5mL AS01 
4 
12 
50µg RH5.1/ 
0.5mL AS01 
50µg RH5.1/ 0.5mL 
AS01 
50µg RH5.1/ 
0.5mL AS01 
 
Phase IIa 
Group 
Group size 
Day 0 
Day 28 
Day 56 
2 weeks post-3rd 
vaccination 
~4 months 
post 3rd  
vaccination 
1-2 weeks 
post 4th  
vaccination 
 
5 
15 (+2) 
10µg RH5.1/ 
0.5mL AS01 
10µg RH5.1/ 0.5mL 
AS01 
10µg RH5.1/ 
0.5mL AS01 
CHMI 
 
 
 
6 (controls) 
15 (+2) 
 
 
 
CHMI 
 
 
 
7 
Subset of Group 
5 (vaccinees) 
5-15 
10µg RH5.1/ 0.5mL 
AS01 
10µg RH5.1/ 0.5mL 
AS01 
10µg RH5.1/ 0.5mL 
AS01 
CHMI 
10µg RH5.1/ 
0.5mL AS01 
CHMI 
 
8 
Subset of Group 
6 (controls) 
5-15 
 
 
 
 
CHMI 
 
CHMI 
 
 
9 
(controls) 
5-6 (+2) 
 
 
 
 
 
 
 
CHMI 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 2: Study groups. Given group sizes indicate planned number of recruits to each group. 

CONFIDENTIAL 
 
VAC063 v9.0 
 
10th October  2018 
The study is designed to assess a ‘standard’ protein-in-adjuvant vaccination regimen of 3 doses given four 
weeks apart, with dose escalation to assess the best dose in healthy adults (acceptable reactogenicity with 
good immunogenicity profiles) in Groups 1, 2 and 4. The efficacy of this regimen will also be assessed using 
the best dose (ascertained from Groups 1, 2 and 4). The other group to receive the vaccine (Group 3) will 
assess the safety and immunogenicity of giving the ‘standard’ first two doses of the vaccine followed by a 
delayed fractional dose. This has been shown to improve efficacy with the RTS,S vaccine given with a similar 
adjuvant to that being used in this study. This effect has not been widely studied with other candidate 
vaccines so this study aims to evaluate whether improvements in immunogenicity and/ or in vitro efficacy 
are seen with this regimen. 
Vaccination of groups will be sequential from Group 1 to Group 3. Group 3 and 4 can be recruited 
simultaneously. Volunteers will be able to choose which group they are allocated to (providing there is still 
space within the group they wish to be in). The vaccination dose for Group 5 was decided following the 
analysis of safety and exploratory immunology assays from Groups 1, 2 and 4. Given the safety and 
tolerability are comparable across all dose groups, with no clinical concerns, the immunogenicity (as 
measured by ELISA) was used to decide the optimum dose for Group 5. The highest median ELISA response 
at day 70 for the volunteers in Groups 1, 2 and 4, (after at least six volunteers in Group 4 had received all 
three vaccinations), was in Group 2. Therefore, the 10 µg dose, administrated at Days 0, 28 and 56, was 
taken forward to the Phase IIa.  Two ‘back-up’ volunteers will be recruited to Groups 5 and 6 in case of 
withdrawal of volunteers prior to CHMI. The back-up volunteers in Group 5 will be enrolled and vaccinated 
with the rest of the group but will only undergo CHMI if another vaccinee withdraws from the study. The 
back up control volunteers (Group 6) will be available at short notice to take part in the trial but will only 
undergo CHMI if a Group 6 volunteer withdraws prior to CHMI. 
The total number of volunteers recruited to Groups 1 and 2 was decided based on the immunogenicity of 
the vaccines at the 2 µg and 10 µg doses. As both the doses are immunogenic the groups are being 
recruited to a total of 12 volunteers. Immunogenicity has been assessed according to the results obtained 
from the VAC057 trial using the viral vectored RH5 vaccines (ChAd63/MVA RH5). If the mean response after 
3 vaccinations in Group 1 and Group 2 was not within the 95% CI of the mean response achieved in boosted 
volunteers in VAC057 the recruitment for these groups was to be held at 6 volunteers per group. This 
would allow sufficient numbers of volunteers to assess the safety of these doses prior to dose escalation. 
However, the mean response has exceeded that in boosted VAC057 volunteers, so 12 are being recruited 
into each group. 
Groups 7-9 constitute the re-challenge phase of the study, where we plan to enrol volunteers from Groups 
5 and 6 to take part in a second homologous P. falciparum challenge. Alongside these we will recruit a fresh 
group of controls to receive a primary challenge. To summarise (and detailed in both Table 2 and Figure 5) 
we will have 3 new groups: 
Group 7 = (vaccinees from group 5) – these will receive a fourth and final vaccination with RH5.1/AS01 
followed 7-14 days later by a repeat homologous malaria challenge. 
Group 8 = (malaria-exposed controls from Group 6) – these will be re-challenged in parallel with Group 7.  
Group 9 = (malaria-naïve controls) – these will receive a primary malaria challenge in parallel with Groups 7 
and 8. 
 
 
 
 

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46 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
While we will aim to recruit as many volunteers as possible from Groups 5 and 6 into Groups 7 and 8 
(respectively), it is important to note that small numbers are routinely studied and reported in numerous 
other CHMI trials (undertaken in Oxford and elsewhere under similar circumstances). We intend to proceed 
if ≥4 volunteers from both groups agree to (and are eligible to) participate.  
It is important to emphasise that there will be no commitment to undergoing repeat CHMI when volunteers 
are screened for initial entry into the study. 
First volunteers 
At each dose of RH5.1 (i.e. 2 µg, 10 µg and 50 µg) the first volunteer to receive each dose will be vaccinated 
alone and then reviewed on the day following vaccination. Providing there are no safety concerns at the 
Day 1 review, or recorded in the diary over the next 24 hours, another two volunteers may be immunised 2 
days after the first volunteer, at least one hour apart. These volunteers will also be reviewed on the day 
following vaccination and providing there are no safety concerns 2 days after vaccination the rest of the 
group can be vaccinated. An independent safety review will be carried out after six volunteers have 
received two of the three vaccinations in Group 1 before vaccinations are started in Group 2, and similarly 
between Group 2 and 3/4. Enrolment for Groups 5 and 6 can commence once at least six Group 4 

VAC063 Protocol v9.0 
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47 
volunteers have received all three vaccinations and completed at least 7 days of safety follow-up with no 
safety concerns (no holding/ stopping rules met). The vaccination dose for Group 5 (10 µg) is now  
confirmed. 
Duration of study  
Volunteers will be considered to be enrolled in the trial on receipt of the first vaccination. 
 
Groups 1, 2 and 4  
Groups 1, 2 and 4 will attend for three vaccinations on days 0, 28 and 56. The follow up visits are as 
described in section 11.3, with a last visit in the initial follow-up period approximately 6 months after 
the final vaccination. Participants will then be invited for a final visit 1-2.5 years following their final 
vaccination. 
 
Group 3 
Group 3 volunteers will attend for three vaccinations on days 0, 28 and 182. The follow up visits are as 
described in section 11.3, with a last visit in the initial follow-up period approximately 6 months after 
the final vaccination. Participants will then be invited for a final visit 1-2.5 years following their final 
vaccination. 
 
Group 5 
Group 5 volunteers will attend for three vaccinations on days 0, 28 and 56. They will undergo blood-
stage CHMI 2 weeks after the final vaccination and will be followed up until approximately 6 months 
after the final vaccination. We will also recruit 2 ‘back-up’ volunteers for Group 5. These will be 
vaccinated alongside the rest of the group but will only undergo malaria challenge if other volunteers 
from the group drop out of, or are withdrawn from, the study. Participants will then be invited for a 
final visit 1-2.5 years following their final vaccination. 
 
Group 6 (controls) 
Group 6 volunteers will be infectivity controls, so will not receive any vaccinations. Control volunteers 
will be considered as enrolled in the study once they have attended the C-1 visit (day prior to 
challenge). In addition to the 15 volunteers to be enrolled in Group 6, back-up volunteers for Group 6 
who have been screened and are eligible to participate in the study will be identified. These volunteers 
will be available to be enrolled in the study at short notice should a planned volunteer withdraw 
consent or become ineligible immediately prior to CHMI. Back-up volunteers may be enrolled in the 
study at Day C-1 and asked to attend clinic on day of challenge in case another control volunteer is 
found to be ineligible at that point. If back-up volunteers are not required on day of challenge they will 
be withdrawn from the study after this point. 
 
Group 7 
Group 5 volunteers will be invited to attend for a fourth vaccination with RH5.1/AS01 in the second 
part of the Phase IIa study, approximately 4 months post their primary malaria challenge. They will then 
undergo a second homologous blood-stage CHMI 7-14 days later and will be followed up until 
approximately 6 months after the final vaccination in the initial follow-up period. They will be 
considered re-enrolled into the study once they have attended their second C-1 visit (day before 
challenge), and will be referred to as a new Group 7. Participants will then be invited for a final visit 1-
2.5 years following their final vaccination. 
 
Group 8 (controls) 
Group 6 volunteers will be invited to be infectivity controls for a second time (in the second part of the 
Phase IIa study), so again will not receive any vaccinations. They will undergo a second blood-stage 

VAC063 Protocol v9.0 
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48 
CHMI in parallel with Groups 7 and 9. They will be considered re-enrolled into the study once they have 
attended their second C-1 visit, and will be referred to as a new Group 8. 
All Group 5 and 6 volunteers who wish to take part in the re-challenge phase will be re-screened (to 
ensure ongoing eligibility) prior to enrolment into Groups 7 and 8 respectively. 
 
Group 9 (controls) 
Group 9 volunteers will be infectivity controls in the second part of the Phase IIa, so will not receive any 
vaccinations. Control volunteers will be considered as enrolled in the study once they have attended 
the C-1 visit. They will undergo a blood-stage CHMI in parallel with the second CHMI administered to 
Groups 7 and 8. In addition to the 5-6 volunteers to be enrolled in Group 9, 2 back-up volunteers for 
Group 9 who have been screened and are eligible to participate in the study will be identified. These 
volunteers will be available to be enrolled in the study at short notice should a planned volunteer 
withdraw consent or become ineligible immediately prior to CHMI. Back-up volunteers may be enrolled 
in the study at Day C-1 and asked to attend clinic on day of challenge in case another control volunteer 
is found to be ineligible at that point. If back-up volunteers are not required on day of challenge they 
will be withdrawn from the study after this point. 
 
Definition of Start and End of Trial 
The start of the trial is defined as the date of the first vaccination of the first volunteer. The end of the trial 
is the date of the last visit of the last volunteer (LVLV). 
 
Potential Risks for volunteers 
9.2
Risks to the volunteers in this trial are associated with phlebotomy, vaccination, malaria infection and 
receipt of a blood product. These risks are outlined below.   
Female participants will be cautioned of the unknown risk of the RH5.1/AS01 vaccine to the foetus and will 
be advised to use adequate contraceptive methods for the duration of the study. 
Phlebotomy 
The total amount of blood collected over the study period will be a maximum of approximately  1523mL (in 
Group 6 volunteers who proceed to a further challenge in Group 8). This amount is drawn over a period of 
~6 months and is not expected to compromise the majority of healthy volunteers, however, volunteers will 
be monitored for anaemia. 
Risks occasionally associated with venepuncture include pain and bruising at the site of venepuncture, 
light-headedness, and syncope (rarely). 
Vaccination with RH5.1/AS01 
As with any vaccine, Guillain-Barré syndrome or immune-mediated reactions that can lead to organ 
damage including serious allergic reactions may occur but this should be extremely rare. Serious allergic 
reactions including anaphylaxis could also occur and for this reason volunteers will be vaccinated in a 
clinical area where Advanced Life Support trained physicians, equipment and drugs are immediately 
available for the management of any serious adverse reactions. 
The most frequent adverse reactions observed in previous clinical trials using protein antigens with the 
AS01 adjuvant system include pain, swelling, erythema, and tenderness at the site of injection, and 
systemic symptoms such as low-grade fever and short-term flu-like symptoms: fatigue, myalgia, headache, 
malaise.  
Febrile seizures assessed as related to RTS,S/AS01 vaccination have been reported in children, but not in 
adults.  

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Some individuals vaccinated with adjuvant components identical to those that will be used in this study 
have reported autoimmune diseases. A causal association between the adjuvant components and 
occurrence of auto-immune diseases (AID) has however not been established, as these can occur in people 
who get other vaccines, or no vaccines at all. A meta-analysis of a GSK Vaccines adjuvanted vaccine showed 
no increased risk of AID associated to the adjuvant 98. 
Risk of Infection with Blood Borne Organisms 
Experimentally induced blood-stage malaria infection (IBSM) for malaria challenge involves the 
administration of parasitised red blood cells, originally frozen down from a single donor in Australia. The 
blood was collected, processed and stored as described in section 5.3. The blood has been stored and 
monitored for over 15 years. The process basically constitutes a very tiny blood transfusion and therefore 
the risk of transmission of a blood borne infection cannot be completely ruled out. Measures have been 
taken to minimise the risks and these are outlined below. 
The donor was screened for a range of blood borne infections prior to the inoculum being collected, and 
has remained well since the first use of the inoculum in 1997 71. The donor tested negative for HIV, 
Hepatitis A, B and C, Syphilis, HTLV1 and Ross River virus. The donor was seropositive for Epstein Barr virus 
(EBV) and Cytomegalovirus (CMV), indicating previous infection. The blood was initially frozen for a year 
whilst the donor was monitored and retested. Over 240 volunteers have received the inoculum since 1997 
and there have been no serious adverse events, and no cases of blood borne infection associated with this. 
There were two individuals who were infected with P. falciparum malaria with the purpose of preparing the 
inoculum but all challenge inocula have since come from one of these donors as the other donor had a 
much lower parasitaemia when blood was collected 71. 
More recently, an ampoule of the parasite seed stock from the donor was thawed and cultured within the 
Queensland Institute of Medical Research (QIMR) laboratory. Culture supernatant tested negative for 
Mycoplasma by PCR. The blood was also tested for CMV and EBV by PCR using methodologies not available 
at the time of the initial cryopreservation, and tested negative. Although the donor remains antibody 
positive for EBV and CMV, it is apparent that the risk of transmission of both CMV and EBV has been greatly 
reduced by leukodepletion of the donor blood (both EBV and CMV cause latent infection of leukocytes) and 
washing of the blood with clinical grade saline prior to use. Initially only CMV and EBV seropositive 
volunteers were enrolled due to a concern about the risk of transmission of these viruses, but the risk has 
since been deemed extremely low. The requirement for CMV and EBV seronegativity was therefore waived 
by QIMR and in the most recent blood-stage CHMI trials carried out in both Nijmegen 84 and Oxford 
(VAC054), serostatus data were collected but not used as inclusion/exclusion criteria. None of the 
seronegative volunteers in VAC054 or the Nijmegen trial seroconverted during follow-up after CHMI. This 
study will therefore not exclude volunteers based on EBV and/or CMV seronegativity, and therefore EBV 
and CMV serostatus will not be assessed.  
The risk of transmission of variant Creutzfeldt Jacob Disease (vCJD) from the inoculum appears remote. The 
two donors are Australian residents, where no cases of either Bovine Spongiform Encephalopathy (BSE) in 
cattle or vCJD in humans have been reported to date. 
As well as the measures outlined above, the risk of infection is further reduced by the very small size of the 
inoculum. The volume to be transfused for this study is many thousand times smaller than the amount 
received in typical blood transfusion. Serum from volunteers will be collected before and after challenge for 
safety serum storage. 
Risk of reaction to the blood sample 
The donor of the blood used in the inoculum is Blood Group O and Rhesus (Rh) negative. People with Blood 
Group O negative blood are considered ‘universal donors’, as recipients of their blood are unlikely to 
develop red cell alloantibodies when given much larger volumes of blood than is envisaged here. The 

VAC063 Protocol v9.0 
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50 
volume of blood to be used in this study is extremely small. Around 10,000 - 120,000 red cells (around 5% 
of which contain parasites) from the donor will be injected into each volunteer. One mL of blood contains 
about 5 billion red cells, demonstrating the very small amount which is to be used in this study. The risk of a 
transfusion reaction or development of antibodies to donor red cells, which may make blood transfusion 
more difficult in the future, cannot be completely excluded but is considered extremely unlikely both 
because of the small volume of blood used and the fact the blood has been leukodepleted. Nevertheless, 
the volunteers will be monitored for this possibility in the period immediately after the administration of 
the malaria parasite dose. Volunteers will be reviewed 15 minutes (+/- 5 minutes) and 1 hour (+/- 10 
minutes) after receiving the inoculum before they are able to leave the CCVTM. The serum collected for 
storage (as described above) could be used to test for antibodies at a later date if deemed necessary. 
Risks relating to Malaria infection 
All non-vaccinated control volunteers and potentially all vaccinees are likely to develop symptomatic 
malaria infection following CHMI. Symptoms and signs will include feverishness, fever, tachycardia, 
hypotension, chills, rigors, sweats, headache, anorexia, nausea, vomiting, diarrhoea, myalgia, arthralgia, 
low back pain, thrombocytopenia and lymphopenia. Unmonitored and untreated P. falciparum infection 
can be fatal and, for this reason, volunteers will be followed up closely post-challenge and only enrolled in 
the study if they are deemed reliable and capable of complying with the intensive follow-up schedule. If 
necessary, volunteers may be admitted for in-patient care. 
The clone of malaria (3D7) is known to be sensitive to antimalarials including chloroquine, Riamet®, 
Malarone® and Fansidar and volunteers will be followed up twice daily following challenge and provided 
with antimalarials as soon as they have: 
 
One morphologically normal parasite detectable on thick blood film with symptoms consistent with 
malaria infection, OR 
 
One morphologically normal parasite detectable on thick blood film and qPCR ≥500 parasites/mL, 
OR 
 
Symptoms consistent with malaria infection and qPCR ≥500 parasites/mL. 
There is no risk of developing recurrent or relapsing episodes of malaria from these infections as this does 
not occur with P. falciparum malaria.  
Groups 7 and 8 will be receiving a second homologous malaria infection. There is no precedent in the 
modern CHMI era for re-challenge of volunteers who were not sterilely protected and reached thick smear 
positive on the primary infection. The primary blood-stage infection that these volunteers receive could 
induce some immunity to a homologous secondary or tertiary challenge (the old neurosyphilis P. vivax 
malaria data 50  showed a reduction in fever episodes and a log reduction the maximum mean parasite 
count after homologous P. vivax re-challenge) but the effect in blood-stage P. falciparum is assessed for the 
first time in this study. In the absence of previous similar data, volunteers will be counselled to expect to 
experience a similar degree of symptoms as with the primary infection. 
Medications Dispensed to Volunteers in the Course of the Trial  
 
(a) Treatment of Plasmodium falciparum Infection 
Malaria infection will be treated with oral Riamet (artemether-lumefantrine) unless there is a 
contraindication to this medication. If there is a contraindication to Riamet, another appropriate 
antimalarial will be used, either oral Malarone or chloroquine. See the Summary of Product Characteristics 
(SmPC) for side effects of and contraindications to chloroquine and Malarone. 
Riamet is generally well tolerated, but may cause some side effects. Common side effects include 
headache, dizziness, abdominal pain and loss of appetite, sleeping problems, palpitations, nausea, 
vomiting, diarrhoea, pruritus, skin rash, cough, muscle or joint pain and fatigue. Volunteers will be 

VAC063 Protocol v9.0 
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51 
counselled that certain side effects, for example dizziness, may impact on the performance of skilled tasks 
such as driving.  
As Riamet may increase the QT interval, Riamet will not be administered to volunteers at risk for QT 
prolongation. This includes those with prolonged QT on baseline ECG, a history of long QT syndrome, a 
family history of congenital QT prolongation or sudden death, cardiac arrhythmias, severe heart disease, 
and hypokalaemia or hypomagnesaemia. Volunteers will be advised to avoid grapefruit juice whilst taking 
Riamet. Riamet is also contraindicated in volunteers using concomitant medications affecting the QT 
interval, and will not be given to these volunteers. Concomitant use of Riamet may decrease effectiveness 
of hormonal contraceptives. Women using hormonal contraceptives will be advised to also use a barrier 
method of contraception whilst on Riamet treatment, and until the start of the next menstruation after 
treatment. 
 
(b) Treatment of Symptoms Associated with Malaria 
Volunteers will be dispensed cyclizine and paracetamol for the treatment of symptoms associated with 
malaria unless there are contraindications to these medications. Cyclizine is generally well tolerated 
however there is a risk of an allergic reaction. Other side effects include skin rashes or itching, drowsiness, 
headache, dry mouth nose or throat, blurred vision, palpitations, difficulty urinating, constipation, anxiety, 
insomnia or hallucinations. Rare side effects include hypotonia, seizures, dizziness, hypertension, 
paraesthesia, jaundice, hepatitis, confusion or dyskinesias. Paracetamol is generally well tolerated however 
it can cause an allergic reaction or rarely pancytopaenia. 
 
Known Potential Benefits 
9.3
Volunteers will not benefit directly from participation in this study. However, it is hoped that the 
information gained from this study will contribute to the development of a safe and effective malaria 
vaccine regimen. Volunteers will also receive information about their general health status. 

VAC063 Protocol v9.0 
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52 
10 EXPERIMENTALLY INDUCED BLOOD-STAGE MALARIA INFECTION INOCULUM 
For details on the preparation and previous use of this inoculum please see section 5.3 
 Storage conditions 
10.1
Between 1994 and 2003 the cryopreserved samples to be used in this trial were stored in dedicated liquid 
nitrogen cylinders in a secure facility at QIMR. The liquid nitrogen containers were kept locked and 
accessible only to approved staff. In 2003 the samples were transferred to Biotec Distribution Ltd., 
Bridgend, UK and then to Thermo Fisher Bishop’s Stortford, Hertfordshire, UK, in 2007 where they have 
been stored on behalf of Oxford University in temperature-monitored liquid nitrogen. 
 Administration of the inoculum 
10.2
Preparation 
Thawing and washing of the inoculum will be done with commercial solutions for human use and with 
disposable syringes and needles according to standard operating procedures used in previous studies at 
QIMR and Oxford 73,81. Work will be carried out in the bio safety category III or derogated category III 
laboratory at the Jenner Institute, Old Road Campus Research Building (ORCRB). Sample manipulations will 
be performed within a safety cabinet that has been especially fumigated, sterilised and dedicated for this 
purpose.  
After thawing of the blood inoculum and preparation of the syringes, the cold chain (2-8°C degrees) will be 
maintained at all times until the inoculum has been administered to the volunteer. 
Administration 
The inoculation will take place in Oxford at the CCVTM. The inoculum will be administered by intravenous 
injection into an indwelling intravenous cannula. Approximately 1,000 infected red blood cells will be 
injected in a total volume of 5 mL of normal saline followed by a saline flush. Subjects will be observed for 
one hour before discharge. The order in which vaccinated and unvaccinated volunteers receive the 
inoculum will be interspersed in case of time effects on viability of the parasites. If the inoculum is given on 
more than one day an equal number of control volunteers will receive the inoculum on each day. All 
volunteers will receive the inoculum within 4 hours of removal from frozen storage. 
 

VAC063 Protocol v9.0 
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53 
11 TREATMENT OF TRIAL VOLUNTEERS 
 Trial Sites 
11.1
Volunteers will be recruited and undergo screening visits, vaccination and clinic visits post-vaccination at 
their local trial site; either at the CCVTM, Oxford, the Guys and St Thomas’ NIHR CRF, London or NIHR 
WTCRF, Southampton for the Phase Ia stage of the trial. Volunteers recruited to the Phase IIa stage of the 
trial will be recruited in Oxford and at Guy’s and St Thomas’ NIHR CRF in London (except for Group 
9volunteers, who will only be recruited from Oxford). Those recruited in London will undergo screening, 
vaccination and post-vaccination visits there (pre CHMI). They will then come to Oxford for CHMI and 
subsequently all post-CHMI follow-up will occur at the CCVTM in Oxford. From the day before challenge 
until completion of a curative course of anti-malarial therapy, all volunteers must be resident within a 15 
mile radius of the CCVTM, Oxford. If necessary, accommodation can be provided for volunteers living 
beyond this distance. 
 Study procedures 
11.2
Procedures will be performed on the visit time points indicated in the schedule of attendances. Additional 
procedures or laboratory tests may be performed, at the discretion of the Investigators, e.g. urine 
microscopy in the event of positive urinalysis. 
Observations 
Pulse, blood pressure and temperature will be measured at the time points indicated in the schedule of 
attendances. Height and weight will be measured at on the day prior to challenge. 
Blood Tests 
Blood will be drawn for the following laboratory tests and processed: 
1. At the Oxford University Hospitals NHS Foundation Trust Laboratories, Guys and St Thomas’ 
Hospital or University Hospital Southampton, using NHS standard procedures: 
 
Haematology; Full Blood Count, Haemoglobinopathy screen, G6PD levels.  
 
Biochemistry; Sodium, Potassium, Urea, Creatinine, Albumin, Liver Function Tests for all 
groups. Magnesium will only be measured at screening for volunteers in Groups 5 and 6 (i.e. 
those undergoing CHMI). For female volunteers only, urine will be tested for beta-human 
chorionic gonadotrophin (HCG) at screening, immediately prior to each vaccination, the day 
before challenge, and just prior to starting anti-malarial treatment.  
 
Diagnostic serology; HBsAg, HCV antibodies, HIV antibodies (specific consent will be gained 
prior to testing blood for these blood-borne viruses).  
 
Immunology; Human Leukocyte Antigen (HLA) typing. 
2. At University of Oxford research laboratories: 
 
Diagnostic Tests: Blood films for malaria parasites, PCR for Plasmodium falciparum DNA.  
 
Immunology: Serological analysis of antibody responses (such as ELISA, functional GIA); B cell 
assays, ex-vivo ELISpot assays for interferon gamma and flow cytometry assays will be 
performed. Other immunological assays including cytokine analysis, DNA and RNA analysis of 
genetic polymorphisms potentially relevant to vaccine immunogenicity and gene expression 
studies (both host and parasite) amongst others may be performed at the discretion of the 
Investigators. Samples may also be used for monoclonal antibody production and B cell 
repertoire analysis. All initial investigations will be outlined in the VAC063 laboratory plan.   

VAC063 Protocol v9.0 
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54 
3. Urinalysis; Urine will be tested for blood, protein and glucose at screening. For female volunteers 
only, urine will be tested for beta-human chorionic gonadotrophin (hCG) at screening, immediately 
prior to each vaccination, the day before challenge, and just prior to starting anti-malarial 
treatment. 
4. Electrocardiogram; An electrocardiogram will be performed at screening for volunteers in Groups 5 
6 and 9. We will not routinely perform another ECG for volunteers who re-enrol into Groups 7 and 
8 if their previous ECG was normal at their first screening visit (unless they were to have 
experienced new chest pain, palpitations or faints since they were last seen).  
5. Samples will be sent to collaborating laboratories for other immunological assays as required. 
These will include laboratories within and outside the UK (including outside of Europe) for 
immunomonitoring and harmonisation of key immunological assays. This would involve the 
transfer of serum, plasma or blood cells to these laboratories, but these would remain anonymised. 
Informed consent for this will be gained from volunteers. 
Immunological assays will be conducted according to the procedures established in the test laboratories. 
With the volunteers’ informed consent, any leftover cells and serum/plasma will be frozen indefinitely for 
future exploratory immunological analysis of malaria-specific or vaccine-related responses. This may 
include human DNA and RNA analysis to search for correlates of vaccine immunogenicity and efficacy. 
Vaccinations 
Before each vaccination, the on-going eligibility of the volunteer will be reviewed. The vaccine will be 
administered as described above in section 6.4. The injection site will be covered with a sterile dressing and 
the volunteer will stay in the local trial site for observation for 1 hour, in case of immediate adverse events. 
Observations will be taken 30 minutes after vaccination (+/- 5 minutes) and the sterile dressing removed 
and injection site inspected. Observations will also be taken at 60 minutes after vaccination (+/- 10 
minutes). An oral thermometer and tape measure will be given to each volunteer, with instructions on use, 
along with the emergency 24 hour telephone number to contact the on-call study physician if needed. 
Volunteers will be asked to complete a diary card which may be in paper or electronic form. 
 Study visits 
11.3
The study visits and procedures will be undertaken by one of the clinical trials team. The procedures to be 
included in each visit are documented in the schedule of attendances. Each visit is assigned a time point 
and a window period, within which the visit will be conducted. These can be found in the schedule of 
attendances. 
Screening Visit  
All potential volunteers will have a screening visit, which may take place up to 90 days prior to enrolment. 
Volunteers from Groups 5 and 6 who wish to re-enrol into Groups 7 and 8 will be re-screened before re-
enrolment to ensure ongoing eligibility. Informed consent will be taken before screening, as described in 
section 8.2. If consent is obtained, the screening procedures indicated in the schedule of attendances will 
be undertaken. To avoid unnecessary additional venepuncture, if the appropriate blood test results for 
screening are available for the same volunteer from a screening visit for another Jenner Institute Clinical 
Trials group vaccine study, these results may be used for assessing eligibility (provided the results date is 
within the 3 months preceding enrolment in VAC063). 
Abnormal clinical findings from the urine or blood tests at screening and throughout the study will be 
assessed using the table in Appendix A and the site specific laboratory adverse events tables. If a test is 
deemed clinically significant it may be repeated to ensure it is not a single occurrence. If an abnormal 
finding is deemed to be clinically significant, the volunteer will be informed and appropriate medical care 

VAC063 Protocol v9.0 
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55 
arranged with the permission of the volunteer. Decisions to exclude the volunteer from the enrolling in the 
trial or to withdraw a volunteer from the trial will be at the discretion of the Investigator. 
An electrocardiogram will be done at screening or at the day 0 (D0) visit for vaccinees or day before CHMI 
(C-1) visit for controls (in cases where ECG was not able to be done at screening). 
Day of Vaccination – Groups 1 - 5 (Days 0, 28 and 56/182) 
Any new medical issues or symptoms that have arisen will be assessed. Physical observations, urinary β 
HCG test in female volunteers and venepuncture for immunology and safety bloods will be undertaken 
according to Tables 3 - 6. The inclusion and exclusion criteria for the study will be reviewed. Vaccines will be 
administered according to the SOP for mixing and administration for RH5.1/AS01. Diary cards (paper or 
electronic) will be issued to the volunteer, with instructions for how these should be completed.  
Reviews Post Vaccination – Groups 1, 2 and 4 (Days 1, 7, 14, 29, 35, 42, 57, 63, 70, 84, 140, 240 and 600) 
Diary cards will be reviewed for details of solicited and unsolicited AEs for 28 days after each vaccination, 
and any new or undocumented medical issues or symptoms that have arisen will be assessed. Physical 
observations and venepuncture for immunology and safety bloods will be undertaken according to Table 3.  
At day 600, new consent will be obtained prior to visit procedures, including consent to contact the GP. Any 
new or undocumented medical issues or symptoms that have arisen will be assessed. Due to length of time 
since last visit, at this visit only, this will include participation in any other trial and any travel history to 
malaria endemic zones. The GP will be contacted to inform them of the attendance at this additional visit. 
Reviews Post Vaccination – Group 3 (Days 1, 7, 14, 29, 35, 42, 56, 183, 189, 196, 210, 266, 366 and 730) 
Diary cards will be reviewed for details of solicited and unsolicited AEs for 28 days after each vaccination, 
and any new or undocumented medical issues or symptoms that have arisen will be assessed. Physical 
observations and venepuncture for immunology and safety bloods will be undertaken according to Table 4.  
At day 730, new consent will be obtained prior to visit procedures, including consent to contact the GP. Any 
new or undocumented medical issues or symptoms that have arisen will be assessed. Due to length of time 
since last visit, at this visit only, this will include participation in any other trial and any travel history to 
malaria endemic zones since the last visit. The GP will be contacted to inform them of the attendance at 
this additional visit. 
Reviews Post Vaccination – Group 5 (Follow-up schedule as per Groups 1, 2 and 4, until C-1 visit) 
Diary cards will be reviewed for details of solicited and unsolicited AEs for 28 days after each vaccination, 
and any new or undocumented medical issues or symptoms that have arisen will be assessed. Physical 
observations and venepuncture for immunology and safety bloods will be undertaken according to Table 5. 
CHMI will take place 2 weeks after the final vaccination, and follow-up after CHMI will be undertaken as per 
Table 5.  
At day 530, new consent will be obtained prior to visit procedures. Any new or undocumented medical 
issues or symptoms that have arisen will be assessed. Due to length of time since last visit, at this visit only, 
this will include participation in any other trial and any travel history to malaria endemic zones since the 
last visit. The GP will be contacted to inform them of the attendance at this additional visit. 
Reviews Post Vaccination – Group 7 
This relates to the final and fourth vaccination at four months and will involve a follow-on Day 1 and Day 7 
visit, with a C-1 visit and CHMI 7-14 days after the final vaccination, as for Group 5. Physical observations 
and venepuncture for immunology and safety bloods will be undertaken according to Table 7.  
At day 540, new consent will be obtained prior to visit procedures. Any new or undocumented medical 
issues or symptoms that have arisen will be assessed. Due to length of time since last visit, at this visit only, 

VAC063 Protocol v9.0 
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56 
this will include participation in any other trial and any travel history to malaria endemic zones since the 
last visit. The GP will be contacted to inform them of the attendance at this additional visit. 
Day before CHMI (C-1) – Groups 5-9 
Any new medical issues or symptoms that have arisen will be assessed. Physical observations, urine β HCG 
test in female volunteers and venepuncture for immunology, PCR and safety bloods will be undertaken 
according to Tables 5 and 7. Results of safety bloods taken at this visit must be available and reviewed prior 
to CHMI. 

VAC063 Protocol v9.0 
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57 
 
S 
RH5.1/ AS01 (1) 
 
 
 
RH5.1/  AS01 (2) 
 
 
RH5.1/ AS01 (3) 
 
 
 
 
 
 
 
Attendance number  
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
Timeline (days) 
 
0 
1 
7 
14 
28 
29 
35 
42 
56 
57 
63 
70 
84 
140 
240 
696 
Window (days) 
(-90) 
 
0 
±2 
±2 
±5 
±1 
±2 
±2 
±5 
±1 
±2 
±2 
±5 
±14 
±14 
±275 
Inclusion / Exclusion criteria 
X 
X 
 
 
 
X 
 
 
X 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Medical History 
X 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
X** 
Physical Examination 
X 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(X) 
Urinalysis 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
β-HCG urine (♀) 
X 
X 
 
 
 
X 
 
 
X 
 
 
 
 
 
 
Review contraindications 
X 
X 
 
 
 
X 
 
 
 
X 
 
 
 
 
 
 
Vaccination 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
 
 
 
 
Physical Observations^ 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
(X) 
(X) 
X 
AEs reviewed* 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Diary card commenced 
 
X 
 
 
 
X 
 
 
X 
 
 
 
 
 
 
 
Diary card completed  
 
 
 
 
X 
 
 
X 
 
 
 
X 
 
 
 
HLA typing (mL) 
 
4 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HBV,HCV,HIV (mL) 
5 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Haematology (mL) 
2 
2 
 
2 
2 
2 
 
2 
2 
2 
 
2 
2 
2 
 
 
 
Biochemistry (mL) 
3 
3 
 
3 
3 
3 
 
3 
3 
3 
 
3 
3 
3 
 
 
 
Immunology 
 
73 
13 
10 
70 
73 
13 
10 
70 
73 
13 
10 
70 
70 
70 
70 
70 
Blood volume per visit (mL) 
10 
82 
13 
15 
75 
78 
13 
15 
75 
78 
13 
15 
75 
75 
70 
70 
70 
Cumulative blood volume (mL) 
10 
92 
105 120 195 
273 
286 
301 376 
454 
467 
482 
557 
632 
702 
772 
842$ 
Table 3: Schedule of attendances for Groups 1, 2 and 4. S = screening visit, (x) = If considered necessary, emphasising any acute complaints. 
^ Physical observations include blood pressure, pulse and temperature, height and weight; however height and weight will only be measured at screening. 
*All AEs will be recorded for 28 days after each vaccination (in an electronic diary). After this, only SAEs or AEs of special interest will be recorded.  
**Medical history at this visit will include travel history to malaria endemic zones and any history of participation in other trials since last visit 
$Approximate cumulative blood volume if blood taken as per schedule, and excluding any repeat safety blood tests that may be necessary. 

VAC063 Protocol v9.0 
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58 
 
S 
RH5.1/ AS01 (1) 
 
 
 
RH5.1/ AS01 (2) 
 
 
 
RH5.1/AS01 (3)  
 
 
 
 
 
 
Attendance number  
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
Timeline (days) 
 
0 
1 
7 
14 
28 
29 
35 
42 
56 
182 
183 189 196 210 266 366 822 
Window (days) 
(-90) 
 
0 
±2 
±2 
±5 
±1 
±2 
±2 
±5 
±14 
0 
±2 
±2 
±5 ±14 ±14 
±275 
Inclusion / Exclusion criteria 
X 
X 
 
 
 
X 
 
 
 
X 
 
 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Medical History 
X 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
X** 
Physical Examination 
X 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(X) 
Urinalysis 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
β-HCG urine (♀) 
X 
X 
 
 
 
X 
 
 
 
X 
 
 
 
 
 
 
 
Review contraindications 
X 
X 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
 
 
 
Vaccination 
 
X 
 
 
 
X 
 
 
 
 
X 
 
 
 
 
 
 
 
Physical Observations^ 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
(X) (X) (X) 
X 
AEs reviewed* 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Diary card commenced 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
 
 
 
 
Diary card completed  
 
 
 
 
X 
 
 
X 
 
 
 
 
X 
 
 
 
HLA typing (mL) 
 
4 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HBV,HCV,HIV (mL) 
5 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Haematology (mL) 
2 
2 
 
2 
2 
2 
 
2 
2 
2 
2 
 
2 
2 
2 
 
 
 
Biochemistry (mL) 
3 
3 
 
3 
3 
3 
 
3 
3 
3 
3 
 
3 
3 
3 
 
 
 
Immunology 
 
73 
13 
10 
70 
73 
13 
10 
70 
70 
73 
13 
10 
70 
70 
70 
70 
70 
Blood volume per visit (mL) 
10 
81 
13 
15 
75 
78 
13 
15 
75 
75 
78 
13 
15 
75 
75 
70 
70 
70 
Cumulative blood volume (mL) 
10 
92 
105 120 195 
273 
286 
301 376 451 
529 
542 557 632 707 777 847 
917$ 
Table 4: Schedule of attendances for Group 3. S = screening visit, (x) = If considered necessary, emphasising any acute complaints. 
^ Physical observations include blood pressure, pulse and temperature. 
*All AEs will be recorded for 28 days after each vaccination (in an electronic diary). After this, only SAEs or AEs of special interest will be recorded.  
**Medical history at this visit will include travel history to malaria endemic zones and any history of participation in other trials since last visit$Approximate cumulative blood volume if blood 
taken as per schedule, and excluding any repeat safety blood tests that may be necessary. 
 

VAC063 Protocol v9.0 
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59 
 
S 
RH5.1/ 
AS01 (1) 
 
 
 
RH5.1/ 
AS01 (2) 
 
 
RH5.1/ 
AS01 (3) 
 
 
C-1 
C 
C+1 C+2-12 
b (Day of 
diagnosis) C+13-23 C+28 
C+90 
C+170 C+625 
Attendance number  
1 
2 
3 
4 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16-37 
 
38-48 
49 
50 
51 
52 
Timeline (days) 
 
0 
1 
7 
14 
28 
29 
35 
42 
56  
57 
63 
69 
70 
71 
72-82 
(AM+P
M) 
 
83-93  
98 
160 
240 
696 
Window (days) 
(-90) 
 
±1 
±2 
±2 
 
±1 
±2 
±2 
 
±1 
±2 
 
-3-
+10 
0 
0 
 
0 
±3 
±7 
±14 
±275 
Inclusion / Exclusion 
criteria 
X 
X 
 
 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
 
 
 
 
 
Informed Consent 
(including 
Questionnaire) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
Medical History 
X 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
Xc 
Physical Examination 
X 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(X) 
Urinalysis 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Electrocardiogram 
X 
(X) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
β-HCG urine (♀) 
X 
X 
 
 
 
X 
 
 
X 
 
X 
 
 
 
X 
 
 
 
 
 
Review 
contraindications 
X 
X 
 
 
 
X 
 
 
 
X 
 
 
X 
X 
 
 
 
 
 
 
 
 
Vaccination 
 
X 
 
 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical 
Observations^ 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
AEs reviewed* 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
(x) 
X 
Diary card provided 
 
X 
 
 
 
X 
 
 
X 
 
 
 
X 
 
 
 
 
 
 
 
 
Diary card collected 
 
 
 
X 
 
 
 
X 
 
 
X 
 
 
 
 
 
 
X 
 
 
 
Medic Alert Card 
Given to Volunteers 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
 
 
 
 
 
 
 
Treatment for 
Malaria 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
X 
(X) 
 
 
 
 
HLA typing (mL) 
 
4 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HBV,HCV,HIV (mL) 
5 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

VAC063 Protocol v9.0 
CONFIDENTIAL 
60 
 
S 
RH5.1/ 
AS01 (1) 
 
 
 
RH5.1/ 
AS01 (2) 
 
 
RH5.1/ 
AS01 (3) 
 
 
C-1 
C 
C+1 C+2-12 
b (Day of 
diagnosis) C+13-23 C+28 
C+90 
C+170 C+625 
Serum for storage 
 
 
 
 
 
 
 
 
 
 
 
 
5 
 
 
 
 
 
 
5 
 
 
Haematology (mL) 
2 
2 
 
2 
2 
2 
 
2 
2 
2 
 
2 
2 
 
 
2£ 
2 
 
2 
2 
 
 
Biochemistry ** (mL) 
3 
3 
 
3 
3 
3 
 
3 
3 
3 
 
3 
3 
 
 
3£ 
3 
 
3 
3 
 
3 
Immunology 
 
70 
10 
10 
70 
70 
10 
50 
70 
70 
10 
50 
70 
 
 
10 per 
visit x 
9 visits 
a 
70 
10 per 
visit x 8 
visits a 
70 
70 
 
70 
 
Blood Film / PCR 
 
 
 
 
 
 
 
 
 
 
 
3 
 
3 
3 x 22 
2 
3 x 11 
 
 
 
 
Blood volume per 
visit (mL) 
10 
79 
10 
15 
75 
75 
10 
55 
75 
75 
10 
55 
83 
0 
3 
161 
77 
113 
75 
80 
 
70 
Cumulative blood 
volume (mL) 
10 
89 
99 114 189 
264 
27
4 
329 404 
479 
489 
544 
627 
627 
630 
791 
868 
981 
1056 
1136 
 
1206$ 
Table 5: Schedule of attendances for Group 5.  S = screening visit, (x) = If considered necessary, emphasising any acute complaints. 
^ Physical observations include blood pressure, pulse and temperature. 
*All AEs will be recorded for 28 days after each vaccination (in an electronic diary). After this, only SAEs or AEs of special interest will be recorded. 
^ Physical observations includes blood pressure, pulse and temperature, height and weight, however height and weight will only be measured at screening and C-1. 
** Biochemistry will include Sodium, Potassium, Urea, Creatinine, Albumin, Liver Function Tests & Magnesium , however Magnesium will only be measured at screening. 
£ Biochemistry and haematology bloods will be checked on day 6 post CHMI 
$Cumulative blood volume if blood taken as per schedule, and excluding any repeat safety blood tests that may be necessary. 
a Immunology blood to be taken at AM visits on days 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20 (but only until day of diagnosis). 
b This bleed to be also carried out at C+21, prior to treatment, if a volunteer is not diagnosed. 
cMedical history at this visit will include travel history to malaria endemic zones and any history of participation in other trials since last visit 
  
The vaccine schedule for Group 5 will be the same as Groups 1, 2 and 4, using the 10 µg dose of RH5.1.  (Windows refer to time since last visit, but windows between 
vaccinations must be a minimum of 21 days and a maximum of 35 days for the first and second vaccinations. The window between final vaccination and challenge must be a 
minimum of 11 days and maximum of 24 days). 

VAC063 Protocol v9.0 
CONFIDENTIAL 
61 
 
S  
C-1 C 
C+1 C+2-12 (AM+PM) 
b (Day of diagnosis) 
C+13-23 C+28 C+90 
Attendance number  
1 
2 
3 
4 
5-26 
 
27-37 
38 
39 
Timeline (days) 
 
-1 
0 
1 
2-12 (AM+PM) 
 
13-23 
28 
90 
Window (days) 
(-90) 
-1 
0 
0 
0 
 
0 
±3 
±7 
Inclusion / Exclusion criteria 
X 
X 
X 
 
 
 
 
 
 
Informed Consent (including Questionnaire) 
X 
 
 
 
 
 
 
 
 
Medical History 
X 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
Physical Examination 
X 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
Urinalysis 
X 
 
 
 
 
 
 
 
 
Electrocardiogram 
X 
 
 
 
 
 
 
 
 
β-HCG urine (♀) 
X 
X 
 
 
 
X 
 
 
 
Review contraindications 
X 
X 
X 
 
 
 
 
 
 
Physical Observations^ 
X 
X 
X 
X 
X 
X 
(X) 
X 
X 
AEs reviewed 
 
X 
X 
X 
X 
X 
(X) 
X 
X 
Diary card provided 
 
 
X 
 
 
 
 
 
 
Diary card collected 
 
 
 
 
 
 
 
X 
 
Medic Alert Card Given to Volunteers 
 
 
X 
 
 
 
 
 
 
Treatment for Malaria 
 
 
 
 
 
X 
(X) 
 
 
HLA typing (mL) 
 
4 
 
 
 
 
 
 
 
HBV,HCV,HIV (mL) 
5 
 
 
 
 
 
 
 
 
Serum for storage 
 
5 
 
 
 
 
 
 
5 
Haematology* (mL)  
5 
2 
 
 
2£ 
2 
 
2 
2 
Biochemistry** (mL) 
3 
3 
 
 
3£ 
3 
 
3 
3 
Immunology 
 
95 
 
 
25 per visit x 9 visits a
110 
 
95 
95 
Blood Film / PCR 
 
3c 
 
3 
3 x 22 
2 
3 x 11 
 
 
Blood volume per visit(s) (mL) 
13 
112 
0 
3 
296 
117 
33 
100 
105 
Cumulative blood volume (mL) 
13 
125 125 128 
424 
541 
574 
674 
779$ 
Table 6: Schedule of attendances for Groups 6, 8 and 9 (infectivity controls) in first and second challenges (primary 
challenges for Groups 6 and 9 and secondary challenge for Group 8).  
S = screening visit (x) = If considered necessary, emphasising any acute complaints. 
^ Physical observations includes blood pressure, pulse and temperature, height and weight, however height and weight will only 
be measured at screening and C-1. *Haematology will include Full Blood Count, G6PD levels and Haemoglobinopathy screen.** 
Biochemistry will include Sodium, Potassium, Urea, Creatinine, Albumin, Liver Function Tests & Magnesium, however Magnesium 
will only be measured at screening. 
£ Biochemistry and haematology bloods will be checked on day 6 post malaria challenge 
$Cumulative blood volume if blood taken as per schedule, and excluding any repeat safety blood tests that may be necessary. 
a Immunology blood to be taken at AM visits on days 3, 5, 6, 7, 8, 9, 10, 11, and 12 (but only until day of diagnosis). 
b This bleed to be also carried out at C+21, prior to treatment, if a volunteer is not diagnosed 
c.Blood film (1mL) and PCR (2mL) will be measured for Group 6. PCR (2mL) only will be measured for Groups 8 and 9, so the 
cumulative blood volume for Groups 8 and 9 will be 35mLs less than for Group 6 (744mLs) 
 To note: for those Group 6 volunteers that subsequently enter into Group 8 and participate in a second CHMI, the 
total cumulative blood volume taken over their study experience (7 months total) will be 779 mLs PLUS 744 mLs = 
1523 mLs.  
 

VAC063 Protocol v9.0 
CONFIDENTIAL 
62 
 
RS  
RH5.1/ 
AS01 (4) 
 
 
C-1 
C 
C+1 
C+2-12 
(AM+PM) 
b (Day ofdiagnosis) 
C+13-23 
C+28 C+9
0 
C+640 
Attendance number  
1 
2 
3 
4 
5 
6 
7 
8-29 
 
30-40 
41 
42 
43 
Timeline (days) 
 
0 
1 
7 
-1 
0 
1 
2-12 
(AM+PM) 
 
13-23 
28 
90 
640 
Window (days) 
(-90) 
 
 
 
-1 
0 
0 
0 
 
0 
±3 
±7 
±275 
Inclusion / Exclusion criteria 
X 
X 
 
 
X 
X 
 
 
 
 
 
 
 
Informed Consent (including 
Questionnaire) 
X 
 
 
 
 
 
 
 
 
 
 
 
X 
Medical History 
X 
(x) 
 
 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
Xc 
Physical Examination 
X 
(x) 
 
 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(x) 
(X) 
Urinalysis 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Electrocardiogram 
X 
 
 
 
 
 
 
 
 
 
 
 
 
β-HCG urine (♀) 
X 
X 
 
 
X 
 
 
 
X 
 
 
 
 
Review contraindications 
X 
X 
 
 
X 
X 
 
 
 
 
 
 
 
Physical Observations^ 
X 
X 
 
 
X 
X 
X 
X 
X 
(X) 
X 
X 
X 
AEs reviewed^^ 
 
X 
 
 
X 
X 
X 
X 
X 
(X) 
X 
X 
X 
Vaccination 
 
X 
 
 
 
 
 
 
 
 
 
 
 
Diary card provided 
 
X 
 
 
 
X 
 
 
 
 
 
 
 
Diary card collected 
 
 
 
 
 
 
 
 
 
 
X 
 
 
Medic Alert Card Given to 
Volunteers 
 
 
 
 
 
X 
 
 
 
 
 
 
 
Treatment for Malaria 
 
 
 
 
 
 
 
 
X 
(X) 
 
 
 
HLA typing (mL) 
 
 
 
 
4 
 
 
 
 
 
 
 
 
HBV,HCV,HIV (mL) 
5 
 
 
 
 
 
 
 
 
 
 
 
 
Serum for storage 
 
 
 
 
5 
 
 
 
 
 
 
5 
 
Haematology* (mL)  
5 
 
 
2 
2 
 
 
2£ 
2 
 
2 
2 
 
Biochemistry** (mL) 
3 
 
 
3 
3 
 
 
3£ 
3 
 
3 
3 
 
Immunology 
 
70 
10 
50 
75 
 
 
10 per visit 
70 
10 per 
70 
70 
70 

VAC063 Protocol v9.0 
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63 
 
RS  
RH5.1/ 
AS01 (4) 
 
 
C-1 
C 
C+1 
C+2-12 
(AM+PM) 
b (Day ofdiagnosis) 
C+13-23 
C+28 C+9
0 
C+640 
x 9 visits a 
visit x 8 
visits  
PCR 
 
 
 
 
2 
 
2 
2 x 22 
2 
2 x 11 
 
 
 
Blood volume per visit(s) (mL) 
13 
70 
10 
55 
91 
0 
3 
139 
77 
102 
75 
80 
70 
Cumulative blood volume (mL) 
13 
83 
93 
148 
239 
239 
244 
383 
460 
562 
637 717 
787 
 
Table 7: Schedule of attendances for Group 7. 
RS = Re-screening visit (x) = If considered necessary, emphasising any acute complaints. 
^ Physical observations includes blood pressure, pulse and temperature, height and weight, however height and weight will only be measured at screening and C-1. 
^^All AEs will be recorded for 28 days after each vaccination (in an electronic diary). After this, only SAEs or AEs of special interest will be recorded. 
*Haematology will include Full Blood Count, G6PD levels and Haemoglobinopathy screen 
** Biochemistry will include Sodium, Potassium, Urea, Creatinine, Albumin, Liver Function Tests & Magnesium , however Magnesium will only be measured at screening. 
£ Biochemistry and haematology bloods will be checked on day 6 post malaria challenge 
$Cumulative blood volume if blood taken as per schedule, and excluding any repeat safety blood tests that may be necessary. Note that the cumulative blood volume taken over these 
volunteers’ entire study experience (all Group 5 and Group 7 visits included over a year’s total follow-up), is 1136+717 mL = 1853 mL. 
a Immunology blood to be taken at AM visits on days 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20 (but only until day of diagnosis). 
b This bleed to be also carried out at C+21, prior to treatment, if a volunteer is not diagnosed 
c Medical history at this visit will include travel history to malaria endemic zones and any history of participation in other trials since last visit 
 
 
To note: for those Group 5 volunteers that enter into Group 7, the original C+170 visit (Table 5) will be cancelled and instead the extra visits detailed in Table 7 will be 
required to incorporate the fourth immunisation and second malaria challenge. This makes the cumulative maximum blood volume for Group 7 (taken over their whole 
study experience - a year’s total follow-up plus one visit 1-2 years after last vaccination) 1136 + 792 mL =1928 mL. 
 

VAC063 Protocol v9.0 
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64 
 
Day 70 – follow up after final vaccination (Group 5), Day 14 follow-up after final vaccination (Group 7) and day of 
CHMI (day of challenge [C]) – Groups 5,  6, 7, 8 and 9  
 
Perform interim history and examine the injection site and any body systems felt to be necessary by the 
Investigator and verify continuing eligibility / contraindications. 
 
Record vital signs. 
 
Blood-stage CHMI (challenge) will be delivered as per the methods described in section 10.2. 
 
Insert cannula in forearm vein and flush cannula with normal saline. 
 
For each volunteer ensure that the inoculum is injected within 4 hours of the inoculum being defrosted. 
Flush cannula with normal saline again. 
 
Observe for 1 hour to evaluate for immediate adverse reactions, then remove cannula. 
 
Medication diary cards, symptomatic treatment (paracetamol and cyclizine) and thermometers will be given 
out. If medications are not dispensed during this visit they will be dispensed at one of the visits in the 
following 5 days. 
A Medic-Alert type card will be issued to each volunteer with information including Malarone/Riamet®/chloroquine 
sensitivity of the challenge malaria strain, study physician contact details and a request that the research team be 
contacted immediately in the event of illness/accident. Each subject will also be issued with an accurate oral 
thermometer. If the subject does not have their own mobile telephone they will be issued with one for the duration 
of the study, and counselled about the importance of keeping it switched on or checking the messages regularly. In 
addition full contact details for each subject will be documented, including home address, mobile, home and work 
land-line telephone numbers where available and next-of-kin address and telephone numbers. Mobile telephone 
numbers will be verified prior to challenge to ensure the volunteers are easily contactable. Volunteers must be 
resident in Oxford / the surrounding area until they have had 2 consecutive negative thick blood films or two 
consecutive qPCR results with substantial reduction in genome copies/mL after commencing antimalarial treatment, 
or have reached Day 28 and commenced antimalarial treatment. Subjects must also provide the Investigators with 
the name and 24 hour telephone number of a close friend, relative or housemate who will be kept informed of their 
whereabouts for the duration of the study. Volunteers will be counselled that should they fail to return for 
treatment having been infected with P. falciparum they could become very unwell and potentially die. They will be 
informed that should they fail to attend a scheduled clinic visit post-challenge, their nominated contact, next of kin 
and the police may be informed and a search started.  
Day C+1 (1 day after Challenge) to C+23 (23 days after Challenge)  
Follow-up visits in this intensive post-CHMI phase will take place at the CCVTM in Oxford. All volunteers will be seen 
by one of the clinical study team at each visit. The Investigators are all physicians with experience in acute medicine 
and infectious diseases and familiarity assessing patients with malaria. The Oxford based research nurses (RNs) are 
qualified RNs with previous experience conducting CHMI trials. 
Each day until a challenge endpoint is passed (i.e. malaria is diagnosed or day 21 post-challenge is reached) 
volunteers will be required to attend for clinic visits at the CCVTM. Volunteers will be reviewed in clinic once on the 
first day post-challenge, then twice daily (approximately 12 hours apart) on days 2 to 12 post-challenge. From day 13 
until day 21 post-challenge, volunteers will be reviewed daily. Upon malaria diagnosis or day 21 post-challenge being 
reached, subjects will be reviewed in clinic approximately 24 and 48 hours after diagnosis and / or starting anti-
malarial therapy, as described in more detail later. 
At each follow-up visit: 
 
Physical observations will be performed. 

VAC063 Protocol v9.0 
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65 
 
Venepuncture will be performed as per schedule of attendances (Tables 56&8). 
 
Volunteers will be questioned as to whether they have; 
o Experienced any of the foreseeable symptoms of malaria. 
o Experienced any other symptoms.  
o Taken any medications including over the counter medications. 
Subjects will be encouraged to contact one of the Investigators on the 24 hour emergency mobile telephone number 
if they develop symptoms of malaria or concerning AEs between the regular clinic reviews. The Investigator will 
consider an extra clinical review and thick film microscopy/ qPCR if the subject’s symptoms are moderate or severe. 
The severity of symptoms will be assessed using grading criteria summarised below. If a volunteer is unwell and 
unable to attend the CCVTM for a visit, they will be visited at home by one of the Investigators. Such visits will be 
conducted according to SOP VC022: Lone Working in the Community. 
 
Malaria Diagnosis 
Diagnosis of malaria infection following challenge (in Groups 5 and 6) will be defined as positive thick film 
microscopy (at least one morphologically normal malaria trophozoite seen in 200 high-power (1000x) fields) by one 
or more experienced microscopists in a patient with symptoms suggestive of malaria.  
Real time qPCR for P. falciparum will simultaneously be performed, although all Investigators (except the Principal 
Laboratory Investigator) will be blinded to the results. If a positive thick film for malaria parasites is seen in an 
asymptomatic volunteer, the most recent qPCR results for this volunteer will be un-blinded to the Chief Investigator 
by the Principal Laboratory Investigator and the volunteer treated only if any available qPCR result for that individual 
has been measured as ≥500 parasites/mL. In this scenario, if all available qPCR results are <500 parasites/mL, 
treatment will be delayed until either the patient develops a further positive thick film in the presence of symptoms 
suggestive of malaria infection in the opinion of the Investigator, or the volunteer has a further positive thick film 
with a qPCR measurement ≥500 parasites/mL (Table 9). 
Should a volunteer describe symptoms or display signs which are highly likely to represent malaria infection in the 
opinion of Investigators (such as fever, rigors or severe symptomatology) despite having a negative thick film and the 
absence of an alternative cause, clinicians may be un-blinded to the qPCR result. If this is positive (≥500 
parasites/mL), the volunteer will be treated for malaria.  
The Investigators are able to treat any volunteer for malaria regardless of the thick film microscopy or qPCR result if 
they are clinically concerned (and have discussed the case with the Chief Investigator), or a volunteer wishes to 
withdraw from the study.  
When a case of malaria is diagnosed, each subject will have a clinical evaluation by one of the Investigators (a 
physician) with appropriate history and physical examination where deemed to be necessary. If necessary, they can 
be admitted to the John Warin Infectious Diseases ward at the John Radcliffe Hospital, Oxford for observation and 
further medical management under the care of the Infectious Diseases Consultant on call. 
 
 
 
 
 
 
 
 

VAC063 Protocol v9.0 
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66 
 
THICK FILM MICROSCOPY  
MALARIAL SYMPTOMS 
Positive 
Negative 
Symptomatic 
Positive diagnosis 
Positive diagnosis if any available 
PCR result is ≥ 500 parasites/mL 
Asymptomatic 
Positive diagnosis if any 
available PCR result is ≥ 500 
parasites/mL 
(Otherwise delay treatment) 
 
Negative diagnosis 
Table 9: Malarial Diagnosis Criteria (Groups 5 and 6) 
 
However, in the re-challenge phase of the study (Groups 7-10) we have decided not to use microscopy as a routine 
diagnostic tool. This is because the qPCR assay that we have used in numerous Oxford-led CHMI challenge studies is 
now qualified and highly sensitive, reliably detecting parasitaemias as low as 20 parasites per mL of blood (0.02 
parasites per μL), long before clinical symptoms manifest. Indeed, based upon results obtained using dilution series 
of microscopically-counted cultured parasites, this method has a lower limit of quantification (LLQ, defined as 
%CV<20%) of around 20 p/mL blood. Counted parasite dilution series results suggest that the lower limit of probable 
detection (LLD, i.e. a probability of >50% of ≥1 positive result among three replicate qPCR reactions) is in the region 
of 5 p/mL, while samples at 1 p/mL are consistently negative (24/24 qPCR reactions). Positive results in this assay 
(even at very low level) are thus essentially 100% specific for genuine parasitaemia, with positive results beneath the 
LLQ likely to signify parasitemia in the range 2-20 p/mL. The qPCR assay has also performed well in an international 
External Quality Assurance (EQA) exercise (https://www.ncbi.nlm.nih.gov/pubmed/24838112). By also establishing a 
revised treatment threshold of 5,000 parasites per mL (5 parasites per μL), any potential complications associated 
with clinical malaria will be minimised.  
It became apparent in the initial challenge (Groups 5 and 6) that microscopy not only added no benefit as a 
diagnostic tool but also contributed nothing to volunteer safety, as by the time parasites were microscopically 
detectable all volunteers had already reached the qPCR threshold for treatment (>500 parasites per mL). By applying 
a revised increased qPCR threshold of 5,000 parasites per mL to the data from the first CHMI, analysis suggests that 
approximately 25% of volunteers would have had a slightly delayed diagnosis, but the concomitant criterion of 
compatible symptoms would ensure that this minor delay would not incur any increased risk to volunteer safety.  
This change also means that we are strengthening the scientific output of the study by ensuring that volunteers are 
not diagnosed prematurely by a chance microscopy finding (in blood-stage malaria there is always a possibility that a 
parasite can be detected at any time, regardless of the absolute parasitaemia). Indeed, our data from the VAC054 
blood-stage CHMI study show that thick film microscopy diagnosed volunteers with a median of 16,374 p/mL (range 
949 – 164,509 p/mL); n=26 (sse Figure 6 below) 39. Thus diagnosis is occurring over a range of > 2 logs parasitaemia, 
with over half the volunteers at < 10,000 p/mL. Premature diagnosis of > 50% of these volunteers by microscopy 
reduces the qPCR data available for the primary / PMR analysis, thus reducing the quality of the scientific output of 
the study. 
In light of the above, the new proposed criteria for diagnosis and immediate treatment of volunteers in Groups 7-10, 
are: 
Asymptomatic with any available qPCR result ≥ 10,000 parasites/mL 
Symptomatic with any available qPCR result  ≥ 5,000 parasites/mL 
 

VAC063 Protocol v9.0 
CONFIDENTIAL 
67 
 Figure 6: Parasite genome copies per mL at diagnosis by thick film microscopy, as determined by quantitative PCR 
for volunteers vaccinated with Apical Membrane Antigen 1 vaccine, FMP2.1/AMS01 and control volunteers  
(VAC054) 
 
By applying these revised diagnostic criteria we are certain that the safety of our volunteers will not be 
compromised. It is also important to note that other trial centres in the USA have recently adopted a similar 
approach - NCT020-15091 was a multi-institution, phase 1, open-label, dose-escalation trial with CHMI, designed to 
assess the safety, immunogenicity, and protective efficacy of PfSPZ Vaccine. In this study PCR was used as the  
primary diagnostic 58. 
Importantly, in the unlikely event of a technical failure with the qPCR machine, we have a working back-up qPCR 
machine that will be available for use 24/7 if required. 
In addition, Investigators, as always, are able to treat any volunteer for malaria regardless of the qPCR result or its 
availability if they are clinically concerned (and have discussed the case with the Chief Investigator). 
 
Malaria Management 
Volunteers will be treated with oral Riamet on diagnosis unless this is contraindicated (see SmPC for Riamet). Riamet 
is a licensed drug in the UK for treatment of Plasmodium falciparum infection. Riamet is a combination drug 
consisting of 20mg artemether and 120mg lumefantrine per tablet. A treatment course of Riamet consists of 6 doses 
of 4 tablets. The first 4 tablets will be given when diagnosis is made, followed by additional doses after 8, 24, 36, 48 
and 60 hours (window period +/- 1 hour for each dose). If a diagnosis is made late at night (after the evening clinic 
has been completed) and the volunteer is asymptomatic, they will be informed of the result and given the choice to 
return to clinic immediately or delay treatment until first thing the following morning. 
Prior to starting Riamet, volunteers will be screened for drug interactions and contraindications. This includes 
checking for pregnancy (urinary β HCG test in female volunteers) and prolonged QT (on pre-challenge ECG). 
Volunteers will be reminded of the potential side effects and given the patient information sheet for Riamet and a 
card outlining when their doses of Riamet should be taken. Volunteers will be advised to avoid grapefruit juice. 
Tablets should be taken together with a fatty meal (a light snack will provided when doses are observed in clinic). At 
least three doses will be directly observed in clinic.  
 
Volunteers who remain undiagnosed with malaria at Day 21 will start a treatment course of Riamet at their 
Day 21 visit.. 
 
If a volunteer is unable to tolerate an oral anti-malarial, they will be admitted for inpatient care and an 
appropriate parenteral anti-malarial therapy prescribed following discussion with the on call infectious 
diseases consultant covering the John Warin ward (Infectious Diseases Unit, Oxford University Hospitals’ 
NHS Trust). 
V A C 0 5 4  D ia g n o s is
P a ra s ite s  / m L
AM A1
C o n tr o ls
1 0 0
1 0 0 0
1 0 0 0 0
1 0 0 0 0 0
1 0 0 0 0 0 0

VAC063 Protocol v9.0 
CONFIDENTIAL 
68 
If a volunteer withdraws/is withdrawn from the study after administration of CHMI but before reaching the criteria 
for malaria diagnosis, a complete, appropriate, curative course of anti-malarial therapy must be completed. The 
importance of this will be emphasised to volunteers at screening. 
Malaria Management – Alternative Anti-Malarial Medications  
If a volunteer has a contraindication to Riamet or is unable to tolerate Riamet, oral chloroquine or malarone 
(atovaquone/proguanil) may be prescribed as an alternative treatment for malaria. 
Malarone is a licensed drug in the UK for treatment of acute uncomplicated malaria caused by Plasmodium 
falciparum. Malarone is a combination drug consisting of proguanil hydrochloride and atovaquone. A treatment 
course of Malarone consists of 4 ‘standard tablets’ of Malarone (proguanil hydrochloride 100mg, atovaquone 
250mg) once daily, orally for 3 days. All three doses of Malarone will be directly observed in clinic. The infecting 
parasites are known to be fully sensitive to Malarone. Prior to starting Malarone, volunteers will be screened for 
drug interactions and contraindications (including a urinary β HCG test in female volunteers). Volunteers will be 
reminded of the potential side effects of Malarone and given the patient information sheet for Malarone. 
Chloroquine (See SmPc for chloroquine) is a licensed drug in the UK for treatment of acute, uncomplicated malaria 
caused by Plasmodium falciparum. The 3D7 clone parasites are known to be fully sensitive to chloroquine. Prior to 
starting chloroquine, volunteers will be screened for drug interactions and contraindications to chloroquine. A 
urinary β HCG test will be performed in female volunteers. Volunteers will be reminded of the potential side effects 
of chloroquine, given the patient information sheet for chloroquine and a card outlining when their doses of 
chloroquine should be taken. A treatment course of chloroquine consists of tablets containing 155mg of chloroquine 
base administered as 620mg (4 tablets) orally at time 0, then 310mg (2 tablets) at 8 hours, 310mg (2 tablets) at 24 
hours and 310mg (2 tablets) at 48 hours (window period +/- 1 hour for each dose). The treatment administration will 
be directly observed by one of the Investigators or the research nurse, for the doses at 0, 24 and 48 hours.   
Malaria Management – Supportive Medications  
Provided there are no contraindications, all volunteers will be provided with a 3 day course of paracetamol (1g orally 
up to four times a day) and a 3 day course of cyclizine (50mg orally three times a day) (see SmPC for Paracetamol & 
Cyclizine). Volunteers will be given the patient information sheet for these medications and advised how frequently 
they can take doses. Volunteers will be issued with a medication diary card on which they will be asked to document 
all doses of medications taken post-CHMI.   
All medications used in trial will be handled and dispensed according to SOP VC021: Handling, Storage and 
Dispensing of Non-IMP Medication.  
Criteria for Hospital Admission  
If any of the following criteria are met, admission to the John Warin ward (Infectious Diseases Unit, Oxford 
University Hospitals’ NHS Trust) will be considered: 
 
Failure of symptoms to improve within 48 hours of starting anti-malarial therapy. 
 
Unable to tolerate oral antimalarial therapy. 
 
Dehydration requiring intravenous fluid therapy. 
 
Signs or symptoms suggestive of pulmonary oedema.  
 
Signs or symptoms of neurological dysfunction including altered consciousness. 
 
Signs, symptoms or laboratory evidence of significant renal dysfunction. 
 
Unanticipated concern about subject’s home circumstances. 
 
Any other significant finding which the Investigator feels warrants inpatient admission.  
Ultimately, the decision regarding admission will be taken by the Investigators in conjunction with the Infectious 
Diseases Consultant on call.  
Follow-up Post Diagnosis 

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Subjects will be reviewed in clinic approximately 24 and 48 hours after the start of anti-malarial therapy for 
observation of Riamet dosing. At least half of the Riamet doses for each volunteer will therefore be observed by the 
study team (for volunteers taking chloroquine, the same applies, and for volunteers taking Malarone, all doses will 
be observed). At the visits 24 and 48 hours after diagnosis, physical observations, assessment of symptoms and 
venepuncture will also be performed. If blood films taken at 24 and 48 hour post-diagnosis are negative for parasites 
(Groups 5 and 6) or qPCR over 48 hours shows a substantial reduction in parasitaemia (Groups 7-10) and the patient 
is asymptomatic or has mild, resolving symptoms, the volunteer will not be seen again in clinic until day 28 post-
CHMI (C+28, Groups 5-9, first and second challenge periods or 6 days post treatment initiation(Groups 8-10, tertiary 
challenge period). If not, the volunteer will continue to be reviewed in clinic daily until they have 2 consecutive 
negative blood films  (Groups 5 and 6) or rapid reduction in parasitaemia on 2 consecutive PCR readings (Groups 7-
10) at least 24 hours apart following start of antimalarial treatment, and all symptoms are mild or resolving.  
Measures to be taken if a Volunteer Goes Missing Post CHMI 
In the unlikely event that a volunteer should (a) fail to attend for a scheduled clinical visit or (b) be un-contactable by 
telephone after blood-stage challenge and before completion of an appropriate course of anti-malarial therapy, the 
following stakeholders will be informed: 
 
All Investigators.  
 
The volunteer’s nominated contact and next of kin. 
 
The trial Sponsor. 
 
The local safety committee. 
 
The Research Ethics Committee. 
 
The competent authority. 
 
Relevant NHS Hospital Trust R&D departments. 
 
The local police department. 
 
Local Accident and Emergency departments. 
All efforts will be made to locate the volunteer by the police. While all parties will aim to preserve the volunteer’s 
confidentiality, if necessary, details of the volunteer’s identity and participation in the study may be passed to the 
national media in order to help locate the missing individual. Volunteers will be informed of this during screening.  
Day C+28 (28 days after Challenge)  
Physical observations will be performed and AEs assessed. Venepuncture will be performed as per schedule of 
attendance (Tables 5 & 6). Where applicable, medication diary cards and unused, dispensed medications will be 
collected from volunteers. 
Volunteers will be counselled to contact the study team or their GP if they feel feverish or unwell in the 6 months 
following the challenge. 
 
Where applicable, medication diary cards and unused, dispensed medications will be collected from volunteers. 
Volunteers will be counselled to contact the study team or their GP if they feel feverish or unwell in the 6 months 
following the challenge. 
 
Day C+90 (90 days after Challenge)  
Physical observations will be performed and AEs assessed. Venepuncture will be performed as per schedule of 
attendance (Tables 5,6 and 8).  
 
Day C+170 (170 days after challenge) – Groups 5 and 7 only 

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This review may be conducted by telephone or as a clinic visit. Any SAEs occurring since the previous visit (day 90 
post CHMI) will be assessed. 
 
 
 
 

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12 ASSESSMENT OF SAFETY 
Safety will be assessed by the frequency, incidence and nature of adverse events and serious adverse events arising 
during the study. 
 Interim Safety Review 
12.1
Prior to each dose escalation (i.e. between Groups 1 and 2, and between Groups 2 and 3/4) the local safety monitor 
will be consulted to provide a review of safety data and adverse events in volunteers before proceeding to the next 
vaccine dose. Six volunteers should have received the first two doses of the vaccine as per the group schedules, and 
have been followed up for at least 7 days following the second dose, before the safety review is conducted. Interim 
safety data may also be made available to manufacturers (in coded format) as specified in the contract with the 
manufacturer(s). 
 Definitions 
12.2
Adverse Event (AE) 
An AE is any untoward medical occurrence in a volunteer, which may occur during or after administration of an 
Investigational Medicinal Product (IMP) and does not necessarily have a causal relationship with the intervention. An 
AE can therefore be any unfavourable and unintended sign (including an abnormal laboratory finding), symptom or 
disease temporally associated with the study intervention, whether or not considered related to the study 
intervention. 
Each participant reported adverse event will be graded by the participant according to the table for grading severity 
of adverse events (see section 12.10). Severity gradings may be reviewed and discussed with the participants at the 
clinic visits. 
Adverse Reaction (AR) 
An AR is any untoward or unintended response to an IMP. This means that a causal relationship between the IMP 
and an AE is at least a reasonable possibility, i.e. the relationship cannot be ruled out. All cases judged by the 
reporting medical Investigator as having a reasonable suspected causal relationship to an IMP (i.e. possibly, probably 
or definitely related to an IMP) will qualify as adverse reactions. 
Unexpected Adverse Reaction  
An adverse reaction, the nature or severity of which is not consistent with the applicable product information (e.g., 
IB for an unapproved IMP). 
Serious Adverse Event (SAE) 
An SAE is an AE that results in any of the following outcomes, whether or not considered related to the study 
intervention. 
 
Death. 
 
Life-threatening event (i.e. the volunteer was, in the view of the Investigator, at immediate risk of death 
from the event that occurred). This does not include an AE that, if it occurred in a more severe form, might 
have caused death. 
 
Persistent or significant disability or incapacity (i.e. substantial disruption of one’s ability to carry out normal 
life functions). 
 
Hospitalisation or prolongation of hospitalisation, regardless of length of stay, even if it is a precautionary 
measure for continued observation. Hospitalisation (including inpatient or outpatient hospitalisation for an 
elective procedure) for a pre-existing condition that has not worsened unexpectedly does not constitute a 
serious AE. 
 
An important medical event (that may not cause death, be life threatening, or require hospitalisation) that 
may, based upon appropriate medical judgment, jeopardise the volunteer and/or require medical or surgical 
intervention to prevent one of the outcomes listed above. Examples of such medical events include allergic 

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reaction requiring intensive treatment in an emergency room or clinic, blood dyscrasias, or convulsions that 
do not result in inpatient hospitalisation. 
 
Congenital anomaly or birth defect. 
Serious Adverse Reaction (SAR) 
An adverse event (expected or unexpected) that is both serious and, in the opinion of the reporting Investigator or 
Sponsors, believed to be possibly, probably or definitely due to an IMP or any other study treatments, based on the 
information provided. 
Suspected Unexpected Serious Adverse Reaction (SUSAR) 
A serious adverse reaction, the nature and severity of which is not consistent with the information about the 
medicinal product in question set out in the IB or Summary of Product Characteristics (SmPC). 
 Foreseeable Adverse Reactions:  
12.3
The foreseeable ARs following vaccination with RH5.1/AS01 include injection site pain, erythema, warmth, swelling, 
and pruritus, and generalised myalgia, arthralgia, fatigue, and feverishness, as well as fever, malaise, headache and 
nausea. These adverse events will be listed as solicited adverse events providing they occur within 7 days of the day 
of vaccination. AEs other than these, or those AEs occurring outside of the 7 days after vaccination, will be listed as 
unsolicited adverse events. 
 Other Foreseeable Medical Occurrences 
12.4
The following medical occurrences are foreseeable: 
 
Clinical P. falciparum disease resulting in hospitalisation. 
 
Clinical P. falciparum disease resulting in fever, tachycardia, hypotension, feverishness, chills, rigor, sweats, 
headache, anorexia, nausea, vomiting, myalgia, arthralgia, low back pain, fatigue, lymphopenia and 
thrombocytopenia.  
 
Adverse reactions to Malarone, Riamet, chloroquine, paracetamol and cyclizine, as detailed in the SmPCs for 
these medications.  
 Expected Serious Adverse Events 
12.5
No serious adverse events are expected in this study. 
 Causality Assessment 
12.6
For every unsolicited AE, an assessment of the relationship of the event to the administration of the vaccine will be 
undertaken by the CI or the CI-delegated clinician at the coordinating site (Oxford). An intervention-related AE refers 
to an AE for which there is a probable or definite relationship to administration of a vaccine. An interpretation of the 
causal relationship of the intervention to the AE in question will be made, based on the type of event; the 
relationship of the event to the time of vaccine administration; and the known biology of the vaccine therapy (Table 
10). Causality assessment will take place during planned safety reviews, interim analyses (e.g. if a holding or stopping 
rule is activated) and at the final safety analysis, except for SAEs, for which causality should be assigned by the 
reporting Investigator. 
 
 
 
 
 
 
 
 

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0 
No Relationship 
No temporal relationship to study product and 
Alternate aetiology (clinical state, environmental or other interventions); 
and 
Does not follow known pattern of response to study product 
1 
Unlikely 
Unlikely temporal relationship to study product and 
Alternate aetiology likely (clinical state, environmental or other 
interventions) and 
Does not follow known typical or plausible pattern of response to study 
product. 
2 
Possible 
 
Reasonable temporal relationship to study product; or 
Event not readily produced by clinical state, environmental or other 
interventions; or 
Similar pattern of response to that seen with other vaccines 
3 
Probable 
 
Reasonable temporal relationship to study product; and 
Event not readily produced by clinical state, environment, or other 
interventions or  
Known pattern of response seen with other vaccines 
4 
Definite 
 
Reasonable temporal relationship to study product; and 
Event not readily produced by clinical state, environment, or other 
interventions; and  
Known pattern of response seen with other vaccines 
Table 10: Guidelines for assessing the relationship of vaccine administration to an AE. 
 Reporting Procedures for All Adverse Events  
12.7
All AEs occurring in the 28 days following each vaccination observed by the Investigator or reported by the 
volunteer, whether or not attributed to study medication, will be recorded. Recording and reporting of all AEs will 
take place as detailed in SOP VC027. AEs occurring after CHMI in Groups 5-9 will also be recorded- these will be 
entered directly into the eCRF. All AEs that result in a volunteer’s withdrawal from the study will be followed up until 
a satisfactory resolution occurs, or until a non-study related causality is assigned (if the volunteer consents to this). 
Serious adverse events (SAEs) will be collected throughout the entire trial period.  
Reporting Procedures for Serious AEs (see SOP OVC005 Safety Reporting) 
In order to comply with current regulations on serious adverse event reporting to regulatory authorities, the event 
will be documented accurately and notification deadlines respected. SAEs will be reported on the SAE forms to 
members of the study team immediately after the Investigators become aware of their occurrence, as described in 
SOP OVC005. Copies of all reports will be forwarded for review to the Chief Investigator and Principal Investigators 
(as the Sponsor’s representatives) within 24 hours of the Investigator being aware of the suspected SAE. The local 
safety committee (LSC) will be notified of SAEs which are deemed possibly, probably or definitely related to study 
interventions; the LSC will be notified immediately (within 24 hours) of the Investigators’ being aware of their 
occurrence. SAEs will not normally be reported immediately to the REC unless there is a clinically important increase 
in occurrence rate, an unexpected outcome, or a new event that is likely to affect safety of trial volunteers, at the 
discretion of the Chief Investigator and/or LSC. In addition to the expedited reporting above, the Investigator shall 
include all SAEs in the annual Development Safety Update Report (DSUR) report. 

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Reporting Procedures for SUSARS 
The Chief Investigator will report all SUSARs to the MHRA and REC within required timelines (15 days for all SUSARs, 
unless life threatening in which case 7 days, with a final report within a further 8 days (total 15)). The Chief 
Investigator will also inform all Investigators concerned of relevant information about SUSARs that could adversely 
affect the safety of participants.  
All SUSARs and deaths occurring during the study will be reported to the Sponsor. For all deaths, available autopsy 
reports and relevant medical reports will be made available for reporting to the relevant authorities. 
Development Safety Update Report 
A Development Safety Update Report (DSUR) will be submitted by the Sponsor to the competent authority and 
ethics committee on the anniversary of the first approval date from the regulatory authority for each IMP. 
 Volunteers to whom an IMP has not been administered 
12.8
Untoward medical occurrences in clinical trial participants not having received an IMP (Group 6, 8, 9 and 10 
participants) will also be solicited, collected, and recorded in the CRF as for Adverse Events. The severity grading will 
be undertaken as for AEs. Where these events result in a patient’s withdrawal from the study or are present at the 
end of the study, they will be followed up until a satisfactory resolution or stabilisation occurs, or until a non-study 
related causality is assigned. 
Should an untoward and unintended response to the blood-stage challenge (non-IMP) occur in a Group 6, 8,9 or 10 
participant, such unexpected serious reactions would be reported to the Local Safety Committee, ethics committees, 
CTRG and other interested parties, including other centres worldwide conducting CHMI studies, would be made 
aware of this. Such serious adverse reactions which are related not to an IMP but to the malaria challenge cannot be 
reported as SUSARs, but they will be notified to ethics and the MHRA under urgent safety measures (as per CT-1 and 
CT-3 guidance http://ec.europa.eu/health/files/eudralex/vol-10/2011_c172_01/2011_c172_01_en.pdf; accessed 28 
September 2012). 
Reporting Procedures for Serious Adverse Events in Group 6, 8, 9 and 10 (volunteers who have not received an 
IMP) 
A serious adverse event (SAE) occurring to an unvaccinated participant should be reported to the REC that gave a 
favourable opinion of the study where in the opinion of the Chief Investigator the event was ‘related’ (resulted from 
administration of any of the research procedures) and ‘unexpected’ in relation to those procedures. Reports of 
related and unexpected SAEs should be submitted within 15 working days of the Chief Investigator becoming aware 
of the event, using the NRES report of serious adverse event form. 
 Adverse Events of Special Interest 
12.9
Adverse events of special interest will be reported as SAEs. These are: 
 
Severe hypersensitivity reactions (e.g. anaphylaxis) 
 
Any new, suspected auto-immune disease 
 

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 Assessment of Severity 
12.10
The severity of clinical and laboratory adverse events will be assessed according to the scales in Tables –11-13. 
Adverse Event  
Grade  
Intensity  
Pain at injection site 
1 
Pain that is easily tolerated 
2 
Pain that interferes with daily activity 
3 
Pain that prevents daily activity 
Erythema at injection site* 
1 
>3 - ≤50 mm 
2 
>50 - ≤100 mm 
3 
>100 mm 
Swelling at injection site* 
1 
>3 - ≤20 mm 
2 
>20 - ≤50 mm 
3 
>50 mm 
*erythema or swelling ≤3mm is an expected consequence of skin puncture and will therefore not be considered an adverse event. 
Table 11: Severity grading criteria for local adverse events. 
 
 
 
Grade 1  
(mild) 
Grade 2  
(moderate) 
Grade 3  
(severe) 
Fever (oral) 
37.6°C - 38.0°C 
38.1°C – 39.0°C 
>39.0°C 
Tachycardia (bpm)* 
101 - 115 
116 – 130 
>130 
Bradycardia (bpm)** 
50 – 54 
40 – 49 
<40 
Systolic hypertension 
(mmHg) 
141 - 159 
160 – 179 
≥180 
Diastolic hypertension 
(mmHg) 
91 - 99 
100 – 109 
≥110 
Systolic hypotension 
(mmHg)*** 
85 - 89 
80 – 84 
<80 
*Taken after ≥10 minutes at rest 
**When resting heart rate is between 60 – 100 beats per minute. Use clinical judgement when characterising bradycardia among some 
healthy subject populations, for example, conditioned athletes. 
***Only if symptomatic (e.g. dizzy/ light-headed) 
Table 12: Severity grading criteria for physical observations 
 
GRADE 0 
None; Symptom not experienced 
GRADE 1 
Mild; Short-lived or mild symptoms; medication may be required. No limitation to usual activity  
GRADE 2 
Moderate: Mild to moderate limitation in activity. Medication may be required 
GRADE 3 
Severe: Considerable limitation in activity. Medication or medical attention required  
Table 13: Severity grading criteria for local and systemic AEs. 
 
 

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 Procedures to be followed in the event of abnormal findings 
12.11
Eligibility for enrolment in the trial in terms of laboratory findings will be assessed as detailed in Appendix A. 
Abnormal clinical findings from medical history, examination or blood tests will be assessed as to their clinical 
significance throughout the trial. Laboratory adverse events will be assessed using the site-specific tables in the 
Institutional site file (ISF)/ trial master file (TMF). If a test is deemed clinically significant, it may be repeated, to 
ensure it is not a single occurrence. If a test remains clinically significant, the volunteer will be informed and 
appropriate medical care arranged as appropriate and with the permission of the volunteer. Decisions to exclude the 
volunteer from enrolling in the trial or to withdraw a volunteer from the trial will be at the discretion of the 
Investigator. 
 Local Safety Committee 
12.12
A Local Safety Committee (LSC) will be appointed to provide real-time safety oversight. The LSC will review SAEs 
deemed possibly, probably or definitely related to study interventions. The LSC will be notified within 24 hours of the 
Investigators’ being aware of their occurrence. The LSC has the power to place the study on hold if deemed 
necessary following a study intervention-related SAE. At the time of writing the LSC will be chaired by Dr Brian 
Angus, a Clinical Tutor in Medicine, Honorary Consultant Physician and Director, Centre for Tropical Medicine at the 
University of Oxford. There will be a minimum of two other appropriately qualified committee members. All 
correspondence between Investigator and LSC will be conveyed by the Investigator to the trial Sponsor. 
The chair of the LSC may be contacted for advice and independent review by the Investigator or trial Sponsor in the 
following situations: 
 
Following any SAE deemed to be possibly, probably, or definitely related to a study intervention. 
 
Any other situation where the Investigator or trial Sponsor feels independent advice or review is important. 
The study can be put on hold upon advice of the Local Safety Monitor, Chief Investigator, Study Sponsor, REC or 
Local Safety Committee, for any single event or combination of multiple events which, in their professional opinion, 
jeopardise the safety of the subjects or the reliability of the data. If the study is placed on hold it may only be 
restarted following discussion with and approval from the LSC, the REC, the trial Sponsor and Chief Investigator. If 
the clinical trial is halted and is unable to resume, a formal letter will be sent to the regulatory authorities by the 
Sponsor explaining the reasons for cessation of the study. 
Safety Profile Review 
The safety profile will be assessed on an on-going basis by the Investigators. The LSM will perform independent 
external safety reviews prior to dose escalations. The Chief investigator, Principal Investigator, and relevant 
Investigators (as per the trial delegation log) will also review safety issues and SAEs as they arise. 

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13 STATISTICS 
 Sample Size Selection for Groups 1 - 4 
13.1
This is a descriptive Phase I trial that will balance the safety of volunteers with the aims to assess the vaccine’s safety 
profile and immunogenicity after selected doses of the vaccines. Groups 1 and 2 will have between 6 and 12 
volunteers recruited to each, based on the immunogenicity of the vaccines at the 2 µg and 10 µg doses. 
Immunogenicity will be assessed according to the results obtained from the VAC057 trial using the viral vectored 
RH5 vaccines (ChAd63/MVA RH5). If the mean response after 3 vaccinations in Group 1 and Group 2 is not within or 
greater than the 95% CI of the mean response achieved in boosted volunteers in VAC057 the recruitment for these 
groups will be held at 6 volunteers per group. This will allow sufficient numbers of volunteers to assess the safety of 
these doses prior to dose escalation. If the 2 µg and 10 µg doses are sufficiently immunogenic 12 volunteers will be 
enrolled into each of these groups. 
Groups 3 and 4 will have 12 volunteers enrolled into each group, which will be sufficient for assessing safety at this 
early phase and should allow for comparison in immunogenicity between the full dose (50 µg) and low dose (2 µg 
and 10 µg) groups. 
 Description of Power Calculations for Groups 5 and 6 
13.2
Any statistically significant change in PMR in a vaccine group would be considered as success, although it remains 
unclear what level of change in PMR would be likely to be significant in terms of clinical outcome. The calculations 
below suggest that the proposed trial design would provide good power to detect vaccine-induced reductions in 
PMR of >33%, and excellent power to detect reductions of 50%. 
Statistical power calculations are heavily dependent upon the assumptions made regarding the distribution of data 
in controls, and the effect of the intervention upon both the location and dispersion of data in the intervention 
group.  
For the current study the trial design mirrored that of a previous study undertaken in Oxford, VAC054 39,99. When the 
VAC054 study was designed, data on the distribution of PMRs in controls was available from previously conducted 
blood-stage challenge trials conducted in Oxford 73,81 and in Nijmegen (RUNMC) 84. The historical mean PMR in 
Oxford had been 12-fold per 48 hours, and at RUNMC has been 10-fold. 
We wished to assess the statistical power of studies with a variety of group sizes up to a maximum total number of 
volunteers of 30, based upon clinical trial site capacity, as follows: 
- 
10 controls (N1) vs 10 vaccinees (N2) 
- 
10 controls (N1) vs 20 vaccinees (N2) 
- 
15 controls (N1) vs 15 vaccinees (N2) 
We wished to consider the power of such studies to detect vaccine efficacy of either a 33% or 50% mean reduction 
in PMR relative to controls, on the basis that preliminary analyses had suggested that a 50% PMR reduction was 
likely to be fairly readily detectable regardless of other variables, whereas a 33% PMR reduction may be challenging 
to detect in some situations. 
We felt that the SD of PMR in the control group and the SD of the vaccine effect upon PMR were sufficiently 
uncertain that we should consider a number of scenarios with various values of these parameters, as follows: 
1. Three possible values for SD of the PMR in the control group: 2, 3 and 4-fold per 48 hours, based upon the 
extremes of observed data from Oxford and RUNMC. 
2. Three possible values for SD of the vaccine effect upon PMR– currently unknown. We used estimates of 2, 3 
and 4-fold per 48 hours.  
Thus a total of 9 possible scenarios (combinations of PMR SD in the control group and vaccine effect PMR) were 
considered for each combination of mean vaccine efficacy (33 v 50%), group size, and underlying PMR in controls. 
Power calculations were performed using a two-sample two-sided t-test power analysis by Dr Nicola Williams at the 
Centre for Statistics in Medicine in Oxford in consultation with the group at the Jenner Institute. 

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Conclusions: 
All three options for group sizes provide sufficient power to detect a 50% reduction in PMR – irrespective of whether 
analysis is based on historical data from Oxford or RUNMC. 
Greater consideration needs to be given to the group sizes required to observe a more modest reduction in PMR, as 
depicted in Table 14. 
 
 
Number of scenarios under which power ≥80% to detect a 33% reduction in 
mean PMR * 
Group Size 
Oxford data (mean 
control PMR = 12) 
RUNMC data (mean 
control PMR = 10) 
Total 
10 vs 10 
4/9 
1/9 
5/18 
10 vs 20 
6/9 
4/9 
10/18 
15 vs 15 
8/9 
4/9 
12/18 
Table 14: 9 situations of underlying SD in the controls and vaccinees were assessed for each combination of group 
size, underlying PMR in control groups, and vaccine effect; data shown here relate to the lower level of vaccine 
efficacy considered, i.e. 33% PMR reduction. 
 
Small differences in the dispersion of PMR between the two groups had a major impact on power of studies with 
smaller numbers of volunteers in the control groups, such that it was not possible to be confident that trials with 10 
controls would be adequately powered to detect a 33% vaccine effect upon PMR. 
A study design with 15 controls versus 15 vaccinees consistently did however provide adequate power to detect a 
33% vaccine effect upon PMR under most circumstances, including those with relatively high dispersion of PMR in 
the controls and/or high dispersion of vaccine efficacy. 
A key comparison is the power of a 10 vs 10 trial as compared to a 15 vs 15 trial to detect a 33% reduction in PMR. 
The former gives ≥80% power under 5/18 tested situations; the latter gives ≥80% power under 12/18 scenarios (as 
shown in Table 14). 
A study design with 15 controls vs 15 vaccinees was therefore chosen for VAC054. 
Since obtaining the VAC054 data39 , these power calculations have been repeated, using the mean PMR (10.31) in 
the 15 unvaccinated infectivity controls, with the SD of 2.36, and using three possible values for SD of the vaccine 
effect upon PMR – currently unknown for RH5.1/AS01. We used estimates of 2, 3 and 4-fold per 48 hours and a 
group size of 15 vaccinees vs 15 controls: 
 
Comparison of scenarios comparing SDs of 2, 3 and 4 for sample size of 15 vaccinees 
to 15 controls with SD 2.36 and mean PMR 10.31  
Vaccinated Group SD 
Power to detect a 33% 
reduction in mean PMR 
Power to detect a 50% 
reduction in mean PMR 
2 
99% 
100% 
3 
93.7% 
99.9% 
4 
81.8% 
99% 
Table 15: Power to detect a 33% or 50% change in PMR in vaccinated volunteers assuming a SD or 2, 3 or 4. 
 

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 Sample Size Selection for Groups 7, 8, 9 and 10 
13.3
We will invite all of Group 5 and 6 back to participate in a re-challenge (Groups 7 and 8), so that we can continue to 
have maximum power to detect any significant difference between the 2 groups. However, all malaria re-challenge 
studies rely on volunteer re-participation – as such, for the second challenge, we intend to proceed if ≥4 volunteers 
in both groups consent to the re-challenge. Small numbers are routinely studied and reported in numerous other 
CHMI trials (undertaken in Oxford and elsewhere under similar circumstances). In addition we shall recruit a 
minimum of 5 new controls into Group 9, to act as infectivity controls for repeat CHMI of the other 2 groups. 5-6 
infectivity controls are commonly recruited for CHMI studies and this would provide a control group of similar 
sample size to the expected number of re-challenges.  
 
 

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14 QUALITY CONTROL AND ASSURANCE PROCEDURES 
Investigator procedures 
Approved site-specific standard operating procedures (SOPs) will be used at all clinical and laboratory sites. 
Monitoring 
Monitoring will be performed according to ICH Good Clinical Practice (GCP) by CTRG. Following written SOPs, the 
monitors will verify that the clinical trial is conducted and data are generated, documented and reported in 
compliance with the protocol, GCP and the applicable regulatory requirements. The Investigator sites will provide 
direct access to all trial related source data/documents and reports for the purpose of monitoring and auditing by 
the Sponsor and inspection by local and regulatory authorities. 
Modification to protocol 
No substantial amendments to this protocol will be made without consultation with, and agreement of, the Sponsor. 
Any substantial amendments to the trial that appear necessary during the course of the trial must be discussed by 
the Investigator and Sponsor concurrently. If agreement is reached concerning the need for an amendment, it will be 
produced in writing by the Chief Investigator and will be made a formal part of the protocol following ethical and 
regulatory approval. 
The Investigator is responsible for ensuring that changes to an approved trial, during the period for which regulatory 
and REC approval has already been given, are not initiated without regulatory and REC’s review and approval except 
to eliminate apparent immediate hazards to the subject. 
Protocol deviation  
Any deviations from the protocol will be documented in a protocol deviation form and filed in the trial master file.  
Audit & inspection  
The QA manager will perform internal audits to check that the trial is being conducted and data recorded, analysed 
and accurately reported according to the protocol, Sponsor’s SOPs and in compliance with ICH GCP. The audits will 
also include laboratory activities according to an agreed audit schedule. The internal audits will supplement the 
external monitoring process and will review processes not covered by the external monitor. 
The Sponsor, trial sites, REC, and authorised individuals from Leidos may carry out audit to ensure compliance with 
the protocol, GCP and appropriate regulations. GCP inspections may also be undertaken by the regulatory authority 
to ensure compliance with protocol and national regulations. The Sponsor will assist in any inspections. 
Serious Breaches 
The Medicines for Human Use (Clinical Trials) Regulations contain a requirement for the notification of "serious 
breaches" to the MHRA within 7 days of the Sponsor becoming aware of the breach.  
A serious breach is defined as “A breach of GCP or the trial protocol which is likely to effect to a significant degree –  
(a) the safety or physical or mental integrity of the subjects of the trial; or 
(b) the scientific value of the trial”. 
In the event that a serious breach is suspected the Sponsor will be informed within one working day. 
Trial Progress 
The progress of the trial will be overseen by the Chief Investigator.  
Publication Policy 
The Investigators will be involved in reviewing drafts of the manuscripts, abstracts, press releases and any other 
publications arising from the study. Authors will acknowledge that the study was funded through financial support to 
Oxford University by the Infectious Disease Division, Bureau for Global Health, United States Agency for International 
Development (USAID). Other contributors, including GSK Vaccines, will be acknowledged in accordance with the 

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International Committee of Medical Journal Editors (ICMJE) guidelines. Other funding support for this trial comes 
from the National Institutes of Health Research (NIHR) through the Oxford Biomedical Research Centre (BRC).  
 

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15 ETHICS 
 Declaration of Helsinki 
15.1
The Investigator will ensure that this study is conducted according to the principles of the current revision of the 
Declaration of Helsinki 2008. 
 ICH Guidelines for Good Clinical Practice 
15.2
The Investigators will ensure that this study is conducted in full conformity with the ICH Good Clinical Practice (GCP), 
the requirements of the Medicines for Human Use (Clinical Trial) Regulations 2004, and local regulatory 
requirements. 
 Informed Consent 
15.3
Written, informed consent will be obtained, as described in section 8.2. 
 Research Ethics Committee (REC) 
15.4
A copy of the protocol, proposed informed consent form, other written volunteer information and the proposed 
advertising material will be submitted to the REC for written approval. The Investigator will submit and, where 
necessary, obtain approval from the REC for all subsequent amendments to the protocol and associated trial 
documents. A non-substantial amendment does not require UK ethics committee approval. The Investigator will 
notify deviations from the protocol or SAEs occurring at the site to the sponsor and will notify the REC of these if 
necessary in accordance with procedures. 
 Volunteer Confidentiality 
15.5
All data will be anonymised; volunteer data will be identified by a unique study number in the CRF and database. Any 
blood samples taken in Oxford will be labelled with the volunteer’s unique study number and barcode only. Samples 
taken at other trial sites will be labelled as per local procedures. Separate confidential files containing identifiable 
information will be stored in secured locations. Only the Sponsor representative, Investigators, the clinical monitor, 
authorised individuals from Leidos and USAID, the REC and the regulatory authorities will have access to the records. 
Photographs taken of vaccination sites (if required, with the volunteer’s written, informed consent) will not include 
the volunteer’s face and will be identified by the volunteer’s trial-specific identification number only. Once 
developed, photographs will be stored as confidential records, as above. This material may be shown to other 
professional staff, used for educational purposes, or included in a scientific publication. 

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16 DATA HANDLING AND RECORD KEEPING 
 Data Handling 
16.1
The Chief Investigator will be the data manager with responsibility for delegating the receiving, entering, cleaning, 
querying, analysing and storing all data that accrues from the study. The Investigators will enter the data into the 
volunteers’ CRFs, which will be in a paper and/or electronic format (using an OpenClinica™ database stored on a 
secure server). Electronic data will be stored on secure servers which are outsourced by OpenClinica™. OpenClinica™ 
meets FDA part 11B standards. This includes safety data, laboratory data (clinical) and outcome data. Safety data will 
also be collected through an electronic diary, which is stored on a secure server. 
 Record Keeping 
16.2
The Investigators will maintain and retain appropriate medical and research records and essential documents for this 
trial in compliance with ICH E6 GCP and regulatory and institutional requirements for the protection of 
confidentiality of volunteers. The Chief Investigator, co-Investigators and clinical research nurses will have access to 
records. The Investigators will permit authorised representatives of the Sponsor, REC, regulatory agencies, 
authorised individuals from Leidos and USAID, and the monitors to examine (and when required by applicable law, 
to copy) clinical records for the purposes of quality assurance reviews, audits and evaluation of the study safety and 
progress. 
 Source Data and Case Report Forms (CRFs) 
16.3
All protocol-required information will be collected in CRFs designed by the Investigator. All source documents will be 
filed in the CRF. Source documents are original documents, data, and records from which the volunteer’s CRF data 
are obtained. For this study, these will include, but are not limited to, volunteer consent form, blood results, GP 
response letters, laboratory records, diaries, and correspondence. In the majority of cases, CRF entries will be 
considered source data as the CRF is the site of the original recording (i.e. there is no other written or electronic 
record of data). In this study this will include, but is not limited to medical history, medication records, vital signs, 
physical examination records, urine assessments, blood results, adverse event data and details of vaccinations. All 
source data and volunteer CRFs will be stored securely.  
 Data Protection  
16.4
The study protocol, documentation, data and all other information generated will be held in strict confidence. No 
information concerning the study or the data will be released to any unauthorised third party, without prior written 
approval of the Sponsor. 
 

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17 FINANCING AND INSURANCE 
 Financing 
17.1
The study will be funded through financial support to Oxford University from the Infectious Disease Division, Bureau 
for Global Health, US Agency for International Development (USAID) and the National Institutes of Health Research 
through the Oxford Biomedical Research Centre. 
 Insurance 
17.2
The University of Oxford has a specialist insurance policy in place which would operate in the event of any 
participant suffering harm as a result of their involvement in the research (Newline Underwriting Management Ltd, 
at Lloyd’s of London). 

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18 COMPENSATION 
Volunteers will be compensated for their time and for the inconvenience caused by procedures. Approximate total 
amounts are shown in Table 15. 
Compensation will be calculated according to the following: 
 
Screening visits will be paid at £25 flat rate. 
 
Travel expenses (enrolled volunteers): 
o £10 per visit. Where travel expenses are greater than £10 per visit because the volunteer lives 
outside the city of the trial site, the volunteer will be given further reimbursement to meet the cost 
of travel necessary for study visits. 
 
Inconvenience of blood tests (enrolled volunteers): 
o £10 per blood donation 
 
Time required for visit (enrolled volunteers):  
o £20 per hour 
 
Illness Compensation (Groups 5-10 during CHMI): £20 per hour 
 
Back-up volunteers (section 9) who are not enrolled in the study will be compensated £200. This is in 
addition to compensation for visits they may have attended. 
 
Extra visits (e.g. where a volunteer is brought back to clinic for a repeat blood test): 
o £20 per visit as a flat rate. 
 
Group No. 
Time in Trial 
(approximately) 
Maximum No. of 
Clinic Visits 
Maximum Volume of 
Blood Taken (mL) 
Maximum 
Compensation 
Amount 
1 
8 months 
17 
842 
£755 
2 
8 months 
17 
842 
£755 
3 
12 months 
18 
987 
£795 
4 
8 months 
17 
842 
£795 
5 
8 - 12 months 
53 
1206 
£2715-£2755 
6 
3 months 
39 
779 
£1765 
7 
6 months 
42 
787 
£1930 
8 
3 months 
39 
744 
£1765 
9 
3 months 
39 
744 
£1765 
Table 15: Approximate compensation amounts for volunteers (including addition of late final bleed time-point for 
Groups 1-5 and 7). Note the approximate time in trial for the vaccinated groups is not inclusive of the lag until the 
late final bleed; this will vary for each volunteer depending on when they received their final vaccination.  
 

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Verstraeten T, Descamps D, David MP, et al. Analysis of adverse events of potential autoimmune aetiology in 
a large integrated safety database of AS04 adjuvanted vaccines. Vaccine 2008;26:6630-8. 
99. 
Payne RO, Milne KH, Elias SC, et al. Demonstration of the Blood-Stage Plasmodium falciparum Controlled 
Human Malaria Infection Model to Assess Efficacy of the P. falciparum Apical Membrane Antigen 1 Vaccine, 
FMP2.1/AS01. The Journal of infectious diseases 2016. 
 

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20 APPENDIX A: LABORATORY VALUES FOR EXCLUSION 
Laboratory parameters for inclusion/exclusion in the trial will be considered on an individual basis, with investigator 
discretion for interpretation of results and the need for repeated tests. In general, volunteers will be excluded if a 
result at screening constitutes what would qualify as a grade 1 (or higher) laboratory adverse event, according to the 
site-specific laboratory adverse event tables (filed in the ISF/TMF). Urinalysis at screening will be assessed as per the 
table below: 
 
ABNORMAL URINE ANALYSIS (using MULTISTIX) 
Protein* 
2+ or Protein creatinine ratio of ≥50mg/mmol 
Blood£ 
≥1+ on two dipstick tests  
Glucose 
1+ 
*In the event of the dipstick testing positive for protein with ≥1+ protein urine should be sent for a protein creatinine ratio. 
£ In the event of urine dipstick testing positive for ≥1+ blood with, or without, protein in volunteers a repeat dipstick test will be 
carried out to confirm haematuria. In female volunteers, a menstrual history will be taken to elicit whether the subject is 
currently menstruating and if they are, urine dipstick will be repeated after 1 - 2 weeks. If blood and/or proteinuria persist in any 
volunteer, they will be excluded from the trial, and the appropriate follow-up arranged.