An Effectiveness Trial (Phase IV) to Evaluate Protection of Pregnant Women by Hepatitis E Virus (HEV) Vaccine in Bangladesh and Risk Factors for Severe HEV Infection.
Phase: PHASE4
Conditions: Hepatitis E Infection
Sponsor: Norwegian Institute of Public Health

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RRC APPLICATION FORM 
 
RESEARCH PROTOCOL  
Number: PR-16014 
Version No. 2.4 
Version date: 07-05-2021 
 
FOR OFFICE USE ONLY 
RRC Approval: 
 Yes 
 No 
Date:17.2.2016 
ERC Approval: 
 Yes 
 No 
Date:28.4.2016 
AEEC Approval: 
 Yes 
 No 
Date:      
External IRB Approval 
 Yes 
 No  
Date:      
Name of External IRB: ___________________________________________ 
Protocol Title: * (maximum 250 characters including space) An effectiveness trial to evaluate the protection of 
pregnant women with a hepatitis E vaccine in rural Bangladesh and the risk factors for severe hepatitis  
E infection   
 
 
Short Title: (maximum 100 characters including space) HEV vaccine study in Bangladesh 
 
 
Key Words: *Hepatitis E vaccine, Effectiveness study, Pregnant women, Bangladesh 
Name of the Research Division Hosting the Protocol:* 
  Health Systems and Population Studies Division (HSPSD) 
  Nutrition and Clinical Services  Division (NCSD) 
  Infectious Diseases  Division (IDD) 
 
   Maternal and Child Health Division (MCHD) 
   Laboratory Sciences and Services Division (LSSD) 
   Other (specify) 
Has the Protocol been Derived from an Activity:*
 No            
 Yes (please provide following information): 
Activity No.  :       
Activity Title:       
PI:       
Grant No.:        
Budget Code:       
 
Start Date:        
End Date:       
icddr,b Strategic Priority/ Initiative (SP 2015-8):* (check all 
that apply)  
   Reducing maternal and neonatal mortality 
   Controlling enteric and respiratory infections 
   Preventing and treating maternal and childhood malnutrition 
   Detecting and controlling emerging and re-emerging 
infections 
 
 
   Achieving universal health coverage 
   Examining the health consequences of climate 
change 
   Preventing and treating non-communicable 
diseases 
Research Phase (4 Ds):* (check all that apply) 
   Discovery 
   Development 
 
   Delivery 
   Evaluation of Delivery 
Anticipated Impact of Research:* (check all that apply) 
   Knowledge Production 
   Capacity Building 
 
   Informing Policy 
   Health and Health Sector Benefits 
   Economic Benefits 
Which of the Sustainable Development Goal This Protocol 
Relates to?:* 
(Please visit:http://www.icddrb.net.bd/jahia/Jahia/....... for 
selecting SDG Code(s) code 3 
  Yes (please select SDGs) 
  No 
Does this Protocol Use the Gender Framework:* 
(Please visit:http://www.icddrb.net.bd/jahia/Jahia/pid/684  for 
Gender Alanysis Tool with instructions) 
  Yes (please complete Gender Analysis Tool) 
  No 
If ‘no’ is the response, its reason(s) in brief:  
Will this Research Specifically Benefit the Disadvantaged (economically, socially and/or otherwise): 
 Yes 
  No      
Protocol

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re 1 
 
Dr. Kaiissar Mannor (M), ideSHi, Bangladesh 

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Student Investigator(s) - Internal:  Sex  
  Female     
  Male 
      
(Position, phone no, extension no, cell, and email address ):  
 
      
 
Signature or written consent of Student Investitor: __________________ 
(electronic signature or email or any sort of written consent) 
 
Have ethics certificate?  
 No    
 Yes  (If Yes, please attach to your CV below) 
Students Affiliation      
 
 
___________________________ 
Approval of the Respective Senior 
Director/ Programme Head 
 
 
(Signature) 
Student Investigator(s) - External: Sex  
  Female     
  Male 
Address (provide full official address, including land phone no(s), extension no. (if any), cell phone number, and email 
address):  
Dr. Joakim  Ø verbø, Norwegian Institute of Public Health, Oslo, Norway 
 
Signature or written consent of Student Investitor: __________________ 
(electronic signature or email or any sort of written consent) 
Collaborating Institute(s): Please provide full official address 
 
Institution # 1 
 
Country 
Norway 
Contact person 
Susanne Gjeruldsen 
Dudman 
Department 
(including Division, Centre, Unit) 
Department of Virology 
Institution 
(with official address) 
Norwegian Institute of Public Health 
Directorate 
(in case of GoB i.e. DGHS) 
      
Ministry (in case of GoB) 
      
 
Institution # 2 
 
Country 
China 
Contact person 
Steven Gao 
Department 
(including Division, Centre, Unit) 
      
Institution 
(with official address) 
XIAMEN Innovax BIOTECH CO.Ltd 
Directorate 
(in case of GoB i.e. DGHS) 
      
Ministry (in case of GoB) 
      

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Institution # 3 
 
 
Country 
Bangladesh 
     
Contact person 
Abdul Muktadir 
     
Department 
(including Division, Centre, Unit) 
      
     
Institution 
(with official address) 
Incepta Pharmaceuticals 
40 Shahid Tajuddin Ahmed Sarani 
Tejgaon I/A, Dhaka-1208. Bangladesh 
Phone: (+88 02) 8891688 - 703 
     
Directorate 
(in case of GoB i.e. DGHS) 
      
     
Ministry (in case of GoB) 
      
     
 
Institution # 4 
 
 
Country 
Bangladesh 
     
Contact person 
Dr. Kaiissar Mannor 
     
Department 
(including Division, Centre, Unit) 
      
     
Institution 
(with official address) 
ideSHi /CMBT  (Institute for Developing Science & Health Initiatives) 
ideSHi /CMBT , IPH Bhaban (2nd floor), Shaheed Tajuddin Ahmed 
Sarani,   Mohakhali Dhaka – 1212, Bangladesh 
     
Directorate 
(in case of GoB i.e. DGHS) 
      
     
Ministry (in case of GoB) 
      
     
 
 
 
Note: If less than or more than three collaborating institutions, please delete or insert blocks as needed. 

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Contribution by the Members of the Scientific Team: 
 
 
Members’ Name 
Contribution 
Research 
idea/ 
concept 
Study 
design 
Protocol 
writing 
Respond 
to external 
reviewers’ 
comments 
Defending 
at IRB 
Developing 
data 
collection 
Tool(s) 
Data 
Collection 
Data analysis/ 
interpretation 
of results 
Manuscript  
writing 
Dr. K. Zaman 
 
 
 
 
 
 
 
 
 
Dr. John D Clemens 
 
 
 
 
 
 
 
 
 
Dr. Susanne 
Gjeruldsen 
Dudman 
 
 
 
 
 
 
 
 
 
Dr Emily Gurley 
 
 
 
 
 
 
 
 
 
Dr Firdausi Qadri 
 
 
 
 
 
 
 
 
 
Dr. Md Yunus 
 
 
 
 
 
 
 
 
 
Dr. Peter Kim 
Streatfield 
 
 
 
 
 
 
 
 
 
Dr . Quamrun Nahar  
 
 
 
 
 
 
 
 
 
Dr. Jahangir Khan 
 
 
 
 
 
 
 
 
 
Dr. Md. Anisur 
Rahman 
 
 
 
 
 
 
 
 
 
Dr..Md.Mustafizur 
Rahman 
 
 
 
 
 
 
 
 
 
Dr. Shafiqul Alam 
Sarker 
 
 
 
 
 
 
 
 
 
Dr. Kathrine Stene-
Johansen,  
 
 
 
 
 
 
 
 
 
Dr. Synne Sandbu 
 
 
 
 
 
 
 
 
 
Dr. Sara Viksmoen 
Watle 
 
 
 
 
 
 
 
 
 
Dr. Kaiissar Mannor 
 
 
 
 
 
 
 
 
 
Dr. Asma Binte Aziz 
 
 
 
 
 
 
 
 
 
Study Population: Sex, Age, Special Group and Ethnicity 
 
Research Subject: 
   Human             
   Animal  
 
   Microorganism 
   Other (specify): _____________ 
 
Sex: 
   Male             
   Female  
   Transgender 
 
Age: 
   0 – 4 years 
   5 – 10 years 
   11 – 17 years 
   18 – 64 years 
   65 + 
Special Group: 
   Pregnant Women 
   Fetuses 
   Prisoners 
   Destitutes  
   Service Providers 
   Cognitively Impaired 
   CSW 
   Expatriates 
   Immigrants 
   Refugee 
   Others (specify): ________________ 
 
Ethnicity: 
No ethnic selection (Bangladeshi) 
  Bangalee 
  Tribal group 
   Other (specify): ________________ 
 
NOTE:It is icddr.b’s policy to include men, women, children and transgender in its research projects involving participation 
of humans, unless there is strong justification(s) for their exclusion.  

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Consent Process: (Check all that apply) 
 
  Written 
  Oral 
  Audio 
  Video 
  None 
Language: 
   Bangla 
   English 
   Other (specify: _______________ 
 
Project/Study Site: (Check all that apply) 
  Chakaria  
  Bandarban 
  Dhaka Hospital  
  Kamalapur Field Site/HDSS  
  Mirpur (Dhaka) 
  Matlab DSS Area 
  Matlab non-DSS Area 
  Matlab Hospital 
  Mirzapur 
 
 
   Bianibazar (Sylhet) 
   Kanaighat (Sylhet) 
   Jakigonj (Sylhet) 
   Other community in Dhaka 
        Name: _________________________________          
   Other sites in Bangladesh 
        Name: _________________________________ 
   Multi-national Study 
        Name of the country______________________   
Project/Study Type: (Check all that apply) 
 
  Case Control Study 
  Clinical Trial (Hospital/Clinic/Field)* 
  Community-based Trial/Intervention 
  Cross Sectional Survey 
  Family Follow-up Study 
  Longitudinal Study (cohort or follow-up) 
  Meta-analysis 
  Programme Evaluation 
 
   Programme (Umbrella Project) 
   Prophylactic Trial 
   Record Review 
   Secondary Data Analysis 
        Protocol No. of  Data Source: _____________ 
   Surveillance/Monitoring 
   Systematic Review 
   Other (specify): _________________________ 
 
 *Note: International Committee of Medical Journal Editors (ICMJE) defines Clinical Trial as “Any research project that 
prospectively assigns human participants to intervention and comparison groups to study the cause-and-effect 
relationship between a medical intervention and a health outcome”. 
PI of the RRC- and ERC-approved Clinical Trials should provide necessary information to IRB Secretariat (Research 
Administration) for registration and uploading into relevant websites (usually at the https://register.clinicaltrials.gov/). 
They should also provide relevant information to the IRB Secretariat in the event of amendment/modification after 
their approval by RRC and ERC.           
Biological Specimen: 
 
a)  Will the biological specimen be stored for future use?          
Yes            
No
 Not applicable 
b)  If the response is ‘yes’, how long the specimens will be 
preserved?     
____5______  years 
c) What types of tests will be carried out with the preserved 
specimens? 
Microbiological and Immunological  tests 
d) Will the consent be obtained from the study participants for use 
of the preserved specimen for other initiative(s) unrelated to this 
study, without their re-consent? 
Yes            
No
 Not applicable 
e) Will the specimens be shipped to other country/ countries? 
If yes, name of institution(s) and country/ countries?   
Yes            
No
 Not applicable 
f) 
If shipped to another country, will the surplus/unused specimen 
be returned to icddr,b?   
If the response is ‘no’, then the surplus/unused specimen must 
be destroyed. 
Yes            
No
 Not applicable 
g) Who will be the custodian of the specimen at icddr,b?  
Dr. K. Zaman 
h) Who will be the custodian of the specimen when shipped 
outside Bangladesh?    
Dr. Susanne Gjeruldsen 
Dudman. Norway 

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i) 
Who will be the owner(s) of the specimens?        
icddr,b and NIPH 
j) 
Has a MoU been signed with regards to collection, storage, use 
and ownership of specimen?                                    
If the response is ‘yes’, please attach a copy of the MoU..   
       If the response is ‘no’, appropriate justification should be 
provided for not signing a MoU. 
Yes            
No
 Not applicable 
Proposed Sample Size: 
 
Sub-group (Name of subgroup e.g. Men, Women) and Number 
 
Name 
Number 
Name 
Number 
(1) Pilot phase  
100 
(3)       
      
(2) Main phase  
20,745   
(4)       
      
 
 
Total sample size 
20,845 
Determination of Risk: Does the Research Involve (Check all that apply) 
  Human exposure to radioactive agents? 
  Foetal tissue or abortus? 
  Investigational new device? 
        Specify: __________________ 
  Existing data available from Co-investigator? 
 
 
  Human exposure to infectious agents? 
  Investigational new drug? 
  Existing data available via public archives/sources? 
  Pathological or diagnostic clinical specimen only? 
  Observation of public behaviour? 
  New treatment regime? 

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Dissemination Plan: [please explicitly describe the plans for dissemination, including how the research findings would be 
shared with stakeholders, identifying them if known, and the mechanism to be used; anticipated type of publication (working 
papers, internal (institutional) publication, international publications, international conferences/seminars/workshops/ 
agencies. [Check all that are applicable] 
 
Dissemination type 
Response 
Description (if the response is a yes) 
Seminar for icddr,b 
scientists/ staff 
 No 
 Yes 
Multiple icddr,b scientists will be working on this clinical trial. The 
results will be shared in internal icddr,b seminars. 
Internal publication 
 No 
 Yes 
 
Working paper 
 No 
 Yes 
 
Sharing with GoB (e.g. 
DGHS/ Ministry, others) 
 No 
 Yes 
The clinical trial has implications for HEV vaccine policy in Bangladesh 
and globally. Therefore, the results will be shared with GoB. 
Sharing with national 
NGOs 
 No 
 Yes 
The results will be shared with national NGOs. 
Presentation at national 
workshop/ seminar 
 No 
 Yes 
The results will be presented at National workshop/seminar. 
Presentation at 
international workshop/ 
conference 
 No 
 Yes 
The clinical trial has implications for HEV vaccine policy. Therefore, the 
results will be shared in international conferences. 
Peer-reviewed publication 
 No 
 Yes 
Multiple peer-reviewed publications are expected. 
Sharing with international 
agencies 
 No 
 Yes 
As the trial has global HEV vaccine policy implications, the results will 
be shared with international agencies. 
Sharing with donors 
 No 
 Yes 
The  results of this study will be shared through presentations and peer 
review publications. 
Policy brief 
 No 
 Yes 
A policy brief will be prepared 
Other 
 
 
 
Other 
 
 
 
` 
Funding: 
Is the protocol fully funded? 
 Yes 
 No 
If the answer is yes, please provide 
sponsor(s)’s name 
1. GLOBVAC 
2. Bill and Melinda Gates Foundation for the sub-study 
2. 
Is the protocol partially funded? 
 Yes 
 No 
If the answer is yes, please provide 
sponsor(s)’s name 
1. 
2. 
 
If fund has not been identified: 
Is the proposal being submitted for funding? 
 Yes 
 No 
If yes, name of the funding agency 
1. 
2. 

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Table of Contents 
 
RRC APPLICATION FORM .............................................................................................................. 1 
Project Summary ................................................................................................................................ 12 
Hypothesis to be tested: .............................................................................................................. 14 
Specific Objectives: .................................................................................................................... 14 
Background of the Project including Preliminary Observations..................................................15 
Research Design and Method.......................................................................................................18 
Sample Size Calculation and Outcome (Primary and Secondary) Variable(s) .......................... 30 
Data Analysis................................................................................................................................35 
Data Safety Monitoring Plan (DSMP)........................................................................................ 37 
Ethical Assurance for Protection of Human rights ..................................................................... 36 
Use of Animals ........................................................................................................................... 37 
Collaborative Arrangements ....................................................................................................... 37 
Facilities Available ..................................................................................................................... 38 
Literature Cited ........................................................................................................................... 38 
        Budget..........................................................................................................................................41 
        Budget Justification......................................................................................................................43 
       Other support.................................................................................................................................44 
       Biography of the Investigators......................................................................................................48 
         Informed Consent (English and Bangla)………………………………………………………………………………………………..61 
       Check list.......................................................................................................................................89 
 
 
 
  Check here if appendix is included 
 
 
 
 
 
 
 
 
 

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Project Summary 
[The summary, within a word limit of 300, should be stand alone and be fully understandable.] 
Principal Investigator: K Zaman 
 
Research Protocol Title: An effectiveness trial to evaluate the protection of pregnant women with a 
hepatitis E vaccine in rural Bangladesh and the risk factors for severe hepatitis  
E infection   
 
Proposed start date: April 1, 2016                                                                  Estimated end date: March 31,  2020 
Background (brief): 
a. Burden: 
Hepatitis E virus (HEV) infection is the commonest cause of acute hepatitis disease in South Asia, 
including Bangladesh. Population-based studies, some with verbal autopsies from Bangladesh showed 
that 19-27% of maternal deaths and 7-13% of neonatal deaths, respectively, were associated with 
acute onset of jaundice as a complication of pregnancy, with at least 60% of these acute icteric 
episodes being due to HEV.  
 
 
b. Knowledge gap: 
There are no data showing that HEV vaccination can prevent hepatitis E disease in pregnant women, 
the group that could benefit most from vaccination. 
 
c. Relevance: 
There are currently no effective treatments for pregnant women who contract HEV. Considering that 
approximately 40% of maternal deaths and 45% of neonatal deaths globally occur in HEV-endemic 
South Asia, efforts to reduce the burden of maternal and neonatal mortality from HEV in the South 
Asia region could have a major global impact. HEV vaccines may offer one option for prevention of 
maternal mortality attributed to HEV. Safe and effective HEV vaccines have been developed, such as 
the HEV 239 (HecolinTM) vaccine manufactured by Innovax in China.  
 
Hypothesis (if any): 
- 
Vaccination of women of childbearing age with Hecolin will decrease HEV disease incidence 
and thus HEV-related complications among vaccinated pregnant women and their children. 
- 
Hecolin is safe and immunogenic in women of childbearing age. 
- 
Hecolin is effective in protecting against HEV genotype 1.  
- 
Vaccination of women against HEV is feasible and cost-effective in Bangladesh  
- 
Dried blood spot and salivary samples (approx 2 ml) are suitable for diagnosing HEV 
infections and evaluating immunity against HEV. 
- 
High viral load, abnormal immune response, and certain subtypes of HEV are all risk factors 
for serious disease. 
 
Objectives: 
Primary 
- 
To determine the effectiveness of hepatitis E virus (HEV) vaccine given in women of child 
bearing age in preventing HEV disease during pregnancy among women in rural Bangladesh 
 
Secondary objectives: 
- 
To determine the safety and immunogenicity of HEV vaccine in Bangladeshi women of 
childbearing age  
- 
To measure the effectiveness of HEV vaccine in preventing HEV disease in non-pregnant 
Bangladeshi women of childbearing age  

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- 
To estimate serological correlates of protection 
- 
To assess the feasibility, acceptability and cost-effectiveness of HEV vaccination of women 
of childbearing age in rural Bangladesh 
- 
 To investigate acute HEV cases virologically, clinically and immunologically in relation to 
outcome. 
- 
To analyze the persistance of vaccine induced serum antibody responses 
 
Methods: 
We propose a cluster-randomized double-blinded effectiveness trial to assess the feasibility, 
acceptability, protective impact, and cost-effectiveness of immunization of women of childbearing age 
with the HecolinTM HEV vaccine as a strategy to prevent clinical hepatitis HEV during pregnancy in 
rural Bangladesh.  
 
 
The trial will be conducted in Matlab where icddr,b has maintained a Maternal, Child Health & 
Family Planning intervention programme (MCH-FP) since 1978. All 67 villages in the MCH-FP area 
will be randomized by village at a 1:1 ratio to receive either HEV vaccine or the control vaccine 
(hepatitis B). All non-pregnant women aged 16-39 years in the study area will be eligible for receipt 
of vaccine. We require a sample size of 20,745 women enrolled at baseline, which will be feasibly 
assembled in the population of the Matlab field site. The primary outcome will be clinical HEV 
disease among pregnant women.  All women enrolled in the study will be visted every week to screen 
for clinical hepatitis and pregnancy. Women who would become pregnant following vaccination with 
confirmed pregnancies will be visited every 2 weeks to collect information about pregnancy 
outcomes. Women with clinical hepatitis will have liver function and virological diagnostic testing 
done to confirm HEV infection. Our proposed project also includes transfer of production technology 
for this vaccine from China to a high quality Bangladesh vaccine manufacturer (Incepta) in providing 
low cost HEV vaccine for public health programmes in Bangladesh.Pretesting (100 participants) will 
be done before proceeding to large scale trail. This pretesting will look mainly the safety and 
immunogenicity. 
Outcome measures/variables: 
Confirmed- HEV diseases among pregnant women, safety, immunogenicity, confirmed HEV diseases 
in non-pregnant women, viral load and subtypes/mutations, altered immune response, maternal and 
perinatal mortality associated with maternal jaundice, perceptions about vaccine acceptability. 
 
 

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Description of the Research Project 
 
Hypothesis to be tested: 
In a hypothesis testing research proposal, briefly mention the hypothesis to be tested and provide the scientific basis of the hypothesis, critically 
examining the observations leading to the formulation of the hypothesis. 
 
Does this research proposal involve testing of hypothesis: 
 No
 Yes (describe below) 
 
Does this research proposal involve testing of hypothesis: 
 No
 Yes (describe below) 
 
- 
Vaccination of women of childbearing age with Hecolin will decrease HEV disease incidence 
and thus HEV-related complications among vaccinated pregnant women and their children. 
- 
Hecolin is safe and immunogenic in women of childbearing age. 
- 
Hecolin is effective in protecting against HEV genotype 1.  
- 
Vaccination of women against HEV is feasible, acceptable and cost-effective in low-income 
countries.  
- 
Dried blood spot and salivary samples (approx 2 ml) are suitable for diagnosing HEV infections 
and evaluating immunity against HEV.  
- 
High viral load, abnormal immune response, and certain subtypes of HEV are all risk factors for 
serious disease.  
 
 
Specific Objectives: 
Describe the specific objectives of the proposed study. State the specific parameters, gender aspects, biological functions, rates, and processes that will 
be assessed by specific methods. 
 
Primary objectives: 
 
- 
To determine the effectiveness of hepatitis E virus (HEV) vaccine given in women of child 
bearing age in preventing HEV disease during pregnancy among women in rural Bangladesh 
 
Primary endpoint: confirmed- HEV diseases among pregnant women 
Secondary objectives: 
 
- 
To determine the safety and immunogenicity of HEV vaccine in Bangladeshi women of 
childbearing age  
- 
To measure the effectiveness of HEV vaccine in preventing HEV disease in non-pregnant 
Bangladeshi women of childbearing age  
- 
To estimate serological correlates of protection 
- 
To assess the feasibility, acceptability and cost-effectiveness of HEV vaccination of women of 
childbearing age in rural Bangladesh 
- 
 To investigate acute HEV cases virologically, clinically and immunologically in relation to 
outcome. 
- 
To analyze the persistance of vaccine induced serum antibody responses 
 
Secondary endpoint: Safety, immunogenicity, confirmed HEV diseases in non-pregnant women, viral 
load and subtypes/mutations, altered immune response, maternal and perinatal mortality associated with 
maternal jaundice, operational challenges in the delivery of the vaccine and acceptance of vaccine by 
the users. 
 
 

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Background of the Project including Preliminary Observations: 
Provide scientific validity of the hypothesis based on background information of the proposed study and discuss previous works on the research topic, 
including information on sex, gender and diversity (ethnicity, SES) by citing specific references. Critically analyze available knowledge and discuss 
the questions and gaps in the knowledge that need to be filled to achieve the proposed aims. If there is no sufficient information on the subject, 
indicate the need to develop new knowledge.  
 
 
1.1 Background – Disease 
1.1.1 Epidemiology and laboratory diagnosis: Hepatitis E virus (HEV) can cause acute hepatitis, 
sometimes leading to acute liver failure and death. Globally, it is probably the most common cause of 
acute hepatitis (Kamar, 2012), estimated to be responsible for 20 million symptomatic hepatitis cases, 
70 000 deaths and 3000 stillbirths per year.  
HEV is prevalent all over the world. It has four genotypes and two distinct geographical patterns. 
Genotype 1 (HEV-1), and less frequently genotype 2 (HEV-2) dominate in many low income countries 
(LIC) causing both large outbreaks and sporadic cases of acute hepatitis. These genotypes infect only 
humans and can be transmitted by the oro-faecal route, usually via contaminated water in areas with 
poor sanitation. Genotypes 3 (HEV-3) and 4 (HEV-4) are often found in high and middle income 
countries and are transmitted zoonotically from animal reservoirs, causing sporadic cases. The main 
reservoirs seem to be both wild and domestic pigs, although HEV is found in a variety of mammals. 
The epidemiological difference related to genotype and outcome is poorly understood. It is a public 
health problem in both rich and poor countries. 
 
Laboratory diagnosis of HEV is done by serology (anti-HEV IgM and IgG) and polymerase chain 
reaction (PCR). IgM anti-HEV antibodies can be detected during the first few months after HEV 
infection, whereas IgG anti-HEV antibodies represent either recent or remote exposure. The presence of 
HEV RNA indicates current infection, (Aggarwal R, 2013). The virus can be further characterized by 
sequencing and/or growing the virus in culture. The current diagnostic tools are not suitable to identify 
acute infections in LICs and need to be optimized for the local situation. Treatment of HEV disease is 
mostly supportive care for serious cases. Ribavirin and Pegyleted interferon have proven effectiveness 
in some cases, but are both contraindicated during pregnancy.  
 
1.1.2 HEV and pregnancy: The propensity of HEV-1 and HEV-2 to kill pregnant women and their 
fetuses or newborns in LICs distinguishes HEV from the other hepatitis viruses. Although the overall 
case fatality ratio is 1 to 3%, it is 5-25% among pregnant women in LICs (Kamar, 2014). The reason for 
this increased mortality is still unclear, as is the reason why pronounced pregnancy-related mortality is 
only seen in LICs. It may be a result of greater virulence of the human-adapted HEV-1 and HEV-2 
genotypes, increased susceptibility of pregnant women in developing countries where these genotypes 
are endemic, or the epidemiological conditions of exposure to these viruses in theses settings (Krain, 
2014). Membrane rupture, miscarriages, stillbirths and high neonatal morbidity and mortality are also 
associated with HEV-infections in pregnancy (Patra. 2007). Population-based studies with verbal 
autopsies in Bangladesh showed that 19-27% of maternal deaths and 7-13% of neonatal deaths were 
associated with acute onset of jaundice as a complication of pregnancy, with at least 60% of these acute 
icteric episodes likely due to HEV (Gurley 2012). 
 
1.1.3 Protective immunity: Little is known about the long-term immunity of HEV. A study from China 
on HEV4 concluded that naturally and vaccine acquired immunity gives 75% protection against 
infection and alleviates the severity of the disease caused be re-infection (Huang, 2014). There are no 
data on the protection from natural-infection or vaccine acquired immunity to other HEV genotypes. 
 
 
 

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1.2 Rationale for the Study 
 
99% of maternal and neonatal mortality occurs in the developing world which also carries the greatest 
burden of HEV. Efforts to reduce the burden of maternal and neonatal mortality from HEV could have a 
major global impact. 
 
The current scientific gaps concerning HEV infection are many. In October 2013, WHO established the 
SAGE Working Group on Hepatitis E for reviewing the evidence with respect to the epidemiology, 
burden and implementation of a vaccine against HEV. In their recommendations from 2014 the 
importance and promising results of the Chinese vaccine were noted, but several knowledge gaps 
pointed out. Effectiveness data that show that the vaccine can be feasibly delivered to women of 
childbearing age, and that the vaccine can reduce the burden of HEV disease in pregnancy in a cost-
effective manner is necessary before the vaccine can be implemented in LICs (Uddin, 2013). The 
project will contribute this important data. 
 
It is imperative to understand the determinants of the clinical course of HEV and factors associated with 
resistance to repeat infection. Deciphering the nuances of individual risk and host-related factors will 
help in improving identification, preventive precautions, and secondary or tertiary management of 
highly vulnerable individuals. In order to document the global disease burden of HEV it is important to 
have rapid and reliable diagnostic tests, as many currently available tests give suboptimal results. Some 
of the main problems of microbiological testing in developing countries are related to sampling and 
transportation of blood samples because of a shortage in trained personnel to take samples and a lack of 
facilities for processing blood and maintaining frozen samples. Saliva could potentially be an alternative 
to blood samples for HEV-testing, which would be safer, easier and cheaper, making HEV-testing more 
available in developing countries. Antibodies against different pathogens are often found in high titres 
in saliva, but very little data is available on the presence of HEV antibodies in saliva. 
 
The effectiveness of a HEV-vaccine needs to be tested in a population with high endemicity to be 
conducted in a reasonable time period. Bangladesh is suitable for this type of study. Recently, it has 
been estimated that there are 1000 HEV-related maternal deaths per annum in Bangladesh alone 
(Labrique, 2012). This study will be conducted at Matlab, a field study area of the International Centre 
for Diarrhoeal Disease Research, Bangladesh (icddr,b). A recent study from this region showed that 
22% of the population had been previously infected with HEV, and the incidence of seroconversion was 
60 per 1000 person years (Labrique, 2010). Further, we have documented baseline data on HEV 
incidence and burden of disease in Bangladesh (Gurley, 2012, Labrique, 2012).  Importantly, the 
epidemiology of HEV in Bangladesh is similar to other parts of South Asia, so results from the trial will 
be relevant for the estimated 1.5 billion South Asians at risk for HEV. Genotype 1, which is 
homologous to the Chinese vaccine antigen, dominates in Bangladesh so there is reason to believe that 
Hecolin will be as effective in Bangladesh as in the Chinese trial where genotype 4 is endemic. Matlab 
has been the site for many successful large-scale vaccine field trials in the past, including trials of oral 
cholera vaccine (Clemens, 1991) and rotavirus vaccine (Zaman, 2010), in addition to several large-scale 
studies of pregnancy (Persson, 2012). Matlab is thus suited for undertaking the trial described in this 
protocol. 
 
Bangladesh has historically been a pioneer in vaccine introduction, and the close partnership between 
icddr,b and the Bangladesh government has played an important role in the deployment of new 
generation vaccines into public health programs. The government recognizes the seriousness of HEV 
disease, especially in pregnant women, and has expressed interest in the potential introduction of HEV 
vaccine in its public sector programs, as the projected impact will be high. However, the feasibility of 
the delivery of the HEV vaccine and acceptance of vaccine by the users are not known. 

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Summary of findings from previous studies 
The vaccine has been shown to be safe and highly efficacious against HEV disease in a large phase III 
trial in China with over 100.000 participants (100% after 3 doses of vaccine, 95% CI: 72.1-100.0), 
where it is commercially manufactured and licensed sale (Zhu, 2010). The majority of cases in this trial 
were due to genotype 4, indicating that the vaccine was able to confer genotype-heterologous 
protection. The vaccine was highly immunogenic with seroconversion rates of 98-100% among 
vaccinees (Zhang, 2014). The study did not provide sufficient data (not powered) to show efficacy in 
preventing HEV disease during pregnancy. Pregnant women are most vulnerable to HEV-infection and 
have the greatest impact of an effective vaccine. 
Summary of known and potential risks 
In phase 1, 2 and a large phase 3 study conducted by the manufacturer, preclinical toxicity of HEV239 
was assessed and Hecolin was well tolerated and safe for use in healthy adults. AEs were mainly local 
with pain, swelling and itching at the injection site. The rate of AEs was similar in the study groups and 
the placebo groups (receiving a Hepatitis B vaccine). AEs of grade 3 or more were reported only very 
rarely, and include injection site swelling, fever and headache. 
 
An extended follow-up study from the phase 3 study collecting data on safety for up to 4.5 years after 
the first vaccine dose, showed the number of reported SAEs (4792 vs 4667; p=0.179) and the number of 
participants with one or more SAE (4602 vs 4490; p=0.221) to be comparable between the vaccine and 
placebo groups. None of the SAEs was judged by the principal investigator (who reminded masked to 
treatment assignment) to be related or possibly related to the hepatitis E vaccine (Zhang, 2015).  
 
Phase III retrospective cohort study - pregnant women 
There are limited data on safety of Hecolin®  on maternal and fetal outcomes following use during 
pregnancy.  
Following completion of the phase III clinical trial (Zhu, 2010), it was found that 37 women in the HEV 
239 vaccine group (out of 31,791) and 31 women in the placebo group (out of 31,735) were either 
pregnant upon commencement of the study or became pregnant during the trial, even though pregnancy 
was an exclusion criterion for this study. Data for this group of participants were reviewed carefully 
(Wu, 2012). The 37 women in the HEV 239 vaccine group had received 53 vaccine doses (22 one dose, 
14 two doses and one three doses). The vaccine was well tolerated in the pregnant women with only one 
woman reporting grade 1 injection site pain. The rate of AEs was similar in the pregnant women who 
had inadvertently received HEV 239 vaccine and the vaccinated non-pregnant women. Half (19; 51.3%) 
of the pregnant women in the HEV 239 group underwent elective abortion; the rate was 45.2% in the 
placebo group. No spontaneous abortions occurred in the vaccine group and the remaining 18 babies, 
delivered either by normal vaginal delivery (n=7) or caesarean section (n=11), were as healthy as those 
in the control group (vaginal delivery n=7; caesarean delivery n=10); none of the babies had any 
congenital abnormality. Birth weights (3573.5±356.7 g vs. 3565.6±531.6 g), lengths (50.7±1.3 cm vs. 
50.8±1.5 cm) and gestational ages (276.2±7.6 d vs. 276.6±7.1 d) of the babies born to the mothers in the 
vaccine group and the placebo group were comparable. 
Global Advisory Committee on Vaccine Safety (GACVS) reviewed the safety of Hecolinin its meeting 
held in June 2014 (World Health Organization, 2014), and concluded as follows: 
In summary, available safety data on Hecolin®  derived from Phase 1, 2 and 3 clinical trials in healthy 
subjects are reassuring. However, GACVS noted that there are no safety data in paediatric subjects (<16 
years of age), the elderly (>65 years of age), persons with underlying diseases or conditions such as 
those who are immunosuppressed persons or have liver disease and thus recommended that studies be 
conducted to assess the safety of Hecolin®  in these subpopulations. Any follow-up of those 
inadvertently vaccinated in pregnancy during the HEV trial should be useful to assess safety in this 
group. The committee also noted that there are as yet no studies to evaluate the safety and 
immunogenicity of Hecolin®  when given concomitantly with other vaccines. In addition, GACVS 

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recommended that a Phase 4 post-marketing study be conducted once the vaccine is in more widespread 
use to further assess the safety profile of Hecolin® , in particular with regard to serious and rare adverse 
events. 
 
 
 
Research Design and Methods 
Describe the research design and methods and procedures to be used in achieving thespecific aims of the research project. If applicable, mention the 
type of personal protective equipment (PPE), use of aerosol confinement, and the need for the use BSL2 or BSL3 laboratory for different part of the 
intended research in the methods.. Define the study population with inclusion and exclusion criteria, the sampling design, list the important outcome 
and exposure variables, describe the data collection methods/tools, and include any follow-up plans if applicable. Justify the scientific validity of the 
methodological approach (biomedical, social, gender, or environmental).  
 
Also, discuss the limitations and difficulties of the proposed procedures and sufficiently justify the use of them. 
Study population participant enrolment 
Selection of Study Site and Population 
The study will be conducted in a rural Bangladesh area called Matlab with a population of over 
220,000, where icddr,b has maintained a field research site since 1963. A health and demographic 
surveillance system (HDSS) which consists of regular cross-sectional censuses and longitudinal 
registration of vital events, has been maintained in the area since 1966 (icddr,b;  2006). Each of the 22 
community health research workers (CHRW) in the MCH-FP area covers a population of about 5800, 
visiting each household every months to record vital events and to collect health information. CHRWs 
conduct spot urine tests for pregnancy for women who have missed their last menstrual periods; 
systematic queries and home urine pregnancy testing by the CHRWs routinely identify pregnancies by 
8-12 weeks’ gestation. Health services, including immunization for children <5 years of age and women 
of childbearing age, are provided by another an additional CHRW at each of 41 fixed site clinics (FSC). 
A Maternal, Child Health & Family Planning intervention program (MCH-FP) is also operating in this  
area from 41 FSC providing health services and systematic queries pregnancy testing and immunization 
(Koenig et al, 1998). EPI (Expanded Programme on Immunization) coverage in the villages is more 
than 90%. Detailed information on all individuals included in the MCH-FP are available and includes 
sex, exact date of birth, date of marriage, migrations, immunization history, pregnancy outcome, date of 
death etc.  The study will be conducted in the MCH-FP area of Matlab. In 2012, the mid-year 
population in the MCH-FP area of Matlab was 116,377. There were 2,994 pregnancies, 2,605 live 
births, 364 miscarriages (121.6/1000 live births) and 25 still births (8.4/1,000 live births) during 2012 
(icddr,b 2014). The infant and neonatal mortality rates were 20.5 and 15.6 per 1,000 live births, 
respectively. The maternal mortality ratio was 119/100,000 live births. More than 80% of deliveries 
took place in healthcare facilities. 
 
General Study Design 
The study will be a cluster-randomized double blinded 
trial to evaluate the efficacy, effectiveness and cost-
effectiveness of vaccinating women of reproductive 
age with three doses of the study vaccine (Hecolin®). 
HEV disease among pregnant women as the primary 
outcome. The study design will also allow for 
investigating possible relationship between host and 
viral factors against the severity of HEV disease and 
vaccine efficacy. The feasibility and acceptability of 
the HEV vaccine will be assessed using qualitative 
methodology. 

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In cluster randomised controlled trials, groups of people, rather than individuals, are randomly allocated 
to the interventions under investigation. The ‘unit of allocation’ in this trial is a village.  
A cluster randomized controlled study has been selected as the method of choice to conduct a vaccine 
effectiveness trial (Clemens, 1996). A vaccine effectiveness trial is a randomized trial designed to evaluate 
vaccine impact, vaccine acceptability and programmatic feasibility when the vaccine is given under realistic 
public health conditions. As such conditions are not achievable in an individually randomized design, but can 
be achieved with cluster randomized design, the latter design is selected. Our trail’s primary aim is to measure 
total vaccine protection. We are aware that the trial may not be adequately powered to measure indirect and 
overall vaccine protection, which are considered secondary aims. The trial investigators are very familiar with 
designing and conducting cluster-randomized vaccine trails.  
 
Pregnant women are most vulnerable to HEV-infection and have the greatest impact of an effective vaccine. 
Effectiveness of the vaccine in pregnant women has not been investigated, which is one of the main reasons for 
this study to be conducted. Hence, the vaccine is not licensed for pregnant women. Some fertilewomen are 
likely to become pregnant within the timeframe of our study, and some of these will have been vaccinated, thus 
providing necessary data for this group. 
 
HEV can not be distinguished from other viral hepatitis infections without specific virological diagnostics. 
Characterization of the virus is important to document the effect of the vaccine on different circulating HEV -   
genotypes. 
 
The inclusion of participants will take place during six months. Vaccines will be administered as a 3-
dose regimen on day 0, at one month, and six months. The follow up period will be average of 2 years 
following the third dose of vaccine. 
 
Study participants will be non-pregnant women who were randomly allocated to receive HEV vaccine 
or HBV vaccine at Day 0, 1 month and 6 months. In the ongoing study blood was collected at baseline 
(day 0) and 1 month after dose 3 (7 month).  
Inclusion Criteria 
• 
Women aged 16-39 years at the time of the first vaccination 
• 
Living in the MCH-FP area of Matlab  
Exclusion Criteria 
Participants will be excluded from the study if they meet any of the following criteria: 
For dose 1: 
• 
Pregnancy (visible or verbal report on date of last menstruation or urine test) * 
• 
History of severe allergic reaction to a vaccine or a vaccine component 
• 
Having other vaccine or immunoglobulin within two weeks 
• 
Serious chronic disease (as assessed by medical officer)  
• 
Acute and chronic infectious disease 
• 
Fever > 38 ºC (temporarily)  
*Women with a history of missed periods, irregular cycles, or uncertain last menstrual period (LMP) date will be tested 
for pregnancy using a urine strip test before enrollment and vaccination. If the test is negative, vaccination will proceed. 
If the test is positive, or if the participant refuse, they will be excluded from enrollment and vaccination.  
Participants will be excluded from further vaccination if they meet any of the five first of above 
mentioned exclusion criteria, but will still be eligible for ITT analysis and participating in the study 

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until the end. In such cases the blood sample for measuring vaccine response will be taken one month 
after the last vaccine dose.  
After 1st dose or after 2nd dose of vaccine if a participant becomes pregnant then surveillance will 
continue, but no further doses of vaccine will be given according to the study protocol exclusion 
criteria. 
Obtaining informed consent 
 
The eligible women will be approached in their homes and will be asked to come to the Fixed site clinic 
(FSC) for enrolment in the study.  
Theinvestigatorordesignatewilldescribetheprotocoltothepotentialparticipantface-to-face. The process 
will ensure that potential participants have an understanding of the potential risks and benefit, or lack of 
benefit, of the vaccine, the study procedures (including maintaining confidentiality and anonymity), 
their right to refuse and/or withdraw from the study at any point without affecting the health services or 
care they receive, and without having to disclose a reason for their refusal or withdrawal.  
Participants have opportunity to inquire about the details of the study. Recruitment is based on 
voluntary participation and the participants can decline at any time. Designated study staff will review 
the consent form with potential participants who meet study eligibility criteria. The consent form will 
also be verbally explained in the appropriate local language.The participants can also request 
destruction of the dataconcerning them.  
Incidental abnormal findings of health importance for the participants will becommunicated. 
Confidentiality of personal identifiers will be maintained by keeping names noted inprimary data 
instruments in secure files and by removing names from the computerized dataset for analysis 
The participants to be enrolled will sign a consent and assent (in case of 16-17 years old participant) 
form informing them of the nature of the study according to the Declaration of Helsinki and the ICH 
Harmonized Tripartite Guidelines for Good Clinical Practices. The Informed consent forms will be 
archived at the Matlab Hospital. 
In accordance with the principles of the current revision of the Declaration of Helsinki, 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 wellbeing. 
The group will continue to follow up all the vaccinees, with their agreement, until the end of the study. 
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, stabilized or a non-trial related causality has been established. 
 
Pretesting Before proceeding a large scale trial, we will perform pretesting of the study. We will look  
mainly at/on the safety and also immunogenicity of this vaccine with this small sample size. This will 
be done outside of the MCH-FP area but within the HDSS area. The sample size for the pretesting phase 
will be 25 female and 25 male from the HEV and HBV group respectively (estimated assuming 70% 
seroresponse in vaccine group vs. 10% in control, p<0.05, 2 tailed, 0.9 power). The sample will be 
randomly selected among nonpregnant women aged 16-39 years and male will be randomely selected 
from the age group of 16-39 years. We will observe each participant for 30 minutes after each 
vaccination. After each dose field worker will visit daily for 7 days at their homes enquiring about any 
untoward events. Blood will be collected before vaccination and 1 month after the second dose. Process 
for determining immunogenity will be same as described in the protocol.   
 
We want to find out the strength and longevity of the immune reaction to a two-dose schedule compared 
to the standard three-dose schedule of the vaccine for the pilot study. We will collect one blood sample 

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(maximum 3ml) from all participants of pilot study (100) to determine the immune response and an 
additional 9 ml blood from the 10 persons previously selected to assess the cellular response 
approximately 2 years after first vaccination. 
 
To better understand the persistence of immunological responses 2 years (24 to35 months) after the last 
dose of the vaccine we will do a sub-study under this main study. We will sequentially enrol for this 
addon study from the list of original enrollment and identify eligible participants who received 3 doses 
of vaccine and completed follow up 2 years (24  to 35 months)  and also who received 1 or 2 doses of 
vaccine (incomplete schedule).We will include total 1,760  (440 participants in each group) HEV 
vaccine study participants for this sub-study  among those who are 1) HEV seronegative at baseline and  
received HEV vaccine, 2) those who were HEV seropositive at baseline and received HEV vaccine, 3) 
who were HEV seropositive  at baseline and received HBV vaccine, 4) participants who are HEV 
seronegative at baseline and received HBV vaccine (pure control group). 
 
Enrolment 
Following informed consent obtained by the medical officer, nurses will administer vaccine to the 
participants. All enrolled women in the study will be provided with an immunization card with 
identification numbers and with a phone number to call if they become ill with jaundice or missed 
periods (>2 weeks weeks from the expected start date) between  the weekly home visits by the study 
field workers.The phone number will be answered by a study staff member who will make household 
visits to screen for suspected hepatitis regardless of whether or not the woman is pregnant. Regular 
SMS messages will be sent to remind participants to report cases of jaundice (>80% of households have 
access to a cellphone). All women whose pregnancies are detected through the weekly visits by study 
field workers or routine MCH-FP visits will be visited every 2 weeks to collect information about 
pregnancy outcomes and to screen for clinical hepatitis. A copy of the consent form and participant 
information sheet will also be provided to the participant before concluding the enrolment visit. 
Study vaccination 
For this study Hecolin and Hepa-B is defined as Investigational Medicinal Products (IMP). 
Administration of vaccine 
On vaccination day, vaccine will be administered according to manufacturer’s instructions and local 
study logistics. The vaccine will be administered intramuscularly in the deltoid muscle of either arm, 
avoiding broken skin or injuries. It is recommended, but not required, that the injection be administered 
into the non-dominant arm.  
Participants will be observed at the vaccination site for 30 minutes after the vaccine is administered to 
monitor for any immediate reactions.  
Dose modification 
There will be no dose modification. Previous large scale study in China used this dose successfully (Zhu 
et al, 2010). 
Concomitant interventions 
Any interventions required to treat a disease or condition in an enrolled participant will be allowed. 
Prohibited interventions are vaccinations with a vaccine against HEV other than the study vaccine. 
All concomitant medication used by the participant will be recorded in the participant’s file and CRF.  

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Drug Accountability 
The responsible site personnel will confirm receipt of study drug and will use the study drug only within 
the framework of this clinical study and in accordance with this protocol. Receipt, distribution, return, 
and destruction (if any) of the study drug must be properly documented according to the sponsor’s 
agreed and specified procedures.  
Drug Labelling 
The investigational product will have a label permanently affixed to the outside and will be labeled 
according with ICH GCP and national regulations, stating that the material is for clinical trial / 
investigational use only and should be kept out of reach of children.  
Information on study interventions 
Interventions 
Intervention treatment 
Hecolin®  is based on a 239 amino acid long recombinant HEV peptide, termed HEV 239, 
corresponding to amino acids 368-606 of open reading frame 2 (ORF2) which encodes the capsid 
protein of HEV. The amino acid sequence is derived from a genotype 1 Chinese HEV strain Hecolin® . 
It was developed and is produced by Xiamen Innovax Biotech CO., LTD (Innovax). The vaccine is 
expressed in Escherichia coli, and is purified to >95% homogeneity (Zhang 2014). The vaccine contains 
30 μg of the purified protein absorbed to 0.8mg of aluminium hydroxide suspended in 0.6 ml of 
buffered saline. 
Control treatment 
A commercial hepatitis B vaccine (Hepa-B® ) produced by Incepta Vaccine Ltd. will be used as a 
control vaccine.   Each 0.5 ml dose (for age 0-18 yrs) contains 10 μg of hepatitis B surface antigen 
absorbed on Alluminium Hydoxide gel equivalent to Al3+ 0.25 mg. Each 1.0 ml dose (for age 19 yrs 
and above). 
 
Allocation of intervention and control 
All 67 villages in the MCH-FP area will be randomized by village at a 1:1 ratio to receive either HEV 
vaccine or the control vaccine according to randomization. We will use hepatitis B vaccine (HBV) as 
the control vaccine because it will be of benefit to the target population and because the dosing regimen 
is the same for both vaccines. Since the volume of the vaccine in each dose is different for the two 
vaccines (HEV 0.6 ml and HepaB 0.5 ml for 16-18 years & 1 ml for 19 years and above), to maintain 
blinding vaccinators will be kept unaware of these differences, and no one involved with vaccination 
will participate in follow-up or adverse event assessment of study participants.. The two vaccines will 
be filled in identical, coded, single dose vials.  Vaccines will be administered as a 3-dose regimen on 
day 0, at one month, and six months. Bangladesh introduced HBV for children <5 years into the EPI 
program in 2005, so women aged ≥16 years have not been routinely vaccinated against HBV and could 
benefit from receiving this vaccine. 
Randomization and blinding procedures 
Incepta will receive bulk vaccine for the trial from Innovax, and will package both the HEV and control 
(hepatitis B) vaccines in identical presentations. The investigational product will have a label 
permanently affixed to the outside and will be labelled according with ICH GCP and national 
regulations, stating that the material is for clinical trial/investigational use only and should be kept out 
of reach of children.  

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An independent statistician will ensure randomization. 
Storage and handling 
Hecolin should be stored at 2°C to 8°C, out of direct sunlight, and has an approved shelf life of 36 
months under appropriate storage conditions. The vaccine is stable for at least 45 months. 
 
 
Visits to participants 
Eligibility and vaccination visits 
All women aged 16-39 have already been identified through existing Matlab HDSS system. The women 
will be approached at their homes by a study team. A standardized form will be used to assess eligibility 
according to the criteria.. If found eligible for the study the women will be asked to come to the FSC for 
enrolment in the study.  
 
After each vaccination dose, the participant will be observed for 30 minutes and a field worker will visit 
daily for 7 consequtive days at their homes enquiring about any untoward events. They will also be 
asked to report if they have any local reactions (i.e., erythema, swelling, induration and pain at the 
injection site), systemic reactions (i.e., nausea, malaise, myalgia, arthralgia, headache) and fever within 
7 days after vaccination.  
 
Procedures for the vaccination visit, including recording immediate post vaccination adverse events, are 
described in SOP “Post Vaccination Observation” Procedure and SOP “Immediate Post Vaccination 
Reaction Management Procedure”. 
Post vaccination scheduled visits 
All participants will have a blood sample taken one month after the last dose of the vaccine. 
All women whose pregnancies are detected through the weekly home visits by the study field workers 
or routine MCH-FP visits will be visited every 2 weeks to collect information about pregnancy 
outcomes and to screen for clinical hepatitis.  
Close of study visits in the pregnant cohort. 
The last study visit to pregnant women included will be 14 days after birth.  The participant’s general 
health status will be recorded and information on any changes in the participant’s occupation, residence 
or other important time-varying factors will be collected at this visit. Information on pregnancy outcome 
and health status of the child will be recorded. Participants will be advised there will be no further 
scheduled study visits but that they should inform the study team by telephone of any possible serious 
adverse events or signs of hepatitis.  
Close of call 
The detection for pregnancies and hepatitis surveillance will end atleast 2 years after the last dose of 
vaccination is given. 
Criteria for Participant Discontinuation 
Participants may be discontinued from study treatment and assessments at any time. Specific reasons for 
discontinuing a participant for this study are: 

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• Voluntary discontinuation by the participant who is at any time free to discontinue his/her 
participation in the study, without prejudice to further treatment. 
• Safety reason as judged by the Principal Investigator 
• Major protocol deviation 
• Incorrect enrolment ie, the participant does not meet the required inclusion/exclusion criteria for 
the study 
• Participant lost to follow-up 
Procedures for Discontinuation 
Participant Discontinuation 
Participant will be offered a clinical assessment for safety prior to leaving the study, consistent with the 
assessments done during follow-up visits. Furthermore, SAEs will be cared for and followed through 
until a cause has been established, even if the participant is withdrawn from the study. 
Trial Discontinuation 
The whole trial may be discontinued at the discretion of the PI or the sponsor in the event of any of the 
following: 
• Occurrence of AEs unknown to date in respect of their nature, severity and duration 
• Medical or ethical reasons affecting the continued performance of the trial 
• Difficulties in the recruitment of participants 
• Cancellation of drug production  
The sponsor and principal investigator will inform all investigators, the relevant Competent Authorities 
and Ethics Committees of the termination of the trial along with the reasons for such action. If the study 
is terminated early on grounds of safety, the Competent Authorities and Ethics Committees will be 
informed within 15 days. 
Safety Monitoring and reporting 
The investigator is responsible for the detection and documentation of events meeting the criteria and 
definition of an adverse event (AE) or serious adverse event (SAE). Each participant will be instructed 
to contact the investigator immediately should they manifest any signs or symptoms they perceive as 
serious.  
The methods for collection of safety data are described below. 
Definitions 
Adverse Event (AE) 
An AE is any untoward medical occurrence in a participant administered a pharmaceutical product and 
which does not necessarily have a causal relationship with this treatment.  
An adverse event (AE) can therefore be any unfavourable and unintended sign (including an abnormal 
laboratory finding), symptom, or disease temporally associated with the use of a medicinal 
(investigational) product, whether or not related to the medicinal (investigational) product.  
The term AE is used to include both serious and non-serious AEs. 

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If an abnormal laboratory value/vital sign are associated with clinical signs and symptoms, the 
sign/symptom should be reported as an AE and the associated laboratory result/vital sign should be 
considered additional information that must be collected on the relevant CRF. 
Serious Adverse Event (SAE) 
Any untoward medical occurrence that:  
 
• 
Results in death 
• 
Is life-threatening, an AE is life threatening if the participant was at risk of death at the time of 
the event; it does not refer to an event that hypothetically might have caused death if it were 
more severe.  
• 
Requires in-participant hospitalization or prolongation of existing hospitalization. In general, 
hospitalization signifies that the participant has been detained (usually involving at least 24 h 
stay) at the hospital or emergency ward for treatment that would not have been appropriate in the 
physician's office or outparticipant setting.  
• 
Results in persistent or significant disability or incapacity. An AE is incapacitating or disabling 
if the event results in a substantial disruption of the participant's ability to carry out normal life 
functions. This definition is not intended to include experiences of relatively minor medical 
significance such as headache, nausea, vomiting, diarrhoea, influenza, injection site reactions 
and accidental trauma (e.g. sprained ankle).  
• 
Is a congenital abnormality or birth defect in the offspring of the study participant.  
• 
Is an important medical event that may jeopardize the subject or may require medical 
intervention to prevent one of the outcomes listed above. Examples of such treatments are 
intensive treatment in an emergency room or at home for allergic bronchospasm; blood 
dyscrasias or convulsions that do not result in hospitalization.  
 
Medical and scientific judgment is to be exercised in deciding on the seriousness of a case. Important 
medical events may not be immediately life-threatening or result in death or hospitalization, but may 
jeopardize the subject or may require intervention to prevent one of the listed outcomes in the 
definitions above. In such situations, or in doubtful cases, the case should be considered as serious. 
Hospitalization for administrative reason (for observation or social reasons) is allowed at the 
investigator’s discretion and will not qualify as serious unless there is an associated adverse event 
warranting hospitalization. 
Hospitalization for either elective surgery related to a pre-existing condition which did not increase in 
severity or frequency following initiation of the study, or for routine clinical procedures (including 
hospitalization for "social" reasons) are not considered as SAEs. When in doubt as to whether 
“hospitalization” occurred or was necessary, the AE will be considered serious.  
The definition of a routine clinical procedure is a procedure, which may take place during the study 
period and should not interfere with the study vaccine administration or any of the on-going protocol 
specific procedures. If anything untoward occurs during an elective procedure and satisfies any of the 
criteria for SAE, this will be documented and reported. 
Time Period for Reporting AE and SAE 
For each participant the standard time period for collecting and recording AE and SAEs will begin at 
the time of the first vaccination and will continue for at least 1 year following the last dose of study 
treatment for each participant.  
During the course of the study all AEs and SAEs will be followed up actively and passively for each 
participant; events will be followed up to resolution, unless the event is considered by the investigator to 

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be unlikely to resolve due to underlying disease. Every effort will be made to obtain a resolution for all 
events, even if the events continue after study completion. 
 
Recording of Adverse Events 
 
If the participant has experienced adverse event(s), the investigator will record the following 
information in the CRF: 
• The nature of the event(s) will be described by the investigator in precise standard medical 
terminology (i.e. not necessarily the exact words used by the participant). 
• The duration of the event will be described in terms of event onset date and event ended data. 
• The intensity of the adverse event: Mild/ Moderate / Severe; according to Common Terminology 
Criteria for Adverse Events version 4.0 (CTCAE). 
• The Investigator will assess the causality of all SAEs, using the following question: “Is there a 
reasonable possibility that the SAE may have been caused by the study vaccine?” After assessment 
of causality, the investigator will classify the SAE as defined below:  
 
Unrelated: 
There is not a temporal relationship to investigational product administration (too early, or late, or 
investigational product not taken), or there is a reasonable causal relationship between non-
investigational product, concurrent disease, or circumstance and the AE. 
[ 
Unlikely:  
There is a temporal relationship to investigational product administration, but there is not a 
reasonable causal relationship between theinvestigational product and the AE. 
 
Possible:  
There is reasonable causal relationship between the investigationalproduct and the AE. Dechallenge 
information is lacking or unclear. 
 
Probable:  
There is a reasonable causal relationship between the investigational product and the AE. The event 
responds to dechallenge. Rechallenge is not required. 
 
Definite:  
There is a reasonable causal relationship between the investigational product and the AE.  
 
• Action taken 
• The outcome of the adverse event – whether the event is resolved or still ongoing. 
If an event meets the criteria to be determined "serious" (see definition of SAE); it will be examined by 
the investigator (and DSMB) to determine all contributing factors applicable to each SAE. These 
contributing factors will be documented and reported appropriately. Every effort will be made by the 
investigator to explain each SAE and assess its causal relationship, if any, to administration of the study 
vaccine.  

27 | P a g e                     v e r s i o n :  2 . 4           D a t e :  0 7  M A Y  2 0 2 1  
 
Reporting Procedure 
AEs and SAEs 
All adverse events and serious adverse events that should be reported as above will be recorded in the 
participant’s CRF. 
All participants will be instructed to contact the investigator team immediately, should the participant 
show any signs or symptoms perceived as serious during the period extending from enrolment to the 
study end. Monitoring will be done for events requiring medical treatment or hospitalization, or deaths. 
Whenever possible, SAEs will be documented in terms of a diagnosis or syndrome rather than multiple 
symptoms that are clearly manifestations of the same diagnosis/syndrome. In case signs and symptoms 
are reported by the participant, a medical diagnosis will be obtained by the investigator. If a diagnosis 
cannot be obtained then enter each sign or symptoms as separate events. Pre-existing conditions or signs 
and/or symptoms (including any which are not recognized at study entry but are recognized during the 
study period) present in a participant prior to enrolment will be recorded in the medical history in the 
participant's CRF. SAEs that occur after participant is enrolled in the study, but prior to first 
vaccination, will be documented in the medical history and pre-existing conditions sections of the CRF, 
and may necessitate delay or cancellation of vaccination for that participant. 
SAEs in all participants will be collected through an SAE form (structured questionnaire) administered 
at scheduled study visits and by participant initiated reports between assessments. SAEs will be 
followed up to resolution, and cessation of treatment or end of study, irrespective of severity or whether 
or not they are considered vaccination-related.  
SAEs observed by the study team or reported by the participant or participant’s relatives will be 
evaluated by the investigator and recorded in the Serious Adverse Event page of the participant’s CRF. 
The diagnosis, date and time (where appropriate) of onset, outcome, severity and relationship to 
vaccination will be established. Details of any treatment given will be recorded appropriately.  
The initial SAE report will be followed by a full summary utilizing the SAE Report Form detailing 
relevant aspects of the adverse events in question. Where applicable, information from relevant hospital 
case records and autopsy reports will be obtained.  
SAEs must be reported by the investigator to the sponsor within 24 hours after the site has gained 
knowledge of the SAE. Every SAE must be documented by the investigator on the SAE pages. The 
Serious Adverse Event Report Form must be completed, signed and sent to the sponsor. The initial 
report shall promptly be followed by detailed, written reports if necessary. The initial and follow-up 
reports shall identify the trial subjects by unique code numbers assigned to the latter.  
The sponsor keeps detailed records of all SAEs reported by the investigators and performs an evaluation 
with respect to seriousness, causality and expectedness. 
Annual Safety Report 
Once a year throughout the clinical trial, the sponsor will provide the Competent Authority with an 
annual safety report. The format will comply with national requirements.  
Clinical Study Report 
The adverse events and serious adverse events occurring during the study will be discussed in the safety 
evaluation part of the Clinical Study Report. 
SAE Reporting to relevant bodies 
The Pharmacovigilance Coordinator will coordinate the safety monitoring and reporting in the study. 
The PI will report SAEs to local IRB/EC following local law and IRB/EC requirements. The PI will 
also report SAEs to the vaccine manufacturer. Adequate documentation will be provided to the Sponsor 
showing that the IRB/EC and manufacturer have been properly notified.  

28 | P a g e                     v e r s i o n :  2 . 4           D a t e :  0 7  M A Y  2 0 2 1  
 
The Pharmacovigilance Coordinator will report SAEs to DSMB, as required. A detailed description of 
DSMB functions and responsibilities and guidelines on the transmission flow of SAEs is provided in the 
DSMB charter. Notification of SAE to concerned National Regulatory Authorities will follow national 
law requirements 
Management of SAEs 
SAE will be managed in line with current Good Medical Practice. Management of any SAE will be 
recorded in the CRF. Medical assistance, consultation and follow up will be done at the Matlab 
Hospital. Participants may also be referred to the local FSC for follow up. 
Pregnancy 
To ensure participant safety and the safety of the unborn child, each pregnancy in a participant who has 
been vaccinated during the study period will be reported to the sponsor within one week of the site 
learning of its occurrence. The pregnancy will be followed to determine outcome, including 
spontaneous or voluntary termination, details of birth, and the presence or absence of any birth defect, 
congenital abnormalities, or maternal and /or newborn complications. The pregnancy follow-up will be 
done until conclusion of of the pregnancy even if the intended duration of safety follow-up for the trial 
has ended. This will be performed by the study field research assistants and female field workers.   
Data management and monitoring 
Case Report Forms (CRFs) 
The designated investigator staff will enter the data required by the protocol into the Case report forms 
(CRF) through interviewing and also reviewing medical records. The Principal Investigator is 
responsible for assuring that data entered into the CRF is complete, accurate, and that entry is performed 
in a timely manner. The signature of the investigator will attest the accuracy of the data on each CRF. If 
any assessments are omitted, the reason for such omissions will be noted on the CRFs. Corrections, with 
the reason for the corrections will also be recorded.  
Source Data 
The records for each participant should contain information which is important for the participant’s  
safety and to fulfil the requirement that critical study data should be verifiable. 
A health and demographic surveillance system has been maintained in the area for the last 50 years. Detailed 
information of all individuals are available which include sex, exact date of birth, date of marriage, 
migrations, immunization history, pregnancy outcome, date of death etc.  
Study Monitoring 
The investigator will be visited on a regular basis to check the following: 
• Informed consent process 
• Reporting of adverse events and all other safety data 
• Adherence to protocol 
• Maintenance of required regulatory documents 
• Study Supply accountability 
• Facilities and equipments  
• Data completion on the CRFs including source data verification (SDV). 
The monitor will review the relevant CRFs for accuracy and completeness and will ask the site staff to 
adjust any discrepancies as required.  

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Sponsor’s representatives (e.g. monitors, auditors) and/or competent authorities will be allowed access 
to source data for source data verification in which case a review of those parts of the hospital records 
relevant to the study may be required.  
Data and Safety Monitoring Board 
The study will be monitored by an Independent Data and Safety Monitoring Board (DSMB) constituted 
by icddr,b with input from the Ethical Review Committee (ERC). The DSMB will include 
representation outside of icddr,b. The DSMB is expected to convene once prior to the start of the study 
after ethical and regulatory approval of the study protocol. The DSMB is expected to convene meeting 
after the completion of the pretesting, at the start of the study, near the middle of the study and at study 
completion. We will present the data of pretesting phase in DSMB before further proceeding of the 
study.The committee will be responsible for the monitoring and review of the safety and conduct of the 
trial. There will be also a DSMB at the NIPH. 
 
Confidentiality 
The investigator shall arrange for the secure retention of the participant identification and the code list. 
The study documentation (CRFs, Site File etc) shall be retained and stored during the study and for 15 
years after study closure. All information concerning the study will be stored in a safe place inaccessible 
to unauthorized personnel. 
Database management 
All the data are kept in a database at icddr,b where each study participant will have an unique 
identification number. Data security procedures ensure the prevention of unauthorized access to or loss 
of participant data and storage (including timeframe) during and after the trial. The system includes 
processes to promote data quality (eg, double data entry; range check for data values).    
 
 
STUDY MANAGEMENT 
Investigator Delegation Procedure 
The icddr,b principal investigator is responsible for making and updating a “delegation of tasks” listing 
all the involved study staffs and their role in the project. He will ensure that appropriate training 
relevant to the study is given to all of these staffs, and that any new information of relevance to the 
performance of this study is forwarded to the staff involved. 
 
Protocol Adherence 
Investigators ascertain they will apply due diligence to avoid protocol deviations.  
All significant protocol deviations will be recorded and reported in the Clinical Study Report (CSR). 
 
Study Amendments 
If it is necessary for the study protocol to be amended, the amendment and/or a new version of the study 
protocol (Amended Protocol) must be notified to and approved by the Competent Authority and the 
Ethics Committee according to EU and national regulations. 
 
Audit and Inspections 
Authorized representatives of a Competent Authority and Ethics Committee may visit the centre to 
perform inspections, including source data verification. Likewise the representatives from sponsor may 
visit the center to perform an audit. The purpose of an audit or inspection is to systematically and 
independently examine all study-related activities and documents to determine whether these activities 

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were conducted, and data were recorded, analyzed, and accurately reported according to the protocol, 
Good Clinical Practice (ICH GCP), and any applicable regulatory requirements. The principal 
investigator will ensure that the inspectors and auditors will be provided with access to source 
data/documents. 
 
Ethical and regulatory requirements 
The study will be conducted in accordance with ethical principles that have their origin in the 
Declaration of Helsinki and are consistent with ICH/Good Clinical Practice and applicable regulatory 
requirements. Registration of participant data will be carried out in accordance with national personal 
data laws. 
Ethics Committee Approval 
The study protocol, including the participant information and informed consent form to be used, must 
be approved by the ethics committee in Bangladesh and Norway before enrolment of any participants 
into the study. 
The icddr,b principal investigator is responsible for informing the ethics committee of any serious and 
unexpected adverse events and/or major amendments to the protocol as per national requirements. 
 
Study registration 
The study will be registered in www.clinicaltrials.gov.  
 
Participant Identification 
The investigator is responsible for keeping a list of all participants (who have received study treatment 
or undergone any study specific procedure) including date of birth and personal number, full names and 
last known addresses.  
The participants will be identified in the CRFs by ID number. 
 
Trial sponsorship and financing 
The study is sponsored by GLOBVAC funds from the Norwegian Research Council.   
 
Trial insurance 
As a standard insurance policy of clinical trails of icddr,b.  
 
Publication policy 
Upon study completion and finalization of the study report the results of this study will be submitted for 
publication. 
The results of this study will also be submitted to the Competent Authority and the Ethics Committee 
according to national regulations. 
All personnel who have contributed significantly with the planning and performance of the study  may 
be included in the list of authors. 
 
 
Sample Size Calculation and Outcome (Primary and Secondary) Variable(s) 
Clearly mention your assumptions. List the power and precision desired. Describe the optimal conditions to attain the sample size. Justify the sample 
size that is deemed sufficient to achieve the specific aims. 
 
 
Sample size: The sample size for the study has been calculated based on the following assumptions 
(data from Matlab HDSS and HEV research studies). The goal will be to estimate total vaccine 
protection in a per protocol analysis. Women 16-39 years constitute 20% of the general population, and 
22% will be HEV seropositive at baseline (we assume that these women will be protected against HEV 

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infection); post dose 3 follow up will range from 22-28 months (average 25 months). During post dose 
3 follow up, 16% of women (followed over a mean of 16 months) will become pregnant and will reach 
term before the end of surveillance; an additional 9% of women (followed over a mean of 9 months) 
will be followed for an average of half full term (4.5 months); this predicts that 20% of the dose 3 
recipients will have "completed" pregnancies, 3806 are expected to become pregnant after dose 3 and  
3073 to be followed to term (follow up of the remaining pregnancies will be right censored by 
termination of follow up); 6% of seronegative pregnant women will become infected during pregnancy 
of which 35% of infections will be symptomatic; the protective efficacy of a 3-dose regimen of HEV 
vaccine against symptomatic infections is > 95%, p<0.05 (2 tailed); there will be 15% loss of person-
time due to migration out; 10% of women will not be included due to pregnancy at baseline, the refusal 
rate will be 5%; another 10% will not complete 3 doses for other reasons (e.g intercurrent pregnancy) 
and the design effect will be 2. To achieve 0.8 power, we will need a sample size of 20,745 women to 
be enrolled at baseline (60% are assumed to receive all 3 doses which takes into account of 10% 
baseline pregnancy, 5% refusal, 15% loss to follow up and 10% for other reasons e.g. intercurrent 
pregnancy), derived from a total population of 116,377, which can be assembled from the MCH-FP area 
population in Matlab (Labrique et al, 2010; icddr,b 2012). Although not a primary outcome, our study 
will have 90% power to evaluate >95% protective efficacy against HEV disease among non-pregnant 
women. Although the ultimate goal of any future vaccination campaign would be to prevent maternal 
and perinatal mortality, the sample size for our study will not be able to directly evaluate these 
outcomes with adequate power due to the low perinatal, maternal death ratios in Matlab. However, 
given the substantial evidence linking maternal and perinatal mortality to HEV disease in pregnancy, 
demonstration of vaccine protection against confirmed HEV disease in pregnancy will provide strong 
evidence that vaccination will likely prevent maternal and perinatal deaths. The table below shows the 
results of the sensitivity analysis of sample size with different assumptions, maintaining 0.8 power and a 
design effect of 2. 
 
 
Incidence rate of symptomatic HEV 
among pregnant women followed to 
term 
Baseline 
sero- 
positive 
Receive 3 
doses 
Loss of 
follow up 
Vaccine 
effectiveness 
Sample 
size 
0.42%
22%
90%
15%
95%
20745
0.40% 
22% 
90% 
15% 
95% 
21788 
0.42% 
27% 
90% 
15% 
95% 
22167 
0 42%
22%
85%
15%
95%
21966
0.42% 
22% 
90% 
20% 
95% 
22042 
0.42% 
22% 
90% 
15% 
90% 
23811 
 
 
Endpoints 
Primary endpoints 
Confirmed HEV disease among pregnant women 
Illness that lasted for at least 3 days; and abnormal 
of serum ALT level of ≥ 2.5 ULN; and detection of IgM anti-HEV in serum collected within 1 month 
after onset; and /or the presence of HEV RNA and/or ≥ 4 folds rise of IgG anti-HEV levels in paired 
sera. 
Total vaccine protection is defined as reduction of the incidence of HEV disease in recipients of 
complete regimens of HEV vaccine in HEV vaccine clusters relative to recipients of complete regimens 
of HBV vaccine in HBV vaccine clusters. 

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Secondary endpoints 
Endpoints- safety, immunogenicity, confirmed HEV diseases in non-pregnant women, viral load and 
subtypes/mutations, altered immune response, maternal and perinatal mortality associated with maternal 
jaundice, perceptions about vaccine acceptability. 
 
Safety:Serious Adverse Events (SAEs) will be assessed. A detailed clinical description using 
standardized forms will be provided, including symptoms, the date and time of onset, first observation, 
diagnosis, end of episode and final outcome, as recommended by the Brighton collaboration. 
 
Confirmed HEV diseases in non-pregnant women: clinical and laboratory criteria as described. 
Maternal and perinatal mortality associated with maternal jaundice as recorded in the local participant 
register.  
 
 
 
 
DATA COLLECTION, MEDICAL EXAMINATION, BIOLOGICAL SAMPLING AND 
LABORATORY ANALYSES 
 
Data collection: Health register data for study participants and their pregnancy outcome. 
 
Biological sampling: A blood sample (max 3 ml) will be collected at the inclusion and one month after 
the last vaccine dose for all participants. Blood and saliva samples will be taken for participants when 
presenting with acute hepatitis. Saliva will be collected in sterile containers in amounts of approx 2 ml 
and stored in a -20 degrees freezer. 
All cases of acute hepatitis will be investigated both clinically and by laboratory diagnostics for the 
presence of markers of viral hepatitis (A, B, C or E). The clinical symptoms and signs included and the 
laboratory analyses are described in SOP and will include diagnostics for confirmation of HEV. 
Laboratory work will be conducted both in Bangladesh and Norway. All blood samples will be 
transported to the Matlab hospital. icddr,b laboratory will perform ELISA tests for HEV and HEV PCR 
an well as other analyses. In addition biochemical parameters with possible relation to vaccine response 
or failure and HEV infection will be analysed. Samples from the acute hepatitis cases will be 
transported to the Department of Virology at NIPH for further characterisation. Thus, the samples will 
be sent abroad and will be stored for 5 years. 
During pre-testing 10 participants (among 100 participants) and during main study 50 participants 
(among 20,745 participants) will be selected randomly for blood collection (9 ml) before and 1 month 
after last vaccine dose. We need to validate DBS method with plasma samples using ELISA .We will 
compare the results and confirm that DBS method is suitable for HEV antibody testing ( IgG and IgM) 
as conducted by using direct plasma samples. During main study these results (PBMC and DBS etc) 
will also be compared with acute hepatitis cases. 
 
In this sub-study another whole blood sample (3 ml) will be collected 2 years (24 to 35 months) after the 
last dose (dose 3) for those who completed full schedule and also who received 1 or 2 doses of vaccine 
(incomplete schedule). 
 
Laboratory Methodology 
 
HEV RNA detection method: Viral RNA will be extracted using QIAamp viral RNA extraction kit 
(Qiagen, Hilden, Germany). HEV RNA will be detected using real time PCR. Negative and positive 
controls will be included in each run. For details, see the latest version of the Lab Analysis Plan.  

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Surveillance 
Two parallel surveillance for clinical hepatitis and pregnancy detection  will be conducted. All 
enrolledwomen in the study will be provided with an immunization card with identification numbers and 
with a phone number to call if they become ill with jaundice or missed periods (>2 weeks weeks from the 
expected start date) between  the weekly home visits by the study field workers. The phone number will be 
answered by a study staff member who will make household visits to screen for suspected hepatitis, 
regardless of whether or not the woman is pregnant. Jaundice is recognized by lay language as 
“Jaundeesh” in the study area. More than 80% of households have access to a cell phone. Regular SMS 
messages will be sent to remind participants to report cases of jaundice. All women whose pregnancies are 
detected through the weekly home visits by the study field workers or routine MCH-FP visits will be 
visited every 2 weeks to collect information about pregnancy outcomes and to screen for clinical hepatitis. 
Laboratory diagnosis will be undertaken in both types of surveillance for any woman with acute onset of 
jaundice of any duration or with illnesses lasting for at least 3 days with at least three of the following 
symptoms: fatigue, loss of appetite, abdominal discomfort, abdominal pain in the right upper quadrant, 
nausea or vomiting (Shrestha, 2007, Clayson 1995). Suspected cases will be referred to Matlab hospital for 
clinical and laboratory examination. Surveillance for hepatitis will continue for approximately 2 years after 
the completion of all vaccinations. 
Acute hepatitis cases with negative HEV diagnostics will be further investigated for other possible causes 
(other hepatitis such as hepatitis B). 
 
Piloting of HEV Surveillance  
 
We want to establish a surveillance system for detection of HEV disease through identifying hepatitis E 
virus (HEV) disease among patients with Hepatitis in adult female aged 16- 39 years before starting the 
main phase of the study.  
 
Vaccine immune responses 
A blood sample will be taken from all participants at baseline and one month after the last dose of the 
vaccine. Paired specimens from each individual will be tested together. Seroconversion will be determined 
using ELISA method (Zhu et al, 2010) and the rates will be compared between recipients of HEV vaccine 
and HBV vaccine. Serological immune correlates of protection will be determined by two methods: 1) 
comparing post-HEV vaccination titres in recipients of a complete regimen of HEV vaccine who develop 
HEV disease versus recipients who do not 2) the method which estimates protective level of antibodies by 
comparing the relative risk of the disease outcome using the reverse cumulative distribution curves of 
antibody responses in vaccinees and comparison group participants (Klugman 1996).  
 
Titers of serum IgG anti-HEV antibodies, as well as of different isotypes for IgG (G1-G4) of these 
antibodies will be determined (following Wantai kit guidelines, China) at the different time points 
(baseline day 0,  1 month after dose 3 and at 2 years (24 to 35 months)  after dose 3 or who received 1 
or 2 doses). 
 
Evaluation of specimen types for acute hepatitis cases 
The feasibility of using dried blood spots (DBS) for detection of HEV RNA and HEV antibodies will be 
evaluated (Lee CE eta al, 2011; Mohamed S et al, 2013) taking into account storage conditions (time 
and temperature) and sensitivity. EDTA-plasma, capillary blood on DBS and saliva samples (approx 2 
ml) from 50 participants with established active HEV infection and 50 vaccinated participants will be 
collected for this project. Standard HEV ELISA anti-HEV IgM/IgG and PCR will be optimised and 
evaluated for the different types of material using plasma samples as gold standard.  
 

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Evaluation of risk factors and the natural course of HEV disease 
A blood and stool sample will be collected form jaundiced patients. If HEV disease is confirmed by the 
presence of anti HEV IgM or HEV RNA, blood samples will be analysed for relevant biochemical, 
microbiological and immunological markers. This include viral load, HEV subtypes,other hepatitis 
infections, antibody titer, cellular response, cytokines, alanine transaminase (ALT), INR and albumin.. 
The patients symtoms and signs will be recorded regularly during the disease by health workers.  
The following possible risk factors for severity of the disease will be looked for: Occupation,  age, 
height, weight, body mass index, sanitation system, water use pattern, Anti-HEV IgG antibody level, 
immunological factors, viral load and  viral sequence. 
Pregnant women will be interviewed for other information (any complications during previous 
pregnancies, foetal loss etc.).  
 
Incidence of HEV during pregnancy: All with confirmed symptomatic and asymptomatic HEV 
disease during pregnancy, matched with possible risk factors. 
 
Mortality and morbidity of HEV disease during pregnancy: Natural course,clinical outcome and 
laboratory results of HEV disease during pregnancy will be recorded. 
 
Pregnancy outcome in HEV infected pregnant women : Data on pregnancy outcome, including 
complications during delivery and health status of mother and child, will be collected on all participants 
and analysed together with records of eventual HEV disease and type, time and number of vaccine 
doses. 
 
Economic analysis 
Cost-effectiveness analysis (CEA) and cost-benefit analyses (CBA) will be carried out for HEV vaccine 
delivery to women in this setting taking the societal perspective (Cartwright, 2005). The cost of 
vaccination will thus be estimated and compared with its outcomes in terms of health gain (DALYs 
averted/QALYs gained) and economic gain (cost-saved from the society) (Manca et al. 2015; Murray 
and Lopez, 2013). Cost of vaccination (total cost, cost per vaccinated woman, marginal cost for 
vaccination) will be calculated for applying in both CEA and CBA. Costing of any intervention is 
concerned about systematic collection of information about resources used, categorizing the resources 
and analysing their costs (Drummond et al. 2005). Ingredient and budgetary approach will be utilized 
for this costing exercise considering the program perspective. All inputs, for instance, staff time, use of 
space, medical equipment, shared administrative costs, will be identified by visiting the site, 
interviewing the relevant key personnel and reviewing the documents of the vaccination program. 
Identified inputs will then be classified into capital and recurrent items as well as into fixed and variable 
items. Annuitization of capital items (like, medical equipment, computer) will be done using the 
lifetime of such items for estimating their annual equivalent costs. In order to adjusting for the 
differential in timing of resources used, discounting rate of 3% will be applied for base analysis and 0% 
and 5% for sensitivity analysis. Cost per vaccinated will be calculated by dividing the total costs with 
the total number of vaccinated women.  
 
Feasibility and acceptability of the vaccine 
Operational feasibility of introduction of HEV vaccine will be assessed by in-dpeth interviews with 
health workers (15-20) (who will motivate women to bring to the health centre for vaccination) and 
health care providers (15-20) (providing vaccines to the study women). These interviews will help to 
identify operational barriers in motivating women for vaccination and in the storage and administration 
of vaccines. Acceptability of the vaccine will be assessed by conducting in-depth interviews with 
vaccine acceptors and non-acceptors. A total of 30-40 interviews will be conducted - half of which will 
be conducted with acceptors and the rest will be conducted with the non-acceptors.  

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Organization of the study 
Study coordination 
 
NIPH 
The team at NIPH consist of Dr. Susanne G. Dudman, Dr. Kathrine Stene-Johansen, Dr. Synne Sandbu, 
Dr. Sara V. Watle. In addition, three researchers financed by funds from the Norwegian Research 
Council will be assigned to the project; Dr. Joakim Ø verbø, Dr. Cathinka H. Julin 
and Dr. Jennifer L.Dembinski. NIPH will constitute a steering committee including representatives from 
the research partners, and will be be chaired by Specialist Director Vaccines Dr. Ingeborg AabergeMD, 
PhD of the Norwegian Institute of Public Health (NIPH).  
 
icddrb 
The team at icddr,b will be headed by Dr. Zaman supported by other investigators.  
icddr,b will implement the study in collaboration with NIPH.  
 
Sykehuset Innlandet 
Professor Tor Strand will be collaborating researcher from this site.  
 
ideSHi 
Dr. Kaise Mannor of ideSHi will be collaborating researcher from this site. 
 
Study timeline 
The overall timeline for the study and milestones are shown in table : 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Capacity building and technology transfer in Bangladesh 
An important additional component of the proposed project will be the establishment of technology 
transfer of the vaccine from Innovax to a highly qualified Bangladesh vaccine producer, Incepta, for 
production of low-cost vaccine in Bangladesh for government immunization programmes. There is 
already established contact between these two producers. Incepta will receive bulk vaccine for the trial 
from Innovax and will package both the HEV and control (hepatitis B) vaccines in identical 
presentations. The agreement on technology transfer for fill finish and production in Bangladesh is in 
process. 
Activities 
2016 
2017 
2018 
2019 
Regulatory 
approvals/site 
preparation and training  
 
 
 
 
 
 
 
 
 
 
 
 
MoU/contract 
between 
NIPH, 
icddr,b,  Innovax and Incepta 
 
 
 
 
 
 
 
 
 
 
 
 
Pretesting, Enrollment/vaccination 
of participants  
 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy 
follow 
up, 
HEV 
surveillance 
 
 
 
 
 
 
 
 
 
 
 
 
Data collection and Lab analyses 
 
 
 
 
 
 
 
 
 
 
 
 
Data analysis, dissemination, report 
and manuscript writing 
 
 
 
 
 
 
 
 
 
 
 
 

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Data Analysis 
 
Describe plans for data analysis, including stratification by sex, gender and diversity. Indicate whether data will be analysed by the investigators 
themselves or by other professionals. Specify what statistical software packages will be used and if the study is blinded, when the code will be opened. 
For clinical trials, indicate if interim data analysis will be required to determine further course of the study. 
 
Statistical methods and data analysis 
Statistical Analysis 
We will measure total vaccine protection as our primary objective in a per protocol analysis of three-
dose vaccine recipients, using analytic methods to adjust for the design effect of cluster randomization 
(Halloran, 1997; Donner 2000). In this analysis we will compare the incidence of confirmed HEV 
disease in pregnant women who have been recipients of a complete three dose regimen of HEV vaccine 
or HBV vaccine and in whom the HEV disease episode begins at least 14 days after the third dose of 
vaccine. We will attempt to assess the indirect vaccine protection (defined as protection of non-HEV 
vaccinees in HEV vaccine clusters) and overall vaccine protection (defined as protection of all members 
of HEV vaccine clusters relative to all members of HBV vaccine clusters), but are aware that our trial 
may not be adequately powered for these analyses. Adverse events, immune responses to vaccines, and 
other outcomes will employ tests appropriate for comparison of categorical and dimensional outcomes, 
adjusted for the design effect of cluster randomization. All statistical tests will be evaluated at P<0.05, 
two tailed. 
 
In one main analysis (Analysis 1), we will compare waning of serum titers of IgG anti-HEV antibodies 
elicited by the third dose of HEV, measured 2 years (24  to 35 months) later after dose 3, among those 
who are 1) HEV seronegative at baseline and  received HEV vaccine, 2) those who were HEV 
seropositive at baseline and received HEV vaccine, 3) who were HEV seropositive  at baseline and 
received HBV vaccine, 4) participants who are HEV seronegative at baseline and received HBV 
vaccine (pure control group). 
 
In a second main analysis (Analysis 2), we will also compare the decline in the attributable percentage 
of HEV seropositive (% HEV vaccinees who are IgG HEV serum antibody seropositive minus % of 
HBV vaccinees who are HEV seropositive) among those who are HEV seronegative at baseline until 
two years after the third dose.In secondary analyses we will conduct similar analyses of serum IgG 
subclass anti-HEV antibodies, as well as similar analyses among persons who only received only the 
first dose, or only the second dose of either vaccine or two doses due to receipt of incomplete vaccine 
regimens. 
 
For cost-effectiveness analysis, cost per DALY averted and QALYs gained will be compared with 
Gross-Domestic Product per capita threshold for classifying the intervention into very cost-effective, 
cost-effective and not cost-effective. The vaccination program will be very cost-effective, cost-effective 
or not cost-effective if the cost-effectiveness ratio estimate is 1, 2 and 3 times less than the GDP per 
capita of the reporting country cost-effectiveness ratio (WHO 2003).  
 
For cost-benefit analysis, the monetary benefits will be calculated by estimated costs saved 
(corresponding to cost of illness) due to HEV infection aversion through vaccination. Net benefit (total 
benefits minus total vaccination cost) and benefit-cost ratio (BCR) will be calculated, where positive 
value of net benefit and value more than 1 of BCR will indicate the acceptability of the vaccination 
against HEV.  

37 | P a g e                     v e r s i o n :  2 . 4           D a t e :  0 7  M A Y  2 0 2 1  
 
 
The cost analysis will give the opportunity for modelling the costs for scaling up the vaccination 
program on the national level.  
 
 
Data Safety Monitoring Plan (DSMP) 
All clinical investigations (research protocols testing biomedical and/or behavioural intervention(s)) should include the Data and Safety Monitoring 
Plan (DSMP). The purpose of DSMP is to provide a framework for appropriate oversight and monitoring of the conduct of clinical trials to ensure the 
safety of participants and the validity and integrity of the data. It involves involvement of all investigators in periodic assessments of data quality and 
timeliness, participant recruitment, accrual and retention, participant risk versus benefit, performance of trial sites, and other factors that can affect 
study outcome. 
 
Data Safety and Monitoring 
A Data Monitoring Board (DSMB) will be tasked with monitoring the conduct of the trial, review the 
accumulating trial data and in particular reports of SAEs (related and not related, irrespective of 
severity) and make recommendations as appropriate. The study will be discontinued according to a 
priori defined stopping rules.  
 
Ethical Assurance for Protection of Human rights 
Describe the justifications for conducting this research in human participants. If the study needs observations on sick individuals, provide sufficient 
reasons for using them. Indicate how participants’ rights will be protected, and if there would be benefit or risk to each participants of the study. 
Discuss the ethical issues related to biomedical and social research for employing special procedures, such as invasive procedures in sick children, use 
of isotopes or any other hazardous materials, or social questionnaires relating to individual privacy. Discuss procedures safeguarding participants from 
injuries resulting from study procedures and/or interventions, whether physical, financial or social in nature. [Please see Guidelines] 
 
The study will be conducted in accordance with all applicable regulatory requirements. 
The study will be conducted in accordance with the ICH Guideline for Good Clinical Practice (GCP), 
all applicable subject privacy requirements and the guiding principles of the Declaration of Helsinki. 
The study has been designed and will be conducted in accordance with the ICH Harmonized Tripartite 
Guideline for clinical investigation of medicinal products in the paediatric population (ICH E11) and all 
other applicable ethical guidelines. 
 
Conduct of the study includes, but is not limited to, the following: 
Institutional Review Board (IRB)/Independent Ethics Committee (IEC) review and approval of study 
protocol and any subsequent amendments and participants informed consent. 
 
 
Use of Animals 
Describe if and the type and species of animals to be used in the study. Justify with reasons the use of particular animal species in the research and the 
compliance of the animal ethical guidelines for conducting the proposed procedures. 
 
Not Applicable 
 
 
Collaborative Arrangements 
Describe if this study involves any scientific, administrative, fiscal, or programmatic arrangements with other national or international organizations or 
individuals. Indicate the nature and extent of collaboration and include a letter of agreement between the applicant or his/her organization and the 
collaborating organization. 
 
The Norwegian Institute of Public Health (NIPH) is a driving force in improving the health, 
quality of life and legal protection of the population. NIPH a wide range of internationally 
recognized scientific expertise reflected in participation in 26 projects in FP7 and an ERC grant in 
2013. The NIPH also collaborates with the WHO, EU, EEA, sister institutions, universities, 
organizations and health authorities in low and middle income countries on global health issues. 
The NIPH is currently involved in several vaccine-trials abroad and nationally, including Ebola 
vaccine in Guinea, meningococcal vaccine in Ethiopia and rotavirus vaccine in India and Norway. 

38 | P a g e                     v e r s i o n :  2 . 4           D a t e :  0 7  M A Y  2 0 2 1  
 
 
Incepta Pharmaceuticals- Established in 1999, one of the largest pharmaceutical industry is involved 
in producing vaccine and drugs. 
 
Xiamen University and Innovax Biotech in China developed HEV 239 (Hecolin™) vaccine. 
 
ideSHi- Optimization and validation of DBS ELISA will be performed from samples of HEV patient’s 
serum those are being collected for completion of PhD Project of Dr. Rosy Sultana, who is working at 
our collaborating institute ideSHi. These optimization and validation of the assay will be performed in 
both places and is very much needed for understanding and assay of samples of vaccine participants 
from HEV pilot project. Optimization and validation of the DBS ELISA assay will help to conduct a 
large scale study to see the vaccine efficacy and thus help to prevent maternal and perinatal mortality. 
 
Facilities Available 
Describe the availability of physical facilities at site of conduction of the study. If applicable, describe the use of Biosafety Level 2 and/or 3 laboratory 
facilities. For clinical and laboratory-based studies, indicate the provision of hospital and other types of adequate participant care and laboratory 
support services. Identify the laboratory facilities and major equipment that will be required for the study. For field studies, describe the field area 
including its size, population, and means of communications plus field management plans specifying gender considerations for community and for 
research team members. 
 
The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) has large multi-
disciplinary international and national scientific research staff. Existing field, hospital, laboratory and 
office facilities will be used for this study. icddr,b scientists have conducted a variety of vaccine studies 
(influenza, pneumococcal, cholera, Shigella, rotavirus, Polio, Japanese encephalitis  etc.). 
 
Field site 
The study will be conducted in rural Matlab. icddr,b has been maintaining a field research centre at 
Matlab for about fifty years. Due to the presence of ongoing health and demographic surveillance 
system (HDSS), clinic and laboratory facilities, effective referral systems and well-established 
infrastructure at Matlab, it offers excellent research facilities for this study. The HDSS is a regularly 
updated information system on the approximate population of 220,000.  
 
Laboratory facilities 
icddr,b and ideSHi laboratory facilities will  be used. icddr,b will provide necessary support with 
reagents for the validation of the assay at ideSHi. 
 
 
Literature Cited 
Identify all cited references to published literature in the text by number in parentheses. List all cited references sequentially as they appear in the text. 
For unpublished references, provide complete information in the text and do not include them in the list of Literature Cited. There is no page limit for 
this section, however, exercise judgment in assessing the “standard” length. 
 
Aggarwal R. Diagnosis of hepatitis E. Nat Rev Gastroenterol Hepatolog  2013; 10: 24-33. 
 
Cartwright WS. Methods for the economic evaluation of health care programmes. Oxford University 
Press. 2005;3(1):43. 
 
Clayson ET, Myint KS, Snitbhan R, Vaughn DW, Innis BL, Chan L, et al. Viremia, fecal shedding, and 
IgM and IgG responses in participants with hepatitis E. The Journal of infectious diseases. 
1995;172(4):927-33. 
 

39 | P a g e                     v e r s i o n :  2 . 4           D a t e :  0 7  M A Y  2 0 2 1  
 
Clemens JD, van Loon F, Sack DA, Chakraborty J, Rao MR, Ahmed F, et al. Field trial of oral cholera 
vaccines in Bangladesh: serum vibriocidal and antitoxic antibodies as markers of the risk of cholera. 
The Journal of infectious diseases. 1991;163(6):1235-42. 
 
Clemens JD, Brenner R, Rao M, Tafari N, Lowe C. Evaluating new vaccines for developing countries. 
Efficacy or effectiveness? The  journal of the American Medical Association. 1996;275(5):390-7. 
 
Donner A KN. Design and analysis of cluster randomization trials in health research. London: Arnold; 
2000. 
 
Drummond MF, Schulpher MJ, Torrance GW, O’Brien BJ, Stoddart GL. 2005. Methods for the 
Economic Evaluation of Health care Programmes, 3rd Edition, Oxford University Press, UK. 
 
Gurley ES, Halder AK, Streatfield PK, Sazzad HM, Huda TM, Hossain MJ, et al. Estimating the burden 
of maternal and neonatal deaths associated with jaundice in Bangladesh: possible role of hepatitis E 
infection. American journal of public health. 2012;102(12):2248-54. 
 
Halloran ME, Struchiner CJ, Longini IM, Jr. Study designs for evaluating different efficacy and 
effectiveness aspects of vaccines. American journal of epidemiology. 1997;146(10):789-803. 
 
Huang S-J, Liu X-H, Zhang J, Ng M-H. Protective immunity against HEV. Current Opinion in 
Virology. 2014;5(0):1-6. 
 
International Centre for Diarrhoeal Disease Research Bangladesh (ICDDR B. Registration of Health 
and Demographic Events. ICDDRB Sci Rep 93. Health and Demographic Surveillance System-Matlab. 
2006;37. 
 
International Centre for Diarrhoeal Disease Research Bangladesh (icddr b. Registration of Health and 
Demographic Events 2012. Scientific Report No. 124 Health and Demographic Surveillance System-
Matlab. 2014;46. 
 
Kamar N, Bendall R, Legrand-Abravanel F, Xia N-S, Ijaz S, Izopet J, et al. Hepatitis E. The Lancet. 
2012;379(9835):2477-88. 
 
Kamar N, Dalton HR, Abravanel F, Izopet J. Hepatitis e virus infection. Clinical microbiology reviews. 
2014;27(1):116-38. 
 
Klugman KP, Koornhof HJ, Robbins JB, Le Cam NN. Immunogenicity, efficacy and serological 
correlate of protection of Salmonella typhi Vi capsular polysaccharide vaccine three years after 
immunization. Vaccine. 1996;14(5):435-8. 
 
Koenig MA, Roy NC, McElrath T, Shahidullah M, Wojtyniak B. Duration of protective immunity 
conferred by maternal tetanus toxoid immunization: further evidence from Matlab, Bangladesh. 
American journal of public health. 1998;88(6):903-7. 
 
Krain LJ, Nelson KE, Labrique AB. Host immune status and response to hepatitis e virus infection. 
Clinical microbiology reviews. 2014;27(1):139-65. 
 
Labrique AB, Sikder SS, Krain LJ, West KP, Jr., Christian P, Rashid M, et al. Hepatitis E, a vaccine-
preventable cause of maternal deaths. Emerging infectious diseases. 2012;18(9):1401-4. 

40 | P a g e                     v e r s i o n :  2 . 4           D a t e :  0 7  M A Y  2 0 2 1  
 
 
Labrique AB, Zaman K, Hossain Z, Saha P, Yunus M, Hossain A, et al. Epidemiology and risk factors 
of incident hepatitis E virus infections in rural Bangladesh. American journal of epidemiology. 
2010;172(8):952-61. 
 
Lee CE,  Ponnampalavanar SS, Omar SFS, Mahadeva S, Ong LY, Adeeba Kamarulzaman A. 
Evaluation of the Dried Blood Spot (DBS) Collection Method as a Tool for Detection 
of HIV Ag/Ab, HBsAg, anti-HBs and anti-HCV in a Malaysian Tertiary Referral 
Hospital. Ann Acad Med Singapore 2011;40:448-53 
 
Mohamed S, Raimondo A, Pe´naranda G, Camus C, Ouzan D, et al. (2013) Dried Blood Spot Sampling 
for Hepatitis B Virus Serology and Molecular Testing. PLoS ONE 8(4): e61077. 
doi:10.1371/journal.pone.0061077 
 
Murray CJ, Lopez AD. Measuring the global burden of disease. The New England journal of medicine. 
2013;369(5):448-57. 
 
Patra S, Kumar A, Trivedi SS, Puri M, Sarin SK. Maternal and fetal outcomes in pregnant women with 
acute hepatitis E virus infection. Annals of internal medicine. 2007;147(1):28-33. 
 
Persson LA, Arifeen S, Ekstrom EC, Rasmussen KM, Frongillo EA, Yunus M. Effects of prenatal 
micronutrient and early food supplementation on maternal hemoglobin, birth weight, and infant 
mortality among children in Bangladesh: the MINIMat randomized trial. JAMA : the journal of the 
American Medical Association. 2012;307(19):2050-9. 
 
 
Shrestha MP, Scott RM, Joshi DM, Mammen MP, Jr., Thapa GB, Thapa N, et al. Safety and efficacy of 
a recombinant hepatitis E vaccine. The New England journal of medicine. 2007;356(9):895-903. 
 
Uddin J, Sarma H, Bari TI, Koehlmoos TP. Introduction of new vaccines: decision-making process in 
Bangladesh. Journal of health, population, and nutrition. 2013;31(2):211-7. 
 
Zaman K, Dang DA, Victor JC, Shin S, Yunus M, Dallas MJ, et al. Efficacy of pentavalent rotavirus 
vaccine against severe rotavirus gastroenteritis in infants in developing countries in Asia: a randomised, 
double-blind, placebo-controlled trial. Lancet. 2010;376 (9741):615-23. 
 
 
Zhu FC, Zhang J, Zhang XF, Zhou C, Wang ZZ, Huang SJ, et al. Efficacy and safety of a recombinant 
hepatitis E vaccine in healthy adults: a large-scale, randomised, double-blind placebo-controlled, phase 
3 trial. Lancet. 2010;376 (9744):895-902. 
 
World Health Organization (WHO). Making choices in health: WHO guide to cost-effective analysis. 
2003. 
 
Wu T, Li S-W, Zhang J, Ng M-H, Xia N-S, Zhao Q. Hepatitis E vaccine development. Human Vaccines 
& Immunotherapeutics 8:6;1-5 2012. 
 
Zhang X, Wei M, Pan H, Lin Z, Wang K, Weng Z, et al. Robust manufacturing and comprehensive 
characterization of recombinant hepatitis E virus-like particles in Hecolin((R)). Vaccine. 
2014;32(32):4039-50. 
 

41 | P a g e                     v e r s i o n :  2 . 4           D a t e :  0 7  M A Y  2 0 2 1  
 
Zhang J, Zhang X-F, Huang S-J, Wu T, Hu Y-M, Wang Z-Z, et al. Long-Term Efficacy of a Hepatitis E 
Vaccine. New England Journal of Medicine. 2015;372(10):914-22. 
 

42 | P a g e                     v e r s i o n :  2 . 4           D a t e :  0 7  M A Y  2 0 2 1  
 
 
 
 
 
Gender Framework 
 
In Relation to 
HEV: 
Are there 
sex 
differences 
in 
How do 
biological 
differences 
between 
women and 
men influence 
their : 
 
 
How do the 
different roles 
and activities of 
men and women 
affect their 
How do gender 
norms / values 
affect men and 
women’s 
How do access to, and 
control over resources 
affect men and women’s 
Vulnerability: 
 
Incidence 
Prevalence  
(male/female) 
No significant 
sex difference 
reported in 
incidence or 
prevalence of 
HEV.  
 
Severity of 
infection 
increases in 
pregnancy  
 
Nothing.  
 
Men may drink 
more 
contaminated 
food and water 
from outside of 
their 
homes/work 
place. They 
may have 
higher chance 
of infection 
Due to job 
nature men 
may be more 
exposed to 
infection and 
chance of 
developing 
diseases  
 
Health 
seeking 
behaviour 
Men may 
seek care 
from 
hospital/medi
cal 
practitioners 
while women 
mostly from 
traditional 
healers  
Nothing known 
Men may work 
outside and take 
care from health 
services   
In many cases 
men get priority 
because of 
higher status.  
Economic factors are 
responsible in seeking 
treatment. Women 
have little control over 
household income. 
They may be non-user 
of services. 
Ability to 
access health 
services 
Men have 
more access 
to health 
services 
Not applicable 
 
Routine treatment of hepatitis in 
pregnancy is hampered by the range of 
cultural, social and economic factors. 
Women more likely to use traditional 
healers 
Experience 
with health 
services and 
health 
providers 
Female 
participants 
had more 
difficulty in 
getting 
services 
Not applicable 
Women, as 
mothers, are 
the target of 
programmes to 
get children to 
health centres  
Women may 
refuse  
examination by 
male providers; 
resulting 
delayed 
diagnosis. 
Gender, a factor 
because women have 
less control over 
household income 
Preventive 
and 
Treatment 
options, 
responses to 
treatment or 
rehabilitation 
 
Hepatitis E 
Vaccine is not 
licensed in 
many 
countries 
including 
Bangladesh. 
It is an 
Non-
involvement of 
women in 
vaccine trials 
may result 
Women may 
have less in  
getting 
preventive and 
treatment  
care.   
Preventive 
programmes 
are usually 
community 
based; where 
social norms 
mean that 
women cannot 
Financial 
considerations are 
usually important  
whether a full course 
of treatment is 
completed – links to 
women’s lesser 
access to income 

43 | P a g e                     v e r s i o n :  2 . 4           D a t e :  0 7  M A Y  2 0 2 1  
 
In Relation to 
HEV: 
Are there 
sex 
differences 
in 
How do 
biological 
differences 
between 
women and 
men influence 
their : 
 
 
How do the 
different roles 
and activities of 
men and women 
affect their 
How do gender 
norms / values 
affect men and 
women’s 
How do access to, and 
control over resources 
affect men and women’s 
effective 
vaccine in  
males.    
participate;  
Outcome of 
health 
problem 
Female 
mortality due 
to Heaptitis is 
higher than 
male. Death 
from Hepatitis 
E may occur 
20-25% in 
pregnant 
women 
Poor prognosis 
during 
pregnancy 
Different 
studies have 
shown higher 
mortality 
among females 
Biologically bad 
outcomes  in 
females, may 
not be due to 
treatment 
seeking 
patterns  
Poor outcomes for 
pregnant women  
Consequence
s (economic 
& social, 
including 
attitudinal)  
Economically 
affects the 
family as 
females are 
worst sufferer 
Biologically bad 
outcome in 
females 
 
 
Poor outcomes in 
females 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

44 | P a g e                     v e r s i o n :  2 . 4           D a t e :  0 7  M A Y  2 0 2 1  
 
 
 
 
Check-List 
 
Check-list for Submission of Research Protocol 
For Consideration of the Research Review Committee (RRC) 
[Please check all appropriate boxes] 
 
 
 
 

57 | P a g e                     v e r s i o n :  2 . 3               D a t e :  4  N O V  2 0 2 0  
 
Protocol No.PR- 16014 
Version No. 2.2 
Date: 29.06.2017 
                                  
 
 
 
 
Protocol Title: An effectiveness trial (phase IV) to evaluate protection of pregnant women by Hepatitis E 
virus (HEV) vaccine in Bangladesh and risk factors for severe HEV infection.  
 
Investigator’s name: K. Zaman 
Organization: icddr,b 
 
Purpose of the research 
The purpose of the main study is to test the effectiveness of hepatitis E virus (HEV) vaccine in preventing HEV 
disease during pregnancy among women in rural Bangladesh and to determine risk factors for severe HEV 
infection. Before starting the study, a pretesting phase will be conducted to confirm the feasibility and 
safety of vaccination and test the procedures. 
 
Background  
 
Hepatitis E virus (HEV) infection is a major cause of liver inflammation worldwide and is the commonest cause 
of acute liver disease in South Asia, including Bangladesh. HEV spreads via contaminated drinking water and 
food. Pregnant women and their babies bear the greatest burden from HEV, since HEV infection causes high 
numbers of disease and death both in pregnant women and their babies. There are currently no effective medicines 
to prevent or treat HEV infection. So efforts to reduce the numbers of HEV infections in pregnancy in the South 
Asia region could have a major global impact. 
A newly developed vaccine from China (Innovax), has been shown to be safe and effective, but data showing that 
it can protect pregnant women are lacking. Bangladesh is an ideal setting to conduct this trial, because of the high 
number of HEV cases. Results from this trial will also be relevant for people living in many other countries affected 
by HEV. 
 
Why invited to participate in the study?  
  
We are inviting you  to participate in this HEV vaccine study  in order to demonstrate how well the vaccine can 
prevent HEV infection in pregnancy and in the general population .We will invite 20,745 non-pregnant women 
aged 16-39 years in the main phase. 
 
Methods and procedures  
 
Pretesting: 
 
We will do pretesting for 25 female and 25 male for HEV and HBV group respectively aged 16-39 years. They 
will receive 3 doses of HEV or HBV vaccine. We will take blood sample (maximum 3 ml) before vaccination and 
one month after the second dose of the vaccine. Among 100 participants, 10 participants will be randomely selected 
for 9 ml blood collection and a finger prick blood sample.  
 
 
Main phase: 
 
 
We will give you either HEV vaccine or Hepatitis B vaccine (HBV) vaccine which will be determined by 
lottery. 
 
You will not know which vaccine you will receive.  
 
Vaccines will be administered as a 3-dose regimen on day 0, at one month, and six months. 

58 | P a g e                     v e r s i o n :  2 . 3               D a t e :  4  N O V  2 0 2 0  
 
 
   We would also like to take finger prick blood sample (maximum 300 micro litre) before   vaccination and 
one month after   the last dose of the vaccine. Among 20,745 participants, 50 participants will be randomely 
selected for 9 ml blood collection.  
          We may take a saliva sample (approx 2 ml).  
 
After each vaccination dose, you will be observed for 30 minutes and a field worker will visit daily for 7 
consequtive days at your home enquiring about any untoward events. 
 
You will also be asked to report if you have any local reactions (i.e., erythema, swelling, induration and 
pain at the injection site), systemic reactions (i.e., nausea, malaise, myalgia, arthralgia, headache) and fever 
within 7 days after vaccination. 
 
 
You will be provided with an immunization card having study and HDSS identification numbers and with 
a phone number to call if you become ill with jaundice or similar symptoms. 
 
The phone number will be answered by our study staff member who will visit you to screen for suspected 
hepatitis.  
 
Regular SMS messages will be sent by cell phone to remind you to report about jaundice. 
 
 
We will do laboratory diagnostic tests if you have jaundice of any duration or illnesses lasting for at least 
3 days with at least three of the following symptoms: abnormal tiredness, loss of appetite, stomach 
discomfort or pain, nausea or vomiting. In such cases, you will be referred to Matlab hospital for 
examination of hepatitis, including blood and stool tests. 
 
 
Risk and benefits 
 
When we take blood, there may be mild, but short lasting pain .  The risk of infection is very small because we will 
clean skin thoroughly and use only new sterile needles. 
If you receive the HEV-vaccine, you are expected to be benefitted with protection against HEV disease, 
particularly during pregnancy. If you receive the HBV-vaccine as part of the control group, it will protect 
you and your new-borns against HBV.  
The project will give knowledge on how to reduce the burden of HEV in a highly endemic area struggling with 
diseases spread by water. The results will be especially beneficial for groups at particular risks who are eligible 
for a future HEV vaccine program. 
 
Privacy, anonymity and confidentiality 
We assure that the privacy, anonymity and confidentiality of data/information identifying you will be 
strictly maintained. We would keep all medical information, description of treatment, and results of the 
laboratory tests performed on you confidential, under lock and key. None other than the investigators of 
this research; possible study monitor; the Ethical Review Committee (ERC) of icddr,b; and any law-
enforcing agency in the event of necessity would have an access to the information. We want to inform 
you that data/samples related to the study may be sent outside the country for analysis, and preserved 
for 5 years where applicable; however, any personal identifiable information will be held and processed 
under secured conditions, with access limited to pre-identified staff of that organisation. 
 
 
Future use of information 
Information collected from this study may be used in future research. In such cases, anonymous or abstracted 
information and data may be supplied to other researchers, which should not conflict with or violate the 
maintenance of privacy, anonymity and confidentiality of information identifying you in any way. 
After we have completed the blood testing for all participants in the study, any remaining samples will be disposed 
of. 
 

59 | P a g e                     v e r s i o n :  2 . 3               D a t e :  4  N O V  2 0 2 0  
 
Right not to participate and withdraw 
Your participation in the study is voluntary, and you have the sole authority to decide for or against your 
participation. You are also able to withdraw your participation any time during the study, without stating any 
cause. Refusal to take part in or withdrawal from the study will involve no penalty or loss of care, benefits or 
attention. Even if you do not want to join this study, or if you withdraw from the study, you will still get all health 
services from Matlab Health Research Centre.  
 
Principle of compensation  
 
There are no costs to you for participating; all study procedures will be performed with no cost to you. You will 
not receive any compensation for your participation. In case of Serious Adverse Events related to the vaccine you 
will be given proper treatment and referred to hospital. If you develop fulminant hepatitis you will be referred to 
appropriate hospital for better management.All treatment cost will be covered by the study. 
 
 
Answering your questions/ Contact persons 
 
We will happily provide you further information about the study. You may communicate with the principal 
investigator of the study at the contact address given below.  
 
Principal Investigator: K. Zaman 
Tel: 880 1713047100 
 
Please contact the IRB Secretariat in case you have any questions or want to know more about your 
rights and benefits as a study participant. 
 
IRB Secretariat:   
M. A. Salam Khan 
Phone No: 9886498 or PABX 9827001-10 Extension. 3206 
 
If you agree to our proposal of enrolling you in our study, please indicate that by putting your signature or your left 
thumb impression at the specified space below 
 
 
Thank you for your cooperation 
 
_______________________________________ 
 
         ____________________ 
Signature or left thumb impression of participant 
 
 
 
Date 
 
_______________________________________ 
 
        ____________________ 
Signature of the impartial witness 
 
 
             
 
Date 
 
_______________________________________ 
 
        ___________________ 
 Signature of the PI or his representative 
 
  
 
 
Date 
 
 
 
 
Assent Form  
Pretesting (male and female) and main study for female (16 -17 years old) 
 
Protocol No.PR- 16014 
Version No. 2.2 
Date: 29.06.2017 

60 | P a g e                     v e r s i o n :  2 . 3               D a t e :  4  N O V  2 0 2 0  
 
                 
 
 
 
 
Protocol Title: An effectiveness trial (phase IV) to evaluate protection of pregnant women by Hepatitis E 
virus (HEV) vaccine in Bangladesh and risk factors for severe HEV infection   
 
Investigator’s name: K. Zaman 
Organization: icddr,b 
 
Purpose of the research 
 
The purpose of the main study is to test the effectiveness of hepatitis E virus (HEV) vaccine in preventing HEV 
disease during pregnancy among women in rural Bangladesh and to determine risk factors for severe HEV 
infection.Before starting the study, a pretesting phase will be conducted to confirm the feasibility and 
safety of vaccination and test the procedures. 
 
 
Background  
 
Hepatitis E virus (HEV) infection is a major cause of liver inflammation worldwide and is the commonest cause 
of acute liver disease in South Asia, including Bangladesh. HEV spreads via contaminated drinking water and 
food. Pregnant women and their babies bear the greatest burden from HEV, since HEV infection causes high 
numbers of disease and death both in pregnant women and their babies. There are currently no effective medicines 
to prevent or treat HEV infection. So efforts to reduce the numbers of HEV infections in pregnancy in the South 
Asia region could have a major global impact. 
A newly developed vaccine from China (Innovax), has been shown to be safe and effective, but data showing that 
it can protect pregnant women are lacking. Bangladesh is an ideal setting to conduct this trial, because of the high 
number of HEV cases. Results from this trial will also be relevant for people living in many other countries affected 
by HEV. 
   
Why invited to participate in the study?  
  
We are inviting you  to participate in this HEV vaccine study  in order to demonstrate how well the vaccine can 
prevent HEV infection in pregnancy and in the general population .We will invite 20,745 non-pregnant women 
aged 16-39 years in the main phase. 
 
Methods and procedures 
  
Pretesting: 
 
We will do pretesting for 25 female and 25 male for HEV and HBV group respectively aged 16-39 years. They 
will receive 3 doses of HEV or HBV vaccine. We will take blood sample (maximum 3 ml) before vaccination and 
one month after the second dose of the vaccine. Among 100 participants, 10 participants will be randomely selected 
for 9 ml blood collection and a finger prick blood sample.  
 
Main phase: 
 
 
We will give you either HEV vaccine or Hepatitis B vaccine (HBV) vaccine which will be determined by 
lottery. 
 
You will not know which vaccine you will receive.  
 
Vaccines will be administered as a 3-dose regimen on day 0, at one month, and six months. 
 
We would also like to take finger prick blood sample (maximum 300 micro litre) before vaccination and 
one month after the last   dose of the vaccine. Among 20,745 participants, 50 participants will be 
randomely selected for 9 ml blood collection.  

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          We may take a saliva sample (approx 2 ml).  
 
After each vaccination dose, you will be observed for 30 minutes and a field worker will visit daily for 7 
consequtive days at your home enquiring about any untoward events. 
 
You will also be asked to report if you have any local reactions (i.e., erythema, swelling, induration and 
pain at the injection site), systemic reactions (i.e., nausea, malaise, myalgia, arthralgia, headache) and fever 
within 7 days after vaccination. 
 
 
You will be provided with an immunization card having study and HDSS identification numbers and with 
a phone number to call if you become ill with jaundice or similar symptoms. 
 
The phone number will be answered by our study staff member who will visit you to screen for suspected 
hepatitis.  
 
Regular SMS messages will be sent by cell phone to remind you to report about jaundice. 
 
 
We will do laboratory diagnostic tests if you have jaundice of any duration or illnesses lasting for at least 
3 days with at least three of the following symptoms: abnormal tiredness, loss of appetite, stomach 
discomfort or pain, nausea or vomiting. In such cases, you will be referred to Matlab hospital for 
examination of hepatitis, including blood and stool tests. 
 
Risk and benefits 
 
When we take blood, there may be mild, but short lasting pain.  The risk of infection is very small because we will 
clean skin thoroughly and use only new sterile needles. 
If you receive the HEV-vaccine, you are expected to be benefitted with protection against HEV disease, 
particularly during pregnancy. If you receive the HBV-vaccine as part of the control group, it will protect 
you and your new-borns against HBV.  
The project will give knowledge on how to reduce the burden of HEV in a highly endemic area struggling with 
diseases spread by water. The results will be especially beneficial for groups at particular risks who are eligible 
for a future HEV vaccine program. 
Privacy, anonymity and confidentiality 
 
We assure that the privacy, anonymity and confidentiality of data/information identifying you will be 
strictly maintained. We would keep all medical information, description of treatment, and results of the 
laboratory tests performed on you confidential, under lock and key. None other than the investigators of 
this research; possible study monitor; the Ethical Review Committee (ERC) of icddr,b; and any law-
enforcing agency in the event of necessity would have an access to the information. We want to inform 
you that data/samples related to the study may be sent outside the country for analysis, and preserved 
for 5 years where applicable; however, any personal identifiable information will be held and processed 
under secured conditions, with access limited to pre-identified staff of that organisation. 
 
 
Future use of information 
Information collected from this study may be used in future research. In such cases, anonymous or abstracted 
information and data may be supplied to other researchers, which should not conflict with or violate the 
maintenance of privacy, anonymity and confidentiality of information identifying you in any way. 
After we have completed the blood testing for all participants in the study, any remaining samples will be disposed 
of. 
 
Right not to participate and withdraw 
Your participation in the study is voluntary, and you have the sole authority to decide for or against your 
participation. You are also able to withdraw your participation any time during the study, without stating any 
cause. Refusal to take part in or withdrawal from the study will involve no penalty or loss of care, benefits or 

62 | P a g e                     v e r s i o n :  2 . 3               D a t e :  4  N O V  2 0 2 0  
 
attention. Even if you do not want to join this study, or if you withdraw from the study, you will still get all health 
services from Matlab Health Research Centre.  
 
Principle of compensation  
 
There are no costs to you for participating; all study procedures will be performed with no cost to you. You will 
not receive any compensation for your participation In case of Serious Adverse Events related to the  vaccine you 
will be given proper treatment and referred to hospital. If you develop fulminant hepatitis you will be referred to 
appropriate hospital for better management.All treatment cost will be covered by the study. 
 
Answering your questions/ Contact persons 
 
We will happily provide you further information about the study. You may communicate with the principal 
investigator of the study at the contact address given below.  
 
Principal Investigator: K. Zaman 
Tel: 880 1713047100 
 
Please contact the IRB Secretariat in case you have any questions or want to know more about your 
rights and benefits as a study participant. 
 
IRB Secretariat:   
M. A. Salam Khan 
Phone No: 9886498 or PABX 9827001-10 Extension. 3206 
 
If you agree to our proposal of enrolling you in our study, please indicate that by putting your signature or your left 
thumb impression at the specified space below 
 
 
Thank you for your cooperation 
 
_______________________________________ 
 
         ____________________ 
Signature or left thumb impression of participant 
 
 
 
Date 
 
_______________________________________ 
 
         ____________________ 
Signature or left thumb impression of Parent                                                    Date 
 
 
  
 
 
 
 
_______________________________________ 
 
        ____________________ 
      Signature of the impartial witness 
 
             
 
Date 
 
_______________________________________ 
 
        ___________________ 
   Signature of the PI or his representative 
 
  
 
 
Date 
 
 
 

63 | P a g e                     v e r s i o n :  2 . 3               D a t e :  4  N O V  2 0 2 0  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed Consent Form  
Piloting of HEV Surveillance for female (18-39 years old) 
 
Protocol No.PR- 16014 
Version No. 2.1 
Date: 22.06.2017 
                                  
 
 
 
 
Protocol Title: An effectiveness trial (phase IV) to evaluate protection of pregnant women by Hepatitis E virus 
(HEV) vaccine in Bangladesh and risk factors for severe HEV infection.  
 
Investigator’s name: K. Zaman 
Organization: icddr,b 
 
Purpose of the research 
The purpose of this pilot surveillance is to identify hepatitis E virus (HEV) infection among patient with Hepatitis 
in adult female (18- 39 years) in rural Bangladesh and to establish a formal surveillance system for detection of 
HEV disease.   
 
Background  
 
Hepatitis E virus (HEV) infection is a major cause of liver inflammation worldwide and is the commonest cause 
of acute liver disease in South Asia, including Bangladesh. HEV spreads via contaminated drinking water and 
food. Pregnant women and their babies bear the greatest burden from HEV, since HEV infection causes high 
numbers of disease and death both in pregnant women and their babies. Bangladesh is an ideal setting to conduct 
this surveillance because of the high number of HEV cases. Results from this surveillance will help to understand 
the process of surveillance system which we will be doing in the main phase.   
 
Why invited to participate in the study?  
  
We are inviting you  to participate in this HEV surveillance as you are living in Matab HDSS area and you are 
afemale of age 18-39 years.   
 
Methods and procedures  
 
Study staff will visit your house once in every two weeks and would want to know about some 
information regarding illness as follows: 
 

64 | P a g e                     v e r s i o n :  2 . 3               D a t e :  4  N O V  2 0 2 0  
 
 Do you have Jaundice (Yellow coloration of skin or Eye)   of any duration with any of these  
following symptoms:  
1. Nausea or Vomiting  
2. Fatigue 
3. Loss of appetite  
4. Abdominal Discomfort 
5. Right upper abdominal pain  
If you have any of these above symptoms then study staff will refer you to Matlab  hospital for care 
and if needed they will collect blood and stool sample for testing to detect the  type of hepatitis and 
assess liver function status. 
 
 
 
Risk and benefits 
 
When we take blood, there may be mild, but short lasting pain at the needle site in the arm.  The risk of infection 
is very small because we will clean skin thoroughly and use only new sterile needles. 
 
 
Privacy, anonymity and confidentiality 
We assure that the privacy, anonymity and confidentiality of data/information identifying you will be 
strictly maintained.  
 
 
Answering your questions/ Contact persons 
 
We will happily provide you further information about the study. You may communicate with the principal 
investigator of the study at the contact address given below.  
 
Principal Investigator: K. Zaman 
Tel: 880 1713047100 
 
Please contact the IRB Secretariat in case you have any questions or want to know more about your 
rights and benefits as a study participant. 
 
IRB Secretariat:   
M. A. Salam Khan 
Phone No: 9886498 or PABX 9827001-10 Extension. 3206 
 
If you agree to our proposal of enrolling you in our study, please indicate that by putting your signature or your left 
thumb impression at the specified space below 
 
 
Thank you for your cooperation 
 
_______________________________________ 
 
         ____________________ 
Signature or left thumb impression of participant 
 
 
 
Date 
 
_______________________________________ 
 
        ____________________ 

65 | P a g e                     v e r s i o n :  2 . 3               D a t e :  4  N O V  2 0 2 0  
 
Signature of the impartial witness 
 
 
             
 
Date 
 
_______________________________________ 
 
        ___________________ 
 Signature of the PI or his representative 
 
  
 
 
Date 
 
 
 
 
Assent Form 
Piloting of HEV Surveillance for female (16 -17 years old) 
 
Protocol No.PR- 16014 
Version No. 2.1 
Date: 22.06.2017 
                 
 
 
 
 
Protocol Title: An effectiveness trial (phase IV) to evaluate protection of pregnant women by Hepatitis E virus 
(HEV) vaccine in Bangladesh and risk factors for severe HEV infection   
 
Investigator’s name: K. Zaman 
Organization: icddr,b 
 
Investigator’s name: K. Zaman 
Organization: icddr,b 
 
Purpose of the research 
The purpose of this pilot surveillance is to identify hepatitis E virus (HEV) infection among patient with Hepatitis 
in adult female (16- 17 years) in rural Bangladesh and to establish a formal surveillance system for detection of 
HEV disease.   
 
Background  
 
Hepatitis E virus (HEV) infection is a major cause of liver inflammation worldwide and is the commonest cause 
of acute liver disease in South Asia, including Bangladesh. HEV spreads via contaminated drinking water and 
food. Pregnant women and their babies bear the greatest burden from HEV, since HEV infection causes high 
numbers of disease and death both in pregnant women and their babies. Bangladesh is an ideal setting to conduct 
this surveillance because of the high number of HEV cases. Results from this surveillance will help to understand 
the process of surveillance system which we will be doing in the main phase.   
 
Why invited to participate in the study?  
  
We are inviting you  to participate in this HEV surveillance as you are living in Matab HDSS area and you are 
afemale of age 16-17 years.   
 
Methods and procedures  
 
Study staff will visit your house once in every two weeks and would want to know about some 
information regarding illness as follows: 
 
 Do you have Jaundice (Yellow coloration of skin or Eye)   of any duration with any of these  
following symptoms:  
6. Nausea or Vomiting  
7. Fatigue 

66 | P a g e                     v e r s i o n :  2 . 3               D a t e :  4  N O V  2 0 2 0  
 
8. Loss of appetite  
9. Abdominal Discomfort 
10. Right upper abdominal pain  
If you have any of these above symptoms then study staff will refer you to Matlab  hospital for care 
and if needed they will collect blood and stool sample for testing to detect the type of hepatitis and 
assess liver function status. 
 
Risk and benefits 
 
When we take blood, there may be mild, but short lasting pain at the needle site in the arm.  The risk of infection 
is very small because we will clean skin thoroughly and use only new sterile needles. 
 
Privacy, anonymity and confidentiality 
We assure that the privacy, anonymity and confidentiality of data/information identifying you will be 
strictly maintained.  
 
Answering your questions/ Contact persons 
 
We will happily provide you further information about the study. You may communicate with the principal 
investigator of the study at the contact address given below.  
 
Principal Investigator: K. Zaman 
Tel: 880 1713047100 
 
Please contact the IRB Secretariat in case you have any questions or want to know more about your 
rights and benefits as a study participant. 
 
IRB Secretariat:   
M. A. Salam Khan 
Phone No: 9886498 or PABX 9827001-10 Extension. 3206 
 
Thank you for your cooperation 
 
Assent of participants: 
 
I have read this consent form and/or the study staff has read the consent form to me. The study staff has informed 
me, to my understanding, about the purpose of this study and its procedures, its risk and benefits, and my rights as 
a participant in the research. 
 
_______________________________________ 
 
         ____________________ 
Signature or left thumb impression of participant 
 
 
 
Date 
 
Consent of parent / Legal Guardian: 
 
 As Parent or legal guardian , I authorize  _______________________________________( Participant’s 
name) to become a participant in this surveillance described above. 
 
_______________________________________ 
 
         ____________________ 
Signature or left thumb impression of Parent/Legal Guardian                      Date