Randomized, Placebo-Controlled, Double-Blind Study to Assess Safety, Immunogenicity, and Protective Efficacy of Radiation Attenuated Plasmodium Falciparum NF54 Sporozoites (PfSPZ Vaccine) During Malaria Transmission Season in Healthy African Adult Women of Childbearing Potential in Mali
Phase: PHASE2
Conditions: Malaria
Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)

 
 
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Randomized, Placebo-Controlled, Double-Blind Study to Assess Safety, Immunogenicity, 
and Protective Efficacy of Radiation Attenuated Plasmodium falciparum NF54 Sporozoites 
(PfSPZ Vaccine) During Malaria Transmission Season in Healthy African Adult Women of 
Childbearing Potential in Mali 
 
NIH Protocol Number: 19-I-N113 
Project Assurance: FWA #00005897 
Multi-institution: Yes 
 
FMPOS Protocol Number: No2019/52/CE/FMPOS  
Project Assurance: FWA #00001769 
 
Clinical Sponsor: 
Office of Clinical Research Policy and Regulatory Operations (OCRPRO), NIAID  
 
IND Sponsor: 
Sanaria, Inc. 
IND Sponsor’s protocol ID: MLSPZV4 
IND: BB-IND # 14826 
 
Principal Investigators: 
Halimatou Diawara, MD 
Patrick Duffy, MD 
 
Version Number: 6.1 
February 13, 2023 
 
The study is co-funded by Grand Challenges Canada and the US National Institute of Allergy and Infectious 
Diseases 
CONFIDENTIAL 

 
 
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Table of Contents 
TABLE OF CONTENTS .......................................................................................................................................... 2 
TEAM ROSTER .................................................................................................................................................... 6 
PARTICIPATING SITES ......................................................................................................................................... 8 
LIST OF ABBREVIATIONS .................................................................................................................................... 11 
PROTOCOL SUMMARY ...................................................................................................................................... 14 
PRECIS .............................................................................................................................................................. 19 
1 
BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE ...................................................................... 20 
 
THE NEED FOR A MALARIA VACCINE ........................................................................................................ 20 
 
CHALLENGES OF DEVELOPING A MALARIA VACCINE ............................................................................... 21 
 
WHOLE ORGANISM P. FALCIPARUM SPOROZOITE-BASED VACCINE ........................................................... 21 
 
THE PRODUCT PFSPZ VACCINE ................................................................................................................ 21 
 
Direct Venous Inoculation of PfSPZ Vaccine ...................................................................................... 21 
 
Previous Trials with Radiation Attenuated PfSPZ (PfSPZ Vaccine) ................................................... 22 
 
Mali (NIAID Protocol 14-I-N010) .......................................................................................................... 24 
 
Mali (NIAID Protocol 16-I-N004) .......................................................................................................... 26 
 
Mali (NIAID Protocol: 18-I-N084) ......................................................................................................... 27 
 
Tanzania, BSPZV1 + BSPZV2 ................................................................................................................. 29 
 
Germany, MAVACHE .......................................................................................................................... 29 
 
Mali (NIH Protocol 19-I-N113) ........................................................................................................... 29 
 
PREGNANCY REGISTRY IN OULESSEBOUGOU, MALI .................................................................................. 34 
2 
CLINICAL TRIAL RATIONALE ...................................................................................................................... 36 
 
RATIONALE FOR ACCELERATED PFSPZ VACCINE SCHEDULE ................................................................... 36 
 
RATIONALE FOR PFSPZ VACCINE DOSES OF 1.8X106 AND 9X105 .............................................................. 37 
 
RATIONALE TO INCLUDE WOCBP IN MALARIA CLINICAL TRIALS ........................................................... 37 
 
RATIONALE TO DEVELOP A VACCINE TO PREVENT MALARIA IN PREGNANT WOMEN ............................... 37 
 
RATIONALE FOR ASSESSING PFSPZ VACCINE IN WOCBP ........................................................................ 38 
 
RATIONALE FOR FOLLOWING WOCBP AND PREGNANT COHORT FOR ANOTHER MALARIA TRANSMISSION 
SEASON 39 
3 
STUDY OBJECTIVES ................................................................................................................................... 40 
 
PRIMARY OBJECTIVE ................................................................................................................................. 40 
 
SECONDARY OBJECTIVE ............................................................................................................................ 40 
 
EXPLORATORY OBJECTIVES ...................................................................................................................... 40 
4 
STUDY DESIGN ......................................................................................................................................... 41 
 
STUDY ARMS............................................................................................................................................. 42 
5 
STUDY ENDPOINTS ................................................................................................................................... 43 
 
PRIMARY ENDPOINTS ................................................................................................................................ 43 
 
SECONDARY ENDPOINTS ........................................................................................................................... 43 
 
EXPLORATORY ENDPOINTS ....................................................................................................................... 43 
 
SAMPLE SIZE AND ESTIMATED DURATION OF THE STUDY ........................................................................ 44 
6 
STUDY AGENTS ........................................................................................................................................ 45 

 
 
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PFSPZ VACCINE ........................................................................................................................................ 46 
 
Storage and Handling .......................................................................................................................... 46 
 
Disposition and Dispensation .............................................................................................................. 47 
 
Administration ..................................................................................................................................... 47 
 
PBS AND HSA DILUENT ........................................................................................................................... 47 
 
Storage and Handling .......................................................................................................................... 47 
 
Disposition and Dispensation .............................................................................................................. 48 
 
Administration and Dosage ................................................................................................................. 48 
 
Accountability ...................................................................................................................................... 48 
 
CONTROL PRODUCT .................................................................................................................................. 48 
 
Storage and Handling .......................................................................................................................... 48 
 
Disposition and Dispensation .............................................................................................................. 48 
 
Administration and Dosage ................................................................................................................. 48 
 
Accountability ...................................................................................................................................... 48 
 
ANTIMALARIAL DRUGS ............................................................................................................................. 48 
 
Preparation and Administration .......................................................................................................... 49 
 
Storage and Handling .......................................................................................................................... 49 
 
Return of Study Product ....................................................................................................................... 49 
 
Drugs used for Pre-emptive Treatment of Malaria .............................................................................. 49 
 
Drugs Used for Management of Symptomatic Malaria ....................................................................... 49 
 
CONTRAINDICATIONS TO VACCINATION ................................................................................................... 50 
 
Indications for Deferral of Vaccination ............................................................................................... 50 
 
PROHIBITED MEDICATIONS ....................................................................................................................... 51 
7 
STUDY POPULATION ................................................................................................................................ 52 
 
CLINICAL SITE ........................................................................................................................................... 52 
 
RECRUITMENT ........................................................................................................................................... 53 
 
INCLUSION CRITERIA ................................................................................................................................. 53 
 
RESCREENING INCLUSION CRITERIA ......................................................................................................... 53 
 
EXCLUSION CRITERIA ............................................................................................................................... 53 
 
RESCREENING EXCLUSION CRITERIA ........................................................................................................ 55 
 
JUSTIFICATION FOR THE EXCLUSION OF PREGNANT WOMEN .................................................................... 55 
 
JUSTIFICATION FOR EXCLUSION OF CHILDREN .......................................................................................... 55 
8 
SCHEDULE ................................................................................................................................................ 56 
 
SCREENING ................................................................................................................................................ 56 
 
RESCREENING ........................................................................................................................................... 57 
 
ASSIGNMENT OF GROUPS .......................................................................................................................... 57 
 
DETAILED STUDY PROCEDURES ................................................................................................................ 58 
9 
STUDY PROCEDURES/EVALUATIONS ......................................................................................................... 58 
 
PHOTOGRAPHS OF RASH OR INJECTION SITE REACTIONS .......................................................................... 58 
 
CLINICAL LABORATORY TESTING ............................................................................................................. 58 
 
ELECTROCARDIOGRAM ............................................................................................................................. 59 
 
MALARIA DIAGNOSTICS ............................................................................................................................ 59 
 
Malaria Blood Smears ......................................................................................................................... 59 
 
Malaria qPCR ...................................................................................................................................... 59 
 
Placental Malaria ................................................................................................................................ 60 
 
UNSCHEDULED BLOOD SMEAR POSITIVE VISITS ....................................................................................... 60 

 
 
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IMMUNOLOGIC LABORATORIES ................................................................................................................. 61 
 
TRANSCRIPTOMIC ANALYSIS ..................................................................................................................... 62 
 
MATERNAL AND NEONATAL CLINICAL OUTCOMES .................................................................................. 62 
10 
RESEARCH USE OF STORED HUMAN SPECIMENS ....................................................................................... 64 
11 
DATA SHARING PLAN ............................................................................................................................... 64 
12 
ASSESSMENT OF SAFETY .......................................................................................................................... 65 
 
DOCUMENTING, RECORDING, AND REPORTING ADVERSE EVENTS ............................................................ 65 
 
DEFINITIONS .............................................................................................................................................. 65 
 
INVESTIGATOR ASSESSMENT OF ADVERSE EVENTS .................................................................................. 68 
 
Severity ................................................................................................................................................ 69 
 
Causality .............................................................................................................................................. 69 
 
INVESTIGATOR REPORTING RESPONSIBILITIES TO THE SPONSOR ............................................................... 71 
 
Adverse Events ..................................................................................................................................... 71 
 
Serious Adverse Events ........................................................................................................................ 71 
 
Unanticipated Problems (UPs) ............................................................................................................ 72 
 
Pregnancy ............................................................................................................................................ 72 
 
REPORTING PROCEDURES TO NIH IRB AND FMPOS EC .......................................................................... 74 
 
Expedited Reporting to the NIH IRB and FMPOS EC ........................................................................ 74 
 
Annual Reporting to the NIH IRB and FMPOS EC ............................................................................. 74 
 
ADDITIONAL INVESTIGATOR REPORTING RESPONSIBILITIES TO THE LOCAL IRB (NIH IRB AND FMPOS 
EC) 
75 
 
REPORTING TO THE DATA AND SAFETY MONITORING BOARD .................................................................. 75 
 
FOLLOW-UP ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS .............................................................. 75 
 
SPONSOR’S REPORTING RESPONSIBILITIES ................................................................................................ 75 
 
PAUSING CRITERIA FOR THE MAIN VACCINE PHASE ................................................................................. 76 
 
PAUSING CRITERIA FOR THE PREGNANCY AND OFFSPRING FOLLOW-UP PHASE ........................................ 76 
 Reporting of Study Pausing ................................................................................................................. 77 
 Resumption of a Paused Study ............................................................................................................. 77 
 
PAUSING CRITERIA FOR A SUBJECT ........................................................................................................... 77 
 Reporting of Pausing for a Subject ...................................................................................................... 77 
 Resumption of a Paused Subject .......................................................................................................... 78 
 
DISCONTINUATION OF STUDY ................................................................................................................... 78 
 
WITHDRAWAL OF AN INDIVIDUAL SUBJECT .............................................................................................. 78 
 Replacement of Withdrawn Subjects .................................................................................................... 79 
 
UNBLINDING FOR THE STUDY .................................................................................................................... 79 
 
SAFETY OVERSIGHT .................................................................................................................................. 80 
 Sponsor Medical Monitor .................................................................................................................... 80 
 Independent Safety Monitor (ISM) in Mali .......................................................................................... 80 
 Data and Safety Monitoring Board (DSMB) ....................................................................................... 81 
13 
CLINICAL MONITORING ............................................................................................................................ 81 
 
SITE MONITORING PLAN ........................................................................................................................... 81 
14 
STATISTICAL CONSIDERATIONS ................................................................................................................ 82 
 
ENDPOINTS AND STATISTICAL METHODS .................................................................................................. 82 
 
Safety Analysis ..................................................................................................................................... 82 
 
Vaccine Efficacy Analysis .................................................................................................................... 82 

 
 
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Immunogenicity analysis ...................................................................................................................... 83 
 
Pregnancy and Neonatal Outcomes ..................................................................................................... 83 
 
SAMPLE SIZE CONSIDERATION .................................................................................................................. 84 
 
RANDOMIZATION AND BLINDING .............................................................................................................. 85 
 
INTERIM ANALYSIS ................................................................................................................................... 86 
15 
HUMAN SUBJECT PROTECTIONS AND ETHICAL OBLIGATIONS ................................................................... 86 
 
INSTITUTIONAL REVIEW BOARD ............................................................................................................... 86 
 
INFORMED CONSENT PROCESS .................................................................................................................. 86 
 
Community Permission in Mali ........................................................................................................... 87 
 
Individual Informed Consent in Mali ................................................................................................... 87 
 
SUBJECT CONFIDENTIALITY ...................................................................................................................... 88 
16 
POTENTIAL RISKS AND BENEFITS .............................................................................................................. 88 
 
VENIPUNCTURE ......................................................................................................................................... 89 
 
DVI IMMUNIZATIONS (EITHER PFSPZ VACCINE OR NORMAL SALINE) ..................................................... 89 
 
PFSPZ VACCINE ........................................................................................................................................ 89 
 
NORMAL SALINE ....................................................................................................................................... 92 
 
ANTIMALARIAL MEDICATION ................................................................................................................... 92 
 
Artemether/Lumefantrine ..................................................................................................................... 92 
 
CARDIAC ABNORMALITIES ........................................................................................................................ 93 
 
PREGNANCY .............................................................................................................................................. 93 
 
RISK TO THE COMMUNITY ......................................................................................................................... 95 
17 
COMPENSATION ...................................................................................................................................... 95 
18 
DATA HANDLING AND RECORD KEEPING .................................................................................................. 96 
 
DATA CAPTURE AND MANAGEMENT ......................................................................................................... 96 
 
TYPES OF DATA ......................................................................................................................................... 96 
 
RETENTION OF STUDY RECORDS ............................................................................................................... 96 
 
PROTOCOL AND ICF REVISIONS ................................................................................................................ 96 
19 
ROLE OF NIH INVESTIGATORS ................................................................................................................... 97 
20 
ROLE OF COLLABORATORS ....................................................................................................................... 97 
21 
APPENDICES ............................................................................................................................................. 98 
APPENDIX A: STUDY SCHEDULE ......................................................................................................................... 98 
APPENDIX B: TOXICITY TABLE .......................................................................................................................... 103 
APPENDIX C: REFERENCES ............................................................................................................................... 115 
 
 
 

 
 
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TEAM ROSTER 
University of Sciences, Techniques and Technology, Bamako (USTTB)  
Principal Investigator: 
 
Halimatou Diawara, MD, MPH  
 
Malaria Research and Training Center (MRTC) 
Faculty of Medicine, Pharmacy, and Dentistry (FMPOS),  
University of Sciences, Techniques and Technology, Bamako  
BP 1805, Point G 
Bamako, Mali 
hdiawara@icermali.org 
Phone +223-7248- 4849 
Senior Investigator: 
Alassane Dicko, MD, PhD 
Associate Investigators: 
 
Djibrilla Issiaka, MD, MPH 
Seydou Traore, MD 
Gaoussou Santara, MD 
Moussa Traore , MD,  
Mamoudou Samassekou, MD 
Oumar Mohamed Dicko, MD 
Ibrahim H. Soumbounou, MD 
Almahamoudou Mahamar, PharmD, MS 
Oumar Attaher, PharmD 
Amatigue Zeguime, PharmD 
Amagana Dolo, PharmD, PhD 
Kalifa Diarra, PharmD 
Amadou Niangaly, PharmD, PhD 
Kadidia Baba Cisse, MS 
Sidi Mohamed Niambele, PharmD 
Independent Safety 
Monitor: 
Oumar Moussokoro Traore, MD 
Reference Health Center of Commune V 

 
 
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Bamako, Mali 
+ 223 76 18 72 71 
Email: baroutraore@yahoo.fr 
National Institute of Allergy and Infectious Diseases (NIAID)  
Principal Investigator: 
Patrick Duffy, MD (D, E, F) 
Laboratory of Malaria Immunology and Vaccinology 
National Institute of Allergy and Infectious Diseases 
National Institutes of Health 
BG 29B RM 4NN06 
9000 Rockville Pike 
Bethesda, MD 20814 
Tel: 301-761-5089 
Email: patrick.duffy@nih.gov  
Associate Investigators: 
 
 
 
 
David Cook, MD (D, E, F) 
Michal Fried, PhD (E, F) 
Sara Healy MD, MPH (D, E, F) 
Aye Diallo, PA-C (D, E, F) 
Biostatistician: 
Zonghui Hu, PhD (E, F) 
NIAID/NIH/BRB 
5601 Fishers Lane, Room 4C21 
Rockville, Maryland 20852 
Collaborator: 
Blair Wylie, MD, MPH (F) 
Beth Israel Deaconess Medical Center, Harvard Medical School 
______________________________________________________________________________ 
Key Study Personnel Roles: 
A. Obtain information by intervening or interacting with living individuals for research 
purposes 
B. Obtaining identifiable private information about living individuals 

 
 
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C. Obtaining the voluntary informed consent of individuals to be subjects 
D. Makes decisions about subject eligibility 
E. Studying, interpreting, or analyzing identifiable private information or data/specimens 
for research purposes 
F. Studying, interpreting, or analyzing coded (linked) data or specimens for research 
purposes 
G. Some/all research activities performed outside of NIH 
 
PARTICIPATING SITES 
Clinical Trial Sites  
Mali, West Africa 
Ouelessebougou, Health Research Center 
Malaria Research and Training Center 
Faculty of Medicine, Pharmacy and Odonto-Stomatology 
Mali 
Study Site 
 
 
Ouelessebougou and surrounding villages, Mali 
Institutional Review Board (IRB)   
National Institutes of Health Institutional Review Board (NIH 
IRB) and Faculty of Medicine, Pharmacy and Odonto-Stomatology 
Ethics Committee (FMPOS EC) 
Clinical Laboratory:  
Malaria Research and Training Center 
DEAP Clinical Laboratory 
Faculty of Medicine, of Odonto-Stomatology Faculty of Pharmacy, 
University of Sciences, Techniques & Technologies, Bamako 
 
 
 
 
BP 1805, Point G 
 
 
 
 
Bamako, Mali 
 
Rodolphe Merieux Laboratory 
Bamako, Mali 
Additional Laboratories 
Laboratory of Malaria Immunology and Vaccinology 
National Institute of Allergy and Infectious Diseases 
National Institutes of Health 
BG 29B  
9000 Rockville Pike 
Bethesda, MD 20814, USA  
 
Malaria Research and Training Center/DEAP Immunology 
Laboratory 
Faculty of Medicine, Pharmacy and Odonto-Stomatology, 
University of Sciences, Techniques & Technologies, Bamako 
 
 
 
 
BP 1805, Point G 

 
 
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Bamako, Mali  
 
 
 
 
 
Antigen Discovery Inc. 
Irvine, CA 92618, USA 
 
Protein Potential LLC 
9800 Medical Center Drive 
Rockville, MD 20850, USA 
 
National Institute of Allergy and Infectious Diseases 
National Institutes of Health 
Vaccine Research Center (VRC) Laboratories 
40 Convent Drive 
Bethesda, MD 20892, USA 
 
Sanaria Incorporated  
9800 Medical Center Drive 
Rockville, MD 20850, USA 
 
National Institutes of Health Research Technologies Branch 
 
 
 
 
Genomic Technologies Section 
 
 
 
 
Building 50, Room 5509 
 
 
 
 
50 South Drive, MSC 8005 
 
 
 
 
Bethesda, MD 20892, USA 
 
 
 
 
 
 
 
 
 
Laboratory of Parasitic Diseases 
 
 
 
 
National Institute of Allergy and Infectious Diseases 
National Institutes of Health 
 
 
 
 
Building 4, Room B1-03 
 
 
 
 
4 Memorial Drive 
 
 
 
 
Bethesda, MD 20892, USA 
 
 
 
 
 
Center for Human Immunology, Autoimmunity, and Inflammation 
 
 
 
 
National Heart, Lung and Blood Institute (NHLBI) 
 
 
 
 
Building 10 - Magnuson CC, 7N110a 
 
 
 
 
10 Center Drive 
 
 
 
 
Bethesda, MD 20892-1655, USA 
 
 
 
 
 
University of Bamako 
 
 
 
 
Laboratory of Immunogenetics and Parasitology 
 
 
 
 
Malaria Research and Training Center 
Mahamadou Diakite, PharmD DPhil 
Bamako, Mali, West Africa 
 
 
 
 
 
Naval Medical Research Center 
 
 
 
 
502 Robert Grant Avenue 

 
 
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Silver Spring, MD 20910, USA 
 
 
 
 
 
University of Maryland 
685 W. Baltimore Street, HSF I, Rm. 480  
Baltimore, MD 21201, US 
 
 
 
 
 
 

 
 
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LIST OF ABBREVIATIONS 
ACT 
Artemisinin-based combination therapy 
AGC 
absolute granulocyte count 
AE 
adverse event/adverse experience 
AL 
artemether/lumefantrine 
ALT 
alanine aminotransferase 
ANC 
absolute neutrophil count 
ASAQ 
artesunate-amodiaquine 
BS 
blood smear 
CBC 
complete blood count 
CFR 
Code of Federal Regulations 
cGMP 
Current Good Manufacturing Practice 
CHMI 
controlled human malaria infection 
CMF 
Clinical Manufacturing Facility 
CoA 
Certificate of Analysis 
Cr 
creatinine 
CRF 
case report forms 
CSP 
circumsporozoite protein 
DNA 
Deoxyribonucleic acid 
DOT 
directly observed therapy 
DSMB 
Data Safety Monitoring Board 
DVI 
direct venous inoculation 
EC 
Ethics Committee 
ECG 
electrocardiogram 
EDTA 
ethylene diamine tetraacetic acid 
ELISA 
enzyme-linked immunosorbent assay 
FDA 
Food and Drug Administration 
FMPOS 
Faculty of Medicine, Pharmacy and Odonto-Stomatology, Bamako, Mali 
GCP 
good clinical practice 
GMP 
good manufacturing practice 
HELLP 
Hemolysis, elevated liver enzymes, low platelets 
HIV 
human immunodeficiency virus 
HRPP 
Human Research Protection Program 
HSA 
human serum albumin 
IATA 
International Air Transport Association 
IB 
Investigator’s Brochure 
ICF 
informed consent form 
ICH 
International Conference on Harmonization 
ICS  
Intracellular cytokine staining 

 
 
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ID 
Intradermal administration 
IFA 
immunofluorescence assay 
IND 
Investigational New Drug Application 
IPTp 
intermittent preventive treatment during pregnancy 
IRB 
Institutional Review Board 
IRS  
Indoor residual spraying 
ISI 
Inhibition of sporozoite invasion assay 
ISM 
Independent Safety Monitor 
ITN 
insecticide-treated bed net 
ITT 
intention to treat 
IV 
intravenous 
LBW 
Low birth weight 
LMIV 
Laboratory of Malaria Immunology and Vaccinology 
LNVP 
liquid nitrogen vapor phase 
MLE 
Maximum likelihood estimation 
MRTC 
Malaria Research and Training Center 
NASBA 
Nucleic acid sequence-based amplification 
NIAID 
National Institute of Allergy and Infectious Diseases  
NIH 
National Institutes of Health 
NOCI 
New Onset of Chronic Illness 
OCRPRO 
Office of Clinical Research Policy and Regulatory Operations 
OHRP 
Office for Human Research Protections 
PBS 
phosphate buffered saline 
PCR 
Polymerase Chain Reaction 
Pf 
Plasmodium falciparum 
PfCSP 
Plasmodium falciparum circumsporozoite protein 
PfSPZ 
Plasmodium falciparum sporozoites 
PfSPZ 
Challenge  
viable Plasmodium falciparum sporozoites produced by Sanaria, Inc. 
PfSPZ Vaccine  radiation attenuated Plasmodium falciparum sporozoites produced by Sanaria, 
Inc. 
PI 
Principal Investigator 
PM 
placental malaria 
qPCR 
quantitative polymerase chain reaction 
QTc 
QT (corrected) interval 
RDT 
rapid diagnostic test 
RNA 
Ribonucleic acid 
SAE 
serious adverse event 
SAR 
suspected adverse reaction 
SC 
Subcutaneous 

 
 
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SMC 
Seasonal malaria chemoprophylaxis 
SNP 
single-nucleotide polymorphism  
SOP 
standard operating procedure 
SPZ 
Sporozoites 
SUSAR 
Serious and Unexpected Suspected Adverse Reaction 
UP 
unanticipated problem 
UPnonAE 
unanticipated problem that is not an adverse event 
USD 
US dollar ($) 
VE 
vaccine efficacy 
VRC 
Vaccine Research Center 
WBC 
white blood cells 
WHO 
World Health Organization 
WOCBP 
Women of child bearing potential 
WRAIR 
Walter Reed Army Institute of Research 
 
 
 

 
 
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PROTOCOL SUMMARY 
 
Full Title: 
Randomized, Placebo-Controlled, Double-Blind Study to Assess 
Safety, Immunogenicity, and Protective Efficacy of Radiation 
Attenuated Plasmodium falciparum NF54 Sporozoites (PfSPZ 
Vaccine) During Malaria Transmission Season in Healthy African 
Adult Women of Childbearing Potential in Mali 
Short Title: 
PfSPZ Vaccine in WOCBP  
Clinical Phase: 
Phase 2 
IND Sponsor: 
 
Sanaria, Inc. 
Clinical Sponsor:  
Office of Clinical Research Policy and Regulatory Operations 
(OCRPRO), NIAID 
Conducted by: 
Malaria Research and Training Center (MRTC), in collaboration 
with the Laboratory of Malaria Immunology and Vaccinology 
(LMIV) 
Principal Investigators:  
Halimatou Diawara, MD, MPH (MRTC) 
Patrick Duffy, MD (National Institute of Allergy and Infectious 
Diseases [NIAID] / National Institutes of Health [NIH]/LMIV) 
Vaccine Sample Size: 
N=300 
Offspring Sample Size: 
N~300 
Accrual Ceiling: 
 
N=900 (WOCBP + offspring) 
Study Population: 
 
Healthy women of child bearing potential (18 to 38 years of age), 
with planned follow-up post vaccination in future pregnant women 
+ offspring, residents in Ouelessebougou and surrounding villages, 
Mali  
Accrual Period: 
 
Approximately May 2019 to August 2020 
 
 
Re- enrollment: June 2022 to August 2022 
 
Study Design: 
 
A randomized double blind, placebo-controlled study to assess the 
safety, tolerability, immunogenicity, and protective efficacy of 1, 
8, 29-day PfSPZ Vaccine regimen given at a dose of 9 x105 PfSPZ 
Vaccine or 1.8x106 PfSPZ Vaccine or placebo in healthy women 
of child bearing potential, who are on pregnancy prevention during 
vaccination, but report plans to become pregnant in the near future.  
 
 
 
Participants will be randomized into three arms. 
  
 
 
 
 
 
Arm 1: (n= 100) will receive 3 doses of PfSPZ Vaccine (9 x105) 
via direct venous inoculation (DVI) at 1, 8, 29 days.  

 
 
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Arm 2: (n= 100) will receive 3 doses of PfSPZ Vaccine (1.8 x106) 
via DVI at 1, 8, 29 days. 
  
 
 
Arm 3: (n=100): will receive 3 doses of normal saline (placebo) 
injection via DVI at 1, 8, 29 days. 
 
 
 
All volunteers will receive antimalarial treatment with 
artemether/lumefantrine (AL) ~2 weeks prior to 1st (study day -14) 
and 3rd injection (study day 15). 
 
 
 
Participants will be monitored for safety, tolerability, 
immunogenicity, and malaria infection during the follow-up 
period.  
 
 
 
Participants will also be monitored closely for pregnancy as well 
post 3rd injection and followed during the course of their pregnancy 
and for 1 year post delivery during Year 1 (as well as their 
offspring if pregnancy occurs during Year 1) for safety and malaria 
infection. 
 
 
 
Women who become pregnant during Year 2 of follow-up will be 
followed during the course of their pregnancy and for ~2 months 
post-delivery or until the end of the study, whichever is longer. For 
pregnancies detected in Year 2, subsequent offspring will not be 
followed beyond delivery. 
 
 
 
Women were followed for an additional year in 2020-2021 (no 
additional product administration) and given continued protective 
efficacy seen during Malaria Season Year 2, women (pregnant or 
non-pregnant) who have received at least two vaccinations are 
being asked to come back to be followed for a 24-week period 
during the 2022-2023 Malaria Season. No product (AL nor PfSPZ 
Vaccine nor Normal Saline) will be administered.  
Study Duration: 
 
Start Date: Approximately May 2019  
Primary End Date: Approximately March 2021 (if not pregnant during the course of the study) 
 
 
Primary End Date: Approximately May 2022 (if WOCBP becomes 
pregnant during the course of the study) 
 
 
Extension End Date: Approximately December 2022 to February 
2023 
Study Agent Description: 
Radiation attenuated, aseptic, purified, vialed, cryopreserved, 
NF54 Plasmodium falciparum sporozoites (referred to as PfSPZ 
Vaccine) produced by Sanaria Inc. will be administered via DVI at 
two doses (9 x105 and 1.8 x106) at 1, 8, 29 days 

 
 
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Normal saline administered via DVI at 1, 8, 29 days.  
Primary Objective:  
 
Safety: 
• Assess safety and tolerability of PfSPZ Vaccine primary 
series in healthy Malian WOCBP when given at 1, 8, 29 
days at two doses (9 x105and 1.8 x106). 
Secondary Objectives: 
 
 
 
Protective Efficacy: 
• Assess the efficacy of PfSPZ Vaccine primary series in 
healthy Malian WOCBP when given at 1, 8, 29 days at two 
doses (9 x105and 1.8 x106).  
Exploratory Objectives: 
  
 
Protective Efficacy: 
• Explore the impact of PfSPZ Vaccine on additional malaria 
infection endpoints. 
 
• Assess the efficacy of PfSPZ Vaccine primary series in 
healthy Malian WOCBP when given at 1, 8, 29 days at two 
doses (9 x105and 1.8 x106) for a second malaria 
transmission season 
• Assess the efficacy of PfSPZ Vaccine primary series in 
healthy Malian WOCBP when given at 1, 8, 29 days at two 
doses (9 x105and 1.8 x106) for another malaria transmission 
season (durability) 
 
Immunogenicity:  
• Characterize and compare host immune responses to 
malarial antigens, and host proteomic profiles and 
transcriptomes in African WOCBP prior to and after 
vaccination with PfSPZ Vaccine and between uninfected 
and infected subjects. 
 
• Explore the impact of PfSPZ Vaccine on the genotype and 
transcriptome profile of parasites isolated from study 
subjects.  
 
 
 
Pregnant Women and Neonates 
 
 
Safety: 
• Assess maternal and neonatal outcomes post receipt of 
PfSPZ Vaccine primary series  
 
 
Protective Efficacy: 

 
 
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• Explore the PfSPZ Vaccine protective efficacy and 
durability of protection in pregnant women.  
• Explore the PfSPZ Vaccine protective efficacy and 
durability of protection in neonates/infants born to PfSPZ 
vaccinated mothers. 
Primary Endpoints:  
 
 
 
Safety: 
• Incidence of local and systemic adverse events (AEs) 
graded by severity occurring within 7 days after each 
vaccine administration.  
Secondary Endpoints:  
 
 
 
Protective Efficacy: 
• P. falciparum blood stage infection defined as time to first 
positive blood smear (detection of at least 2 P. falciparum 
parasites by microscopic examination of 0.5 µL) starting 
immediately following 3rd injection over 24 weeks. 
 
Exploratory Endpoints: 
 
Protective Efficacy: 
• Measurement and comparison of various malaria infection 
endpoints, such as PCR, gametocytemia, non-falciparum 
parasitemia, symptomatic malaria 
• P. falciparum blood stage infection defined as time to first 
positive blood smear (detection of at least 2 P. falciparum 
parasites by microscopic examination of 0.5 µL) starting 
approximately 1 year post receipt of 3rd injection for 24 
weeks. 
• P. falciparum blood stage infection defined as time to first 
positive blood smear (detection of at least 2 P. falciparum 
parasites by microscopic examination of 0.5 µL) starting 
approximately 3 years’ post receipt of last injection for 24 
weeks. 
 
Immunogenicity  
• Measurement and comparison of various immunological 
parameters: 
    
 - in the same subject prior to and after vaccination 
- between parasitemic and aparasitemic subjects 
Determination of the genotype of parasites isolated from 
study subjects, using microsatellite typing, sequencing, 
and/or single-nucleotide polymorphism (SNP) chip assays. 
 

 
 
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Pregnant Women and Neonates 
 
 
Safety: 
• Incidence of maternal obstetric outcomes 
(miscarriage/stillbirth, intrauterine growth restriction, 
hypertensive diseases in pregnancy, preterm delivery) and 
neonatal outcomes (neonatal death, low birth weight, small 
for gestational age, major malformations, and 
microcephaly) 
 
 
Protective Efficacy: 
• P. falciparum blood stage infection defined as time to first 
positive blood smear (detection of at least 2 P. falciparum 
parasites by microscopic examination of 0.5 µL) during the 
pregnancy, during infancy, and starting immediately 
following 3rd injection 
• P. falciparum placental infection defined as any positive 
placental blood smear for P. falciparum.  
 
 

 
 
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PRECIS 
Pregnant women are highly susceptible to Plasmodium falciparum malaria, leading to substantial 
maternal, perinatal, and infant mortality. While malaria vaccine development has made 
significant progress in recent years, no trials of malaria vaccines have ever been conducted in 
only women of child bearing potential (WOCBP) or in pregnant women.  
PfSPZ Vaccine (Sanaria, Inc) is an advanced malaria candidate being developed for use in 
pregnant women, owing in part to its highly favorable safety profile. The vaccine is comprised of 
aseptic, metabolically active, non-replicating, purified, cryopreserved P. falciparum sporozoites. 
In multiple double-blind, placebo-controlled trials, there have been no differences in adverse 
events between vaccinees versus controls. PfSPZ Vaccine induces immune responses to the 
sporozoite and liver stages of parasite development in the human host and prevents progression 
to blood stage parasitemia as well as averting disease sequelae; a compelling rationale to test 
PfSPZ Vaccine for its benefits in this proposed population.  
Sanaria has already achieved vaccine efficacy against homologous and heterogenous parasite 
populations in endemic areas following three doses of PfSPZ Vaccine in several studies with 
9.0x105 and 1.8x106 PfSPZ Vaccine and has explored accelerated regimens, such as 1, 8, 29 
days. Accelerated PfSPZ Vaccine regimens such as this could induce protection earlier in 
pregnancy, minimizing the period at risk and improving pregnancy outcomes over the control 
group.  
Given this, the Malaria Research and Training Center, the Laboratory of Malaria Immunology 
and Vaccinology National Institute of Allergy and Infectious Diseases, and Sanaria, Inc. propose 
to initiate testing of the day 1, 8, and 29 dosing regimen of PfSPZ Vaccine in WOCBP, and in 
subsequent studies, in pregnant women, using doses of 9.0x105 and 1.8x106 PfSPZ Vaccine. This 
will be the first step in a clinical development plan for PfSPZ Vaccine in WOCBP and pregnant 
women: 1) safety and efficacy studies in non-pregnant WOCBP (this trial), 2) studies of the 
safety and efficacy of a primary immunization series in all trimesters, and 3) studies to evaluate 
the safety and efficacy of boosting during pregnancy. 
A pregnancy registry study (#17-I-N018) has been ongoing in Mali since 2017 to gain 
background data on maternal/fetal outcomes in the target population in anticipation of this study. 
Women who become pregnant during the course of this study, and their offspring, will be 
followed for maternal clinical outcomes and malaria infection.  
 

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

 
 
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  Challenges of Developing a Malaria Vaccine 
Designing a malaria vaccine is not straightforward (M. Walther, 2006). In contrast to most 
infectious diseases, natural sterile immunity to P. falciparum has not been demonstrated. Nature 
does not provide a clear template for protective immune mechanisms that a vaccine could mimic. 
The inability to completely clear parasitemia or to prevent re-infection may be the result of an 
array of sophisticated immune evasion strategies used by the parasite, such as clonal antigenic 
variation, antigenic diversity, and impairment of dendritic cell maturation by parasitized red 
blood cells (Casares & Richie, 2009; Chen et al., 1998; Plebanski et al., 1999; Urban et al., 
1999). A prospective vaccine will have to overcome all of these. 
  Whole Organism P. falciparum Sporozoite-based Vaccine 
Hopes that sterile protection against malaria infection can be induced by a whole organism 
vaccine stem from studies demonstrating that immunization by bites of mosquitoes with 
radiation-attenuated (>120 Gray units) Plasmodium falciparum sporozoites (PfSPZ) in their 
salivary glands can induce full protection of considerable longevity in mice and humans lasting 
for up to 10 months, with some evidence of strain-transcending protection (Clyde, 1990; Clyde, 
McCarthy, Miller, & Hornick, 1973; Hoffman et al., 2002; Nussenzweig, Vanderberg, Most, & 
Orton, 1967; Rieckmann, Carson, Beaudoin, Cassells, & Sell, 1974). Irradiation of infectious 
mosquitoes disrupts the gene expression of sporozoites, which remain capable of hepatocyte 
invasion but are no longer able to complete liver-stage maturation or progress to the pathogenic 
blood stage (Mellouk, Lunel, Sedegah, Beaudoin, & Druilhe, 1990). Infection of human subjects 
with irradiated sporozoites thus exposes them to liver-stage antigens and generates pre-
erythrocytic immunity. However, the requirement of a minimum of 1,000 bites by irradiated 
mosquitoes during five or more immunization sessions in order to successfully induce sterile 
immunity in humans precludes this method for routine immunization (Hoffman et al., 2002). 
  The Product PfSPZ Vaccine 
Over the last decade, Sanaria Inc. (Rockville, MD) has developed a novel manufacturing process 
for obtaining aseptic, purified, cryopreserved sporozoites from the NF54 isolate of P. falciparum. 
PfSPZ are produced by raising adult A. stephensi mosquitoes aseptically and having them feed 
on blood cultures containing aseptic P. falciparum gametocytes. Within P. falciparum -infected 
mosquitoes, these P. falciparum gametocytes develop into sporozoites. To prepare radiation-
attenuated PfSPZ, mosquitoes are irradiated at this stage. This product is named ‘PfSPZ 
Vaccine’ (Epstein et al., 2011; Hoffman et al., 2010). The salivary glands are subsequently 
removed by dissection to release the sporozoites. The sporozoites undergo purification steps, are 
counted, and cryopreserved at a specified concentration. This process is in compliance with 
cGMPs and regulatory requirements for production of high-quality PfSPZ (for more detailed 
information, see Section 6.1 of this protocol). 
 Direct Venous Inoculation of PfSPZ Vaccine 
Several animal studies indicate that the immunogenicity and protective efficacy of radiation-
attenuated PfSPZ depends to a large extent on the amount of sporozoites reaching the liver which 
can be influenced by the route of immunization. Compared to subcutaneous (SC) or intradermal 

 
 
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(ID) administration, intravenous (IV) immunization using PfSPZ Vaccine induced a significantly 
higher frequency of PfSPZ-specific CD8+ IFN-γ producing T cells in the liver (demonstrated in 
nonhuman primates and mice), and conferred protection (tested in mice) (Epstein et al., 2011). 
Further, protection in IV-vaccinated mice was associated with a 30-fold higher parasite liver load 
compared to the ID regimen, indicating a high number of sporozoites reaching the liver is a 
prerequisite for the development of protective immune responses, and that this can be achieved 
more easily with IV administration of sporozoites (Nganou-Makamdop et al., 2012; Ploemen et 
al., 2013). 
 Previous Trials with Radiation Attenuated PfSPZ (PfSPZ Vaccine) 
Multiple trials in US and African adults (as summarized in Table 1) have been completed to date 
with reassuring safety results at different PfSPZ vaccine doses (up to 2.7x106 PfSPZ) and dosing 
regimens. Promising protective efficacy results have also been seen, in particular with an 
accelerated 1, 8, 29 day regimen as proposed for our study in WOCBP. 
Table 1: Chronological Listing of Trials of PfSPZ Vaccine 
Study Identifier 
(Clinicaltrials.gov) 
Start Date 
Study Design Summary 
PfSPZ Vaccination Schedules Evaluated (Dose, Route, 
Number of administrations) 
Vaccine groups 
and Numbers of 
Volunteers 
1. NMRC/UMB CVD 
(NCT01001650) 
May 2009 (completed) 
Phase 1, open-label, dose-escalation 
with CHMI in USA (ID, SC only)  
7.5x103 SC x 4; 7.5x103 ID x 4; 
3x104 SC x 4; 3x104 ID x 4; 
1.35x105 SC x 4 or 6; 1.35x105 ID x 4 or 6 
Malaria-naïve 
adults: 80 
2. VRC 312 
(NCT01441167) 
Oct 2011 (completed) 
Phase 1, open-label, dose-escalation 
with CHMI in USA (IV only) 
2x103 IV x 2; 7.5x103 IV x 4 or 6; 
3x105 IV x 4 or 6; 1.35x105 IV x 4 or 5 
Malaria-naïve 
adults: 40 
3. VRC 314 
(NCT02015091) 
Dec 2013 (completed) 
Phase 1, open-label, dose-escalation, 
regimen comparison with CHMI in USA 
(IV or IM) 
2.2x106 IM x 4; 
1.35x105 IV x 4 + 4.5x105 IV boost; 
2.7x105 IV x 3 or 4; 
2.7x105 IV x 2 + 4.5x105 IV x 2; 
9x105 IV x 3 
Malaria-naïve 
adults: 93 
Administration in all following trials by DVI only 
4. Mali 1  
(NCT01988636) 
Jan 2014 (completed) 
Phase 1, randomized, double-blind 
placebo-controlled* field efficacy in 
Mali 
1.35x105 + 2.7x105; 
2.7x105 x 5 
Malaria-exposed 
adults: 58 
 
5. BSPZV1  
(NCT02132299) 
May 2014 (completed) 
Phase 1, randomized, double- blind 
placebo-controlled* with CHMI (by 
needle and syringe) in Tanzania 
3x104; then 1.35x105; then 2.7x105 
1.35x105 x 5; 
2.7x105 x 5 
Malaria-exposed 
adults: 49 
 

 
 
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Study Identifier 
(Clinicaltrials.gov) 
Start Date 
Study Design Summary 
PfSPZ Vaccination Schedules Evaluated (Dose, Route, 
Number of administrations) 
Vaccine groups 
and Numbers of 
Volunteers 
6. WRAIR 2080 
(NCT02215707) 
Jun 2014 (completed) 
Phase 1, open-label, regimen 
comparison with CHMI in USA 
2.7x105 x 5; 
4.5x105 x 3 
 
Malaria-naïve 
adults: 45 
7. EGSPZV1  
(NCT02418962) 
Mar 2015 (completed) 
Phase 1, open-label, dose-escalation in 
Equatorial Guinea 
1.35x105; then 2.7x105 
2.7x105 x 3 
Malaria-exposed 
adults: 23 
8. BSPZV2 
(NCT02613520)  
Dec 2015 (completed) 
Phase 1 dose escalation, double-blind, 
randomized, placebo-controlled* with 
CHMI (by needle and syringe) in 
Tanzania 
Adults, older children: 9x105 x 3; then 1.8x106 x 3 
Younger children, infants: 4.5 x 105 x 3; then 9x106 x 3 
Malaria-exposed 
adults: 12 
children: 36 
infants: 15 
9. Mali 2 
(NCT02627456) 
Jan 2016 (completed) 
Phase 1 dose escalation with CHMI 
followed by Phase 2 randomized, 
double-blind, placebo-controlled* 
field efficacy in Mali 
Ph 1: 4.5x105 x 1; then 9x105 x 1; then 1.8x106 x 3 
Ph 2: 1.8x106 x 3 
Malaria-exposed 
adults: 100 
10. Burkina Faso 1 
(NCT02663700)  
Apr 2016 (completed) 
Phase 1 dose escalation followed by 
Phase 2, randomized, double-blind 
placebo-controlled* field efficacy in 
Burkina Faso 
Ph 1: 4.5x105 x 2; then 9x105 x 2; then 1.8x106 x 2; then 
2.7x106 x 2 
Ph 2: 2.7x106 x 3 
Malaria-exposed 
adults: 32 
11. Warfighter 2 
(NCT02601716)  
Apr 2016 (completed) 
Phase 2, open-label, regimen 
comparison with CHMI in USA 
4.5x105 x 5 (Days 1, 3, 5, 7 and week 16); or 9x105 x 3 
(Weeks 1, 9, 17); or 
1.8x106 x 3 (Weeks 1, 9, 17); or 2.7x106 x 1 + 9x105 x 2 
(Weeks 1, 9, 17) 
Malaria-naive 
adults: 60 
12. KSZPV1 
(NCT02687373)  
Jul 2016 (completed) 
Phase 1 dose escalation followed by 
Phase 2 double-blind, randomized, 
placebo-controlled* with field efficacy 
in Kenya 
Ph 1 - Older children: 4.5x105 x 1; then 9x105 x 2; then 
1.8x106 x 2 
Ph 1 - Younger children, infants: 1.35x105 x 1; then 
2.7x105 x 1; then 4.5x105 x 1; then 9x105 x 2; then 1.8x106 
x 2, all 
Ph 2 - Infants:  4.5x105, 9x105, or 1.8x106, all x 3 
Malaria-exposed 
children: 64 
infants: 352 
13. MAVACHE 
(NCT02704533)  
Sep 2016 (completed)  
Phase 1 dose escalation, regimen-
condensation and dose number 
reduction with CHMI in Germany 
9x105 x 3 (Days 1, 8, 29); then 1.8x106 x 2 (Days 1, 8); then 
2.7x106 x 2 (Days 1, 8) 
Malaria-naive 
adults: 42 
14. EGSPZV2 
(NCT02859350)  
Nov 2016 (completed)  
Phase 1 dose escalation, randomized 
double-blind, placebo-controlled* 
with head-to-head PfSPZ Vaccine and 
PfSPZ-CVac comparison in Equatorial 
Guinea 
Adults (PfSPZ Vaccine): 2.7x106 x 3 
Adults (PfSPZ-CVac): 1x105 x 3 
Children, infants (PfSPZ Vaccine): 1.8x106 x 3 
Malaria-exposed 
adults: 52** 
children: 36 
infants: 15 

 
 
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Study Identifier 
(Clinicaltrials.gov) 
Start Date 
Study Design Summary 
PfSPZ Vaccination Schedules Evaluated (Dose, Route, 
Number of administrations) 
Vaccine groups 
and Numbers of 
Volunteers 
15. BSPZV3a 
(NCT03420053) 
(completed) 
Phase 1 dose escalation, randomized 
double-blind, placebo-controlled* 
with CHMI in Tanzania 
4.5x105 x 5 (Days 1, 3, 5, 7 and 29); or 9x105 x 5 (Days 1, 3, 
5, 7 and 29) 
Malaria-exposed 
HIV- and HIV+ 
adults: 21 
16. MSPZV3 
(NCT03510481) 
(ongoing) 
Phase 2 double-blind, randomized, 
placebo-controlled* with field efficacy 
in Mali 
9x105 x 3 (Days 1, 8 and 29); or 9x105 x 3 (Weeks 1, 9, 17) Malaria-exposed 
adults: 210 
17. LaSPZV1 
(NCT03521973) 
(ongoing) 
Phase 2 double-blind, randomized, 
placebo-controlled* with field efficacy 
in Gabon 
9x105 x 3 (Days 1, 8 and 29) 
Malaria-exposed 
children: 200 
18. EGSPZV3 
(NCT03590340) 
(ongoing) 
Phase 1 double-blind, randomized, 
placebo-controlled* with CHMI in 
Equatorial Guinea 
9x105 x 3 (Days 1, 8 and 29); or 9x105 x 5 (Days 1, 3, 5, 7 
and 29); or 9x105 x 5 (Days 1, 3, 5, 7 and Week 17); or 
9x105 x 4 (Days 1, 3, 5, 7) 
Malaria-exposed 
adults: 104 
*The placebo control used in all trials is normal saline; ** 20/52 adult volunteers in EGSPZV2 received PfSPZ-CVac. 
 In these trials, dosing schedules have evaluated various intervals between vaccinations ranging from 4 to 16 weeks.   
 
 Mali (NIAID Protocol 14-I-N010) 
The first, randomized, double-blind, placebo-controlled trial testing vaccine efficacy (VE) 
against naturally transmitted malaria was conducted in Mali (#4 in Table 1) by the NIAID 
Laboratory of Malaria Immunology and Vaccinology [LMIV] and the Malaria Research and 
Training Center, University of Bamako [MRTC]). Healthy Malian adults aged 18 to 35 were 
immunized with five doses of 2.7×105 PfSPZ (total of 13.5×105 PfSPZ) or normal saline 
(placebo) in 2014 (Sissoko et al., 2017). Vaccinations were well-tlerated overall with no serious 
adverse events (SAEs) reported and most study subjects reporting no local or systemic 
reactogenicity following vaccination. The most commonly reported solicited systemic adverse 
event (AE) in both the PfSPZ Vaccine group and the placebo group was headache, followed by 
fatigue, fever, and myalgia. No significant differences in local or systemic reactogenicity 
between PfSPZ Vaccine and placebo recipients were noted (Sissoko et al., 2017). 
 
P. falciparum infections as recorded starting 28 days post vaccination 5 occurred significantly 
earlier in the control group than the PfSPZ Vaccine group; interval censored log-rank p= 0.01 
(VE based on Cox HR, 48.27% 95% CI (14.45, 68.72)). The proportion of individuals with any 
infection as recorded starting 28 days post vaccination 5, during the malaria season, was 28.8% 
lower (95% CI 8.2-47.2, p=0.006) in the PfSPZ Vaccine group than the control group. The non-
parametric maximum likelihood estimation (MLE) curves, accounting for interval censoring, for 
the vaccine and placebo groups in the Mali trial are presented in Figure 1 (Sissoko et al., 2017). 

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

 
 
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Figure 2: USA vs Mali PfCSP ELISA Results 
 
Controls from 14-I-N010 (N = 44) are also included. Assay was performed on serum drawn following the third 
vaccine dose. The Malians had significantly lower responses, with many giving negative results (i.e., lower OD 1.0 
following the third dose than prior to the first vaccination). Green dots represent volunteers who were protected 
against CHMI or natural exposure; red dots represent volunteers who were not protected.  
 Mali (NIAID Protocol 16-I-N004) 
Following review of the safety data from a dose escalating pilot phase, 120 subjects healthy 
Malian adults aged 18-45 years of age were randomized into the double blind, placebo-controlled 
phase of the study in Mar/Apr 2016 to receive 1.8x106 PfSPZ Vaccine or normal saline at 0, 8, 
16 weeks during the dry season (#9 in Table 1). All participants received ASAQ to eliminate Pf 
before first and last vaccination. During the malaria transmission season (Aug-Dec 2016), 
volunteers were examined, and BS obtained every 2 weeks for 24 weeks in total; the primary 
efficacy endpoint was detection of first positive BS following third vaccination. 57/60 (95%) 
PfSPZ Vaccine subjects received all three doses and 55/60 (91.7%) normal saline placebo 
subjects received all three doses.  
PfSPZ vaccinations were safe and well tolerated except there were three additional unanticipated 
significantly elevated transaminases (Grade 3 to 4) in three Main Phase participants (1 PfSPZ 
Vaccine, 2 placebo) at varying stages post vaccination and ASAQ (14 to 65 days post ASAQ). 
Including the ALT liver enzyme derangement seen in the Pilot Phase subject, all four subjects 
were asymptomatic at presentation with no associated agranulocytosis. All laboratory 

 
 
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abnormalities resolved without sequelae (duration 169 to 214 days). At the time of the laboratory 
abnormalities the study was blinded, and the unblinded data was reviewed by the DSMB and 
submitted to the Food and Drug Administration (FDA) for review. Testing for potential of other 
etiologies, through imaging, expanded laboratory testing, and serology, identified no other 
possible contributing causes, except a traditional medicine provided to the first subject 
presenting with liver enzymes derangements. Serum antibodies to AQ are pending at this time.  
Overall, there were no significant differences in local or systemic AEs or laboratory 
abnormalities between PfSPZ Vaccine and placebo groups.  
55 subjects in the PfSPZ Vaccine group and 54 subjects from the placebo group were evaluable 
for per protocol analysis. Of these participants, 42 (77.8%) from the placebo group and 32 
(58.1%) from the vaccine group developed Pf infection (Figure 3). Per protocol, VE was 51% 
(p=0.004, 95% CI 20-70) by time-to-infection analysis (ITT 39%, p=0.033) and 24% (p=0.031, 
95% CI 2-41) by proportional analysis (ITT 22%, p= 0.041).  
Figure 3: Protective Efficacy of PfSPZ Vaccine Against Naturally Occurring Infection 
 
Protective efficacy was analyzed by time to first positive blood smear (BS), with Day 0 starting immediately after 
the third and final vaccination. The survival curves include participants who received all three vaccinations.  
 Mali (NIAID Protocol: 18-I-N084) 
Healthy Malian adult subjects were randomized into the double blind, placebo-controlled phase 
of the study in Mar/Apr 2016 to receive 1.8x106 PfSPZ Vaccine or normal saline at 0, 8 and 16 

 
 
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weeks or a condensed regimen of 1, 8, and 29 days (#16 in Table 1). The study started in June 
2018 and the 3rd vaccination was administered in September 2018. Currently, the participants are 
nearing the end of the malaria follow up phase post primary vaccination series with a plan for a 
booster dose in June/July 2019.  
Thus far, the vaccine regimen has been safe and well tolerated. There have been no serious 
adverse events (SAEs) or Grade 4 AEs. As expected, there are higher numbers of AEs in 
standard longer regimen Arm (Arm 1/3a) as this group has been enrolled and in follow up for a 
longer period of time than the condensed regimen Arm (Arm 2/3b). However, as demonstrated in 
Table 2, the proportions of AEs are similar between the two regimens indicating that 
administering PfSPZ Vaccine within a short period of time does not result in higher numbers of 
AEs compared to the standard longer regimen. All AEs were transient and have resolved without 
sequalae.   
Table 2: Summary of AEs to date 
 
 
 
 
 
 
 
 
X(Y%): Number of AEs (Percentage of total AEs in Arm) 
Vaccine efficacy started immediately after the third vaccination. The study is currently still 
blinded, but in general, there appears to be no significant differences between the study arms in 
the number of positive blood smears, clinical malaria and the unique individuals experiencing 
these events (see Table 3 below).  
Table 3: Current Rates* of Malaria Infection after Vaccination #3 
Study Arms             
(# of participants who 
received vaccination #3) 
 Positive P. falciparum 
Blood smears          
(Unique individuals) 
Clinical Malaria           
(Unique Individuals) 
1/3a (n=101) 
87 (53) 
45 (35) 
2/3b (n=103) 
77 (51) 
40 (36) 
*September 2018 to Early February 2019  
 
Arm 1/3a 
(n=105) 
Arm 2/3b 
(n=105) 
TOTAL 
Clinical AEs 
Grade 1 
397 (72%) 
194 (69%) 
591 (71%) 
Grade 2 
17 (3%) 
11 (4%) 
28 (3.4%) 
Grade 3 
9 (1.6%) 
5 (1.8%) 
16 (1.9%) 
Lab abnormalities 
Grade 1 
97 (18%) 
56 (20%) 
153 (18.4% 
Grade 2 
29 (5.3%) 
14 (5%) 
43 (5.2%) 
Grade 3 
1 (0.2%) 
1 (0.3%) 
2 (0.2%) 
TOTAL 
550 (66%) 
281 (34%) 
831 (100%) 

 
 
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 Tanzania, BSPZV1 + BSPZV2 
When healthy, young males in Tanzania (clinical trial BSPZV1 conducted by the Ifakara Health 
Institute, (#5 in Table 1) received five doses of either 1.35×105 PfSPZ Vaccine (total of 
6.75×105 PfSPZ) or 2.7×105 PfSPZ Vaccine (total of 13.5×105 PfSPZ)(regimens similar to that 
which protected 69% and 92% of volunteers in the USA, respectively), and underwent 
homologous CHMI (by DVI of 3,200 viable Plasmodium falciparum sporozoites produced by 
Sanaria, Inc. [PfSPZ Challenge]) three weeks after the fifth dose, only 4/19 (21%) and 4/20 
(20%) were protected. As in Mali, the vaccine was well-tolerated and immune responses were 
markedly reduced compared to those recorded in malaria-naïve individuals. 
In the BSPZV2 trial conducted in Bagamoyo, Tanzania (#8 in Table 1), 6/6 (100%) volunteers 
receiving 3 doses of 9x105 PfSPZ of PfSPZ Vaccine (total dose 2.7x106 PfSPZ) at 1, 9 and 17 
weeks were protected against homologous CHMI conducted 3-10 weeks after last dose of 
vaccine, whereas all 6 controls became infected (Jongo, submitted). Interestingly, as might be 
predicted from the results in malaria-naïve volunteers, a 50% higher dose of vaccine 
administered on the same schedule protected only 33% of volunteers – thus, beyond a certain 
threshold, higher doses did not appear to be better, duplicating the results seen in malaria-naïve 
individuals. 
 Germany, MAVACHE 
In a phase 1 dose escalation, regimen condensation, and dose number reduction study in healthy 
German adults, 9.0x105 PfSPZ of PfSPZ Vaccine was administered by DVI on 1, 8, and 29 day 
schedule. This regimen was also found to be safe and tolerable and resulted in protection of 
14/17 (78.8%) volunteers against 3- or 10-week homologous CHMI and 10/12 (83.3%) against 
3- or 10-week heterologous CHMI.  
 Mali (NIH Protocol 19-I-N113) 
MRTC/LMIV/Sanaria initiated a phase 2, randomized double blind, placebo-controlled study to 
assess the safety, tolerability, immunogenicity, and protective efficacy against Pf malaria 
infection of the 1, 8, 29 day PfSPZ Vaccine regimen given at a dose of 9x105 PfSPZ (n=100) or 
1.8x106 PfSPZ (n=100) or placebo (normal saline; n=100) in healthy adult (18-38 year-old) 
WOCBP who anticipated becoming pregnant in the future. This design was selected to allow an 
assessment of PfSPZ Vaccine safety for pregnancy when the vaccine was administered prior to 
the pregnancy, to detect any safety signals that might be associated with the immune response to 
the vaccine.  
The study started in June 2019 in Ouélessébougou and surrounding villages in Mali [#19-I-N113 
(NIH) / No2019/52/CE/FMPOS (Mali)]. 324 female participants actively using contraception 
initially enrolled and underwent day -14 blood draw, of which 320 received artemether-
lumefantrine (AL) prior to scheduled vaccinations #1 and #3. All study vaccinations were 
completed between 10 July to 27 August 2019.  
Women who enrolled in this study reported planning to become pregnant in the next 1-2 years 
and were actively followed post vaccination for pregnancy. Those women who were found to be 

 
 
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pregnant during the first year after vaccination were followed for the course of their pregnancy, 
through delivery, and at least 1 year post-partum. Infants born to these women were also 
followed for 1 year post delivery. Follow-up in these participants is expected to be completed in 
April 2022 
The study was extended for another malaria season (September 2020 to February 2021), without 
any additional study intervention, to explore the durability of vaccine efficacy. Women who 
became pregnant from this point further were only followed for the duration of the pregnancy 
and their offspring were followed only for delivery outcomes.  
All participants and their offspring remained blinded for the entire duration of the study until the 
end of the second malaria season (~February/March 2021). All women and their associated 
offspring completed follow-up by April 2022.   
Vaccinations were overall well tolerated by participants. The majority of AEs seen in every 
study arm were mild (Grade 1). There were no statistical differences seen between vaccine arms 
(9x105 PfSPZ Vaccine, 1.8x106 PfSPZ Vaccine) and normal saline (placebo) for total AEs, 
related AEs, solicited AEs (local, systemic, individual AEs), laboratory abnormalities, nor vital 
sign changes.  
Per protocol, participants were followed actively every two weeks (for 24 weeks post dose #3) 
and passively for unscheduled sick visits since receipt of Vaccination #3. After the completion of 
Year 1 malaria follow-up (24-week period post vaccination #3), protective efficacy analysis was 
completed on a group basis (see Table 4 below) to determine if any significant protection was 
seen to rationalize continuing to follow the study population for another year, including another 
malaria transmission season.   
Modified intention-to-treat (mITT) was the primary vaccine efficacy analysis and was based on 
time to the first infection, which was defined ≥ two Pf parasites per 0.5 milliliters (mL) by thick 
blood smear examination. The two vaccination arms were compared to placebo arm by logrank 
test for interval-censored data. Vaccine efficacy was defined as one minus the hazard ratio which 
was estimated from proportional hazard model accounting for interval censoring with baseline 
survival function as Weibull. VE analysis was completed by time to first infection (or time to 
event, TTE), binary (1-relative risk) as well as for the mITT and per protocol populations and are 
summarized below in Table 4.  
In both PfSPZ Vaccine arms, in both populations (mITT and PP), there was statistically 
significant and consistent protective efficacy seen by both TTE and by proportional analysis 
(binary) (Table 4). 
 
 
 

 
 
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Table 4. Protective efficacy, by mITT and PP, against Pf Infection 24-weeks post dose 3 
(Malaria Season Year 1, Aug 2019-Feb 2020) 
TTE (modified ITT) 
TTE (per protocol) 
VE (%) 
95% CI 
p value 
VE (%) 
95% CI 
p value 
PfSPZ Vaccine 
9x105 on 1, 8, 
29 days 
41% 
15, 59 
0.007 
41% 
14, 59 
0.008 
PfSPZ Vaccine 
1.8x106 on 1, 8, 
29 days 
54% 
34, 69 
<0.001 
57% 
36, 71 
<0.001 
Binary (modified ITT) 
Binary (per protocol) 
No. infected/ 
No. per arm 
VE  
(95% CI) 
p value 
No. infected/ 
No. per arm 
VE  
(95% CI) 
p value 
Normal saline 
on 1, 8, 29 days 
69/94 
 
65/87 
 
 
PfSPZ Vaccine 
9x105 on 1, 8, 
29 days 
52/94 
25%  
(5%, 41%) 
 
0.015 
52/92 
24%  
(5%, 41%) 
0.016 
PfSPZ Vaccine 
1.8x106 on 1, 8, 
29 days 
47/100 
36%  
(18%, 51%) 
<0.001 
44/95 
38%  
(20%, 53%) 
<0.001 
 
Additional vaccine efficacy analysis was completed to look at clinical malaria, defined as the 
presence of asexual P. falciparum parasites at any parasitemia level and/or positive rapid 
diagnostic test with either an axillary temperature of 37.5 °C or more or one or more of the 
following symptoms: headache, myalgia, arthralgia, malaise, nausea, dizziness, or abdominal 
pain. During the first malaria transmission season immediately post dose 3, there was protective 
efficacy seen in both PfSPZ Vaccine arms by mITT and PP analyses for TTE (46-48%) and the 
proportional (32-33%) endpoint (Table 5).  
Table 5. Protective efficacy, by mITT and PP, against clinical malaria 24-weeks post dose 3 
(Malaria Season Year 1, Aug 2019-Feb 2020) 
TTE (modified ITT) 
TTE (per protocol) 
VE (%) 
95% CI 
p value 
VE (%) 
95% CI 
p value 
PfSPZ Vaccine 9x105 
on 1, 8, 29 days 
47% 
20, 65 
0.004 
45% 
17, 64 
0.007 
PfSPZ Vaccine 18x105 
on 1, 8, 29 days 
48% 
22, 65 
0.001 
48% 
21, 66 
0.002 
Binary (modified ITT) 
Binary (per protocol) 
 
No. clin. 
malaria/ No. 
per arm 
VE  
(95% CI) 
p value 
No. clin malaria/ 
No. per arm 
VE  
(95% CI) 
p value 
Normal saline on 1, 8, 
29 days 
57/94 
 
53/87 
 
 
PfSPZ Vaccine 9x105 
on 1, 8, 29 days 
38/94 
33%  
(9%, 52%) 
 
0.008 
38/92 
32%  
(7%, 51%) 
0.013 
PfSPZ Vaccine 
1.8x106 on 1, 8, 29 
days 
40/100 
34%  
(10%, 52%) 
0.006 
38/95 
34%  
(10%, 53%) 
0.007 

 
 
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Given the results reported above, the protocol was amended to follow women (pregnant and non-
pregnant) for another year. No additional study product (vaccinations nor schedule anti-malarial 
drug) was provided prior to Year 2 follow-up, which started in September 2020. 
As noted above, participants (pregnant and non-pregnant) were reconsented in September 2020 
and followed in the same manner as in Year 1 with active visits every two weeks (for 24 weeks 
post reconsent) and passively for unscheduled sick visits. After the completion of Year 2 malaria 
follow-up (24-week period post reconsent = March 2021) protective efficacy analysis was 
completed using the same parameters as Year 1 (see Table 6 below).    
In both PfSPZ Vaccine arms, in the mITT, there was continued statistically significant and 
consistent protective efficacy seen by both TTE and by proportional analysis (binary) (Table 6). 
This continued to be seen in the 9x105 PfSPZ Vaccine Arm for the PP population but was not 
statistically significant for the 1.8x106 PfSPZ Vaccine Arm.   
Table 6. Protective efficacy, by mITT and PP, against Pf Infection 24-weeks post Reconsent 
(Malaria Season Year 2, Sept 2020-Mar 2021) 
TTE (modified ITT) 
TTE (per protocol) 
VE (%) 
95% CI 
P value 
VE (%) 
95% CI 
p value 
PfSPZ Vaccine 9x105 
on 1, 8, 29 days 
61 
36, 77 
0.001 
58 
28, 75 
0.005 
PfSPZ Vaccine 
1.8x106 on 1, 8, 29 
days 
45 
13, 65 
0.029 
42 
6, 64 
0.068 
Binary (modified ITT) 
Binary (per protocol) 
 
No. infected/ 
No. per arm 
VE (95% CI) 
p value 
No. infected/ 
No. per arm 
VE (95% CI) 
p value 
Normal saline on 1, 8, 
29 days 
50/84 
 
 
44/77 
 
 
PfSPZ Vaccine 9x105 
on 1, 8, 29 days 
28/84 
44% (19, 62) 
0.001 
28/82 
40% (13, 60) 
0.006 
PfSPZ Vaccine 
1.8x106 on 1, 8, 29 
days 
38/92 
31% (5, 50) 
0.023 
36/87 
28% (-2, 49) 
0.063 
As in Year 1, clinical malaria was also explored as a malaria endpoint. As seen in Table 7, 
significant protective efficacy persisted for a second malaria transmission season for both PfSPZ 
Vaccine arms by TTE (45-50%) and proportional analysis (31-35%).   
 
 
 
 
 
 

 
 
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Table 7. Protective efficacy, by mITT and PP, against clinical malaria 24-weeks post 
Reconsent (Malaria Season Year 2, Sept 2020-Mar 2021) 
TTE (modified ITT) 
TTE (per protocol) 
VE (%) 
95% CI 
P value 
VE (%) 
95% CI 
p value 
PfSPZ Vaccine 9x105 
on 1, 8, 29 days 
56 
22, 75 
0.008 
50 
12, 72 
0.026 
PfSPZ Vaccine 
1.8x106 on 1, 8, 29 
days 
40 
2, 64 
0.069 
34 
-11, 61 
0.158 
Binary (modified ITT) 
Binary (per protocol) 
 
No. clin. malaria/ 
No. per arm 
VE (95% CI) 
p value 
No. clin. malaria/ 
No. per arm 
VE (95% CI) 
p value 
Normal saline on 1, 8, 
29 days 
39/84 
34/77 
 
 
PfSPZ Vaccine 9x105 
on 1, 8, 29 days 
23/84 
41% (9, 63) 
0.016 
23/82 
36% (0, 61) 
0.051 
PfSPZ Vaccine 
1.8x106 on 1, 8, 29 
days 
31/92 
27% (-7, 52) 
0.116 
30/87 
22% (-18, 49) 
0.268 
 
Exploring protective efficacy further in our pregnant population, we looked specifically at 
malaria-related events occurring during pregnancy. When analyzing Pf parasitemia during a 
woman’s first pregnancy post vaccination (over a two year period), with accounting to timing of 
conception as a regressor, we saw continued protective efficacy through pregnancy by time to 
first infection for both PfSPZ Vaccine arms (see Figure 4 for per protocol population; PfSPZ 
Vaccine 9x105: VE 57%, CI 15-78%; p=0.0148; PfSPZ Vaccine 1.8x106: VE 49%, CI 2-73%, 
p=0.0447) and proportional analysis (PfSPZ Vaccine 9x105: VE 48%, CI 11-73%; p=0.0125; 
PfSPZ Vaccine 1.8x106: VE 38%, CI 1-67%, p=0.0418). When completing the same analysis on 
the mITT population this finding continued to be seen in both PfSPZ Vaccine arms for both 
analyses with similar VE values but lost significant for time to first infection in the 1.8x106 
PfSPZ Vaccine arm (VE 46%, CI -3-72%, p=0.06). 

 
 
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Figure 4. Vaccine efficacy, by PP, against Pf Infection during first pregnancy over a two 
year period. 
 
Given these promising results and in particular durability (over 2 years) of protection seen with 
PfSPZ Vaccine in non-pregnant and pregnant women, we would like to explore further if vaccine 
efficacy continues over another defined malaria season 3 years post recent primary vaccination 
to see if protection against parasitemia and clinical malaria continues.   
 Pregnancy Registry in Oulessebougou, Mali 
Placental malaria (PM) leads to poor outcomes for pregnant women and their babies, and is 
caused by Plasmodium falciparum sequestration in the intervillous spaces of the placenta and 
ensuing inflammation. Severe maternal anemia, low birth weight (LBW) delivery and fetal loss 
are common sequelae. Malaria-related LBW alone is estimated to cause 62,000-363,000 infant 
deaths in Africa each year. To reduce poor pregnancy outcomes associated with malaria 
infection, WHO recommends monthly anti-malarial treatment with sulfadoxine pyrimethamine 
(SP) during the second and third trimester and the use of insecticide-treated bed nets. However, 
in East and Southern Africa, SP has lost its efficacy due to the spread of drug-resistant parasites. 
Therefore, an effective vaccine for PM is needed. Although the ideal vaccine will be given to 
adolescent girls prior to becoming pregnant, at this early stage of pregnancy malaria vaccine 
development, it is unknown if a boosting dose may be needed during pregnancy.  
Before testing new interventions to improve pregnancy outcomes, it is important to obtain 
baseline information on pregnancy outcomes in the target population. In our recent longitudinal 
study (NIAID Protocol #10-I-N-156) of 1,885 pregnant women in Mali, in which women were 

 
 
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closely followed during pregnancy (including malaria prevention and treatment), 2.9%, 2.4% and 
6% of pregnancies ended in miscarriage, stillbirth, and preterm delivery, respectively.  
The primary goal of a larger follow-up study in Oulessebougou was put in place in 2017 (NIAID 
Protocol #17-I-N018) to assess pregnancy outcomes in women in the community with access to 
the WHO recommended standard of care. In the first part of the study, all women presenting for 
an antenatal visit at Ouelessebougou health centers were recruited into the study. In the second 
part of the study, non-pregnant women were enrolled and followed to capture data on pregnancy 
outcomes including early pregnancy losses. Pregnancy outcome information have been collected 
after the birth of the child or after pregnancy termination (i.e. miscarriage/stillbirth).  
Under this protocol, between February 2017 and May 2018, ~1800 women consented to 
participate in the study (Table 7a). The proportions of miscarriage/stillbirths and early neonatal 
deaths was 4.3%, similar to that observed in our longitudinal cohort study, but women were often 
identified as pregnant starting in their second trimester of pregnancy.  
Then, non-pregnant women of child-bearing age who were not under contraception or in early 
breastfeeding (<12 months) and were planning to become pregnant were recruited into the study 
and were followed prospectively in the second cohort starting in November 2018 and followed 
monthly to identify those who became pregnant. To date, as seen in Table 7b, the study has had 
~800 enrolled WOCBP, of which 6% per month of the enrolled WOCBP have become pregnant 
with 10.4% of those detected early pregnancies during the first visit resulting in miscarriage thus 
far. 
Overall pregnancy outcomes by age for the study, including women enrolling early in the first 
trimester as well as those enrolling late during their pregnancy, are summarized by age as noted 
below in Table 7c. Additional follow-up in non-pregnant women of child-bearing potential is 
ongoing and information regarding targeted outcomes will continue to help inform the 
community background rate of adverse events during pregnancy. 
Table 7: Oulessebougou Pregnancy Registry (#17-I-N018) 
Table 7a. Total Enrollment to Date by Age in Oulessebougou Pregnancy Registry (#17-I-
N018) 
Age group 
N (%) 
<18 
228 (12.7%) 
18-24 
791 (43.9%) 
25-30 
499 (27.7%) 
31-35 
181 (10.0%) 
36-40 
93 (5.2%) 
>=41 
10 (0.6%) 
Total 
1802 
 
 

 
 
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Table 7b. Enrollment of WOCBP and Subsequent Pregnancies in Oulessebougou 
Pregnancy Registry (#17-I-N018) 
1 % Miscarriage calculated based on the (number of reported miscarriages that month)/(number of detected and 
ongoing pregnancies the months prior) x 100 
Table 7c. Pregnancy Outcomes by Age Group in Oulessebougou Pregnancy Registry (#17-
I-N018) 
Outcome 
Age 
group 
OR (95% CI) 
p-value 
Fetal loss 
<18 
2.7 (1.25-5.85) 
0.01 
  
18-24 
1.66 (0.86-3.19) 
0.1 
  
25-30 
REF 
  
  
31-35 
.74 (0.71-4.26) 
0.2 
  
36-40 
0.9 (0.2-4.07) 
0.9 
  
>=41 
9.12 (1.76-47.2) 
0.008 
Preterm Delivery <18 
6.13 (2.77-13.56) 
<0.0001 
  
18-24 
3.06 (1.48-6.36) 
0.003 
  
25-30 
REF 
  
  
31-35 
0.94 (0.25-3.52) 
0.9 
  
36-40 
5.20 (1.95-13.88) 
0.001 
  
>=41 
No cases 
  
 
2 Clinical Trial Rationale 
 Rationale for Accelerated PfSPZ Vaccine Schedule 
There is ample evidence that the dose of PfSPZ Vaccine plays an important role in the development 
of protective immunity, but the importance of the dosing schedule is not as clear. A number of 
PfSPZ Vaccine studies have been completed and are currently ongoing to determine a highly 
effective vaccine schedule but given the targeted population in this study and subsequent proposed 
studies, a regimen that can be completed over a short period of time is ideal in order to quickly 
induce protection as early as possible in pregnancy.  
Perhaps surprisingly to many, women generally do not receive any preventive measures during 
their first trimester, when most antimalarial drugs are contraindicated. Even in the presence of 
preventive measures such as IPTp, which entails periodic full antimalarial treatment after the first 
trimester, pregnancy malaria still occurs at a high rate.  By inducing protection either prior to 
Enrolled 
WOCBP 
Number of 
Monthly Visits 
Completed 
Number of 
Women Seen 
per Month 
Number (%) 
of New 
Pregnancies 
Total 
Number 
(%) of 
Pregnancies 
Number (%) 
of 
Miscarriage 
799 
 
 
 
 
 
 
1 
799 
48 (6%) 
48 (6%) 
0 (0%) 
  
2 
696 
41 (6.3%) 
84 (10.5%) 
5 (10.4%)1 

 
 
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pregnancy or during the first trimester of pregnancy, providing a longer window of protection may 
result in improved pregnancy and neonatal outcomes.  
In addition, an accelerated approach could be deployed as a seasonal malaria immunoprotection 
for pregnant women living in the Sahel, similar to current seasonal malaria chemoprophylaxis 
(SMC) regimens used in children.  In order for this to be implementable, a regimen that can be 
completed over a short period of time leading up to the seasonal malaria transmission season would 
be needed. Even if the protection seen with PfSPZ Vaccine is not long lived, in women who are 
pregnant, prolonged protection (years) is not required to see significant benefit to the mother and 
child. 
In previously completed studies, a condensed PfSPZ Vaccine regimen of 1, 8, and 29 days has 
been found to be safe and well tolerated in multiple studies conducted in malaria naïve and malaria 
experienced individuals (as described in Section 1.4.2-1.4.7).  
 Rationale for PfSPZ Vaccine Doses of 1.8x106 and 9x105  
The initial hypothesis underlying the sequence of studies completed and/or planned with PfSPZ 
Vaccine was that higher doses of PfSPZ Vaccine would lead to improved efficacy. It was argued 
that increasing the quantity of the immunogen should increase the antigenic stimulus and should 
also broaden the repertoire of immune responses to include less highly expressed proteins, 
improving vaccine efficacy.  
Findings of multiple studies have shown that the threshold dose hypothesis is only partially true 
and is not as definitive as expected. The initial studies did confirm that vaccine efficacy increased 
with the dose of PfSPZ Vaccine administered and there was a clear dose response seen in several 
cases with increasing vaccine efficacy with increasing PfSPZ Vaccine doses (Epstein et al., 2017; 
Ishizuka et al., 2016) However, as individual doses were increased above about 9.0x105 PfSPZ 
Vaccine in malaria naïve and experienced subjects, further improvements in vaccine efficacy were 
not consistently seen. 
Given these preliminary results, in this study we propose to evaluate a known efficacious dose in 
an adult malaria exposed population (1.8x106 PfSPZ Vaccine) as well as the optimal dose proposed 
by the sponsor, Sanaria Inc. (9.0x105 PfSPZ Vaccine) to assess if dose amount given in the same 
dosing regimen (1, 8, 29 days) will provide increased protection in this population.  
 Rationale to Include WOCBP in Malaria Clinical Trials  
Women of childbearing potential (WOCBP) are often excluded from participating in clinical 
trials owing to concerns about adverse maternal and fetal effects due to vaccination.  But we 
believe it is important that vaccine developers consider the need for early transition of 
efficacious products to trials in young women; a generally underappreciated population in 
vaccine development.  
 Rationale to Develop a Vaccine to Prevent Malaria in Pregnant Women 
Even in the presence of preventive measures such as IPTp, pregnancy malaria occurs frequently. 
Many women develop malaria before their first IPTp dose, which is only administered when 

 
 
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women present for their first antenatal visit, typically around 20 weeks gestation in many 
communities. Less than 20% of African mothers receive the recommended 3 doses of IPTp 
during pregnancy. Other recommended interventions such as insecticide-treated bed nets and 
case management of intercurrent malaria infections are variably implemented, but even in areas 
of relatively good uptake the rate of pregnancy malaria remains high. Further, drug-resistant 
parasites and insecticide-resistant mosquitoes are inexorably spreading, which will further erode 
the benefits of existing interventions. Thus, a vaccine to specifically reduce pregnancy malaria or 
a universal vaccine to reduce all malaria, is urgently needed to improve pregnancy outcomes. To 
have maximum benefit, an effective vaccine should be administered before first pregnancies but 
also needs to be assessed if can be given safely during pregnancy as a primary series and/or 
booster.   
Specific vaccines to prevent malaria in pregnant women could potentially be an important 
method of preventing malaria in pregnancy but their rationale, and the current approaches to 
research, development and clinical evaluation require further consideration. Any successful 
vaccine aimed at preventing malaria infection or disease would be expected to reduce the burden 
of malaria in pregnant women. A vaccine with lifelong efficacy could be given with other 
childhood vaccines but a vaccine with shorter duration of efficacy could potentially be delivered 
at a similar time as a vaccine for prevention of HPV, providing boosting prior to pregnancy, or 
be given early during pregnancy.  
No reproductive toxicity studies have been performed yet on PfSPZ Vaccine to assess preclinical 
safety and immunogenicity in pregnant animals, but is planned to occur in 2019. These studies 
are planned to assess inoculation at different stages of pregnancy and investigate whether PfSPZ 
can cross the placenta and/or cause adverse outcomes in pregnancy and/or to the fetus. Once 
Reproductive toxicity studies have been completed and reviewed and safety data has been 
reviewed from the first year of this study, as noted prior, our clinical development plan for 
PfSPZ Vaccine in WOCBP and pregnant women, would next include studies of the safety and 
efficacy of a primary immunization series and studies to evaluate the efficacy of boosting during 
pregnancy. 
 Rationale for Assessing PfSPZ Vaccine in WOCBP  
Malaria is a scourge of pregnant women in developing countries, causing maternal, perinatal, and 
infant mortality. Current tools (drugs, bed nets) are losing activity and the search for new safe 
tools has been unsuccessful. Further, as noted prior, no malaria vaccine has ever been tested in 
WOCBP or pregnant women in Africa, and no vaccine of any kind is FDA-approved to date for 
use in pregnancy, highlighting the paucity of data in a highly malaria-impacted population.  
When tested in healthy, non-pregnant, non-lactating adults, and in children and infants, Sanaria’s 
vaccines are safe and well-tolerated, and protective in both malaria-naive and malaria-
experienced adults.  Sanaria has now amassed sufficient safety and protection data to justify 
studies in more vulnerable populations, such as HIV-infected individuals (study started in 
Tanzania in February 2018) and now in WOCBP and pregnant women. There are extensive data 

 
 
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from 3,652 immunizations into 1,130 individuals that PfSPZ Vaccine is safe, well tolerated, and 
able to protect against Pf infection for sustained periods.  
In addition, PfSPZ Vaccine is formulated without an adjuvant thereby avoiding the systemic 
reactogenicity and safety concerns of more inflammatory products that may result in systemic 
inflammation resulting in poor pregnancy outcomes. 
NIH/NIAID/LMIV, MRTC, and Sanaria hosted a two-day meeting of experts to develop a 
pathway to test the safety of the vaccines in pregnancy, to explore the need for malaria vaccines 
in pregnancy, and to conceptualize clinical trials to measure protective efficacy of PfSPZ-based 
vaccines against malaria infection during pregnancy. A main conclusion of the meeting was that 
the potential benefits of PfSPZ immunization greatly outweigh hypothetical risks during 
pregnancy, and therefore there is an ethical imperative to proceed with testing. 
Our vision is for PfSPZ Vaccine to be scaled up as a public health tool that prevents malaria in 
WOCBP and pregnant women. We have proposed to evaluate this vaccine first in WOCBP with 
booster doses being evaluated post receipt of primary series, especially at the onset of pregnancy. 
Rolling out studies in a controlled stagger manner, we would like to then move to giving 
pregnant women, who have not been immunized prior, a primary series during various trimesters 
of pregnancy.   
In addition, as already planned in Equatorial Guinea, mass vaccination programs will need to 
include women of reproductive age and pregnant women to achieve high vaccine coverage. To 
achieve the requisite high population coverage, the vaccine must be safe in all age and risk 
groups, including women of reproductive age and pregnant women.  In addition to the direct 
protection that PfSPZ Vaccine might offer pregnant women, the plan for mass vaccination 
programs, mandates that we establish the safety, tolerability and efficacy of PfSPZ-based 
vaccines in pregnancy.  
 Rationale for Following WOCBP and Pregnant Cohort for Another Malaria 
Transmission Season  
Limited data are available on the protective efficacy durability and longevity of PfSPZ Vaccine 
over two independent malaria transmission seasons. Combined evaluation of PfSPZ Vaccine VE 
over two malaria transmission seasons was assessed for a PfSPZ Vaccine study in Burkina Faso 
(NCT02663700; unpublished) which did show significant efficacy over two years combined by 
time-to-event analysis. To confirm this finding, we would like to continue to follow our study 
cohort in a blinded fashion for a second transmission season. We will examine vaccine efficacy 
during the 24 week period encompassing the second transmission season, and also over the entire 
two year period after vaccination. Given continued protective efficacy seen in non-pregnant and 
pregnant women during the second transmission season, we will examine vaccine efficacy 
during another 24 week period encompassing a malaria transmission season three years post 
initial vaccinations.  
The question of longevity is key for vaccine development in WOCBP and pregnant women and 
future clinical trial designs for PfSPZ Vaccine in this population; in particular addressing 

 
 
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40 
 
questions regarding timing and need for booster vaccinations. Knowing how long a primary 
PfSPZ Vaccine series sustains protection, without additional intervention, will address important 
unknowns that will be essential to answer. 
3 STUDY OBJECTIVES 
 Primary Objective 
 
Safety:  Assess safety and tolerability of PfSPZ Vaccine primary series in healthy Malian 
WOCBP when given at 1, 8, 29 days at two doses (9.0 x105 and 1.8 x106)  
 
 
Secondary Objective  
 
Protective Efficacy: Assess the efficacy of PfSPZ Vaccine primary series in healthy 
Malian WOCBP when given at 1, 8, 29 days at two doses (9.0 x105and 1.8 x106) 
 
 Exploratory Objectives 
Protective Efficacy: 
• Explore the impact of PfSPZ Vaccine on additional malaria infection endpoints 
 
Immunogenicity:  
• Characterize and compare host immune responses to malarial antigens and host 
proteomic profiles and transcriptomes in African WOCBP prior to and after 
vaccination with PfSPZ Vaccine and between uninfected and infected subjects 
• Explore the impact of PfSPZ Vaccine on the genotype and transcriptome profile 
of parasites isolated from study subjects  
• Assess the efficacy of PfSPZ Vaccine primary series in healthy Malian WOCBP 
when given at 1, 8, 29 days at two doses (9 x105and 1.8 x106) for a second 
malaria transmission season 
• Assess the efficacy of PfSPZ Vaccine primary series in healthy Malian WOCBP 
when given at 1, 8, 29 days at two doses (9 x105and 1.8 x106) for another malaria 
transmission season (durability) 
 
              Pregnant Women and Neonates 
 
 
Safety: 
• Assess maternal and neonatal outcomes post receipt of 
PfSPZ Vaccine primary series  
 
 
Protective Efficacy: 
• Explore the PfSPZ Vaccine protective efficacy and 
durability of protection in pregnant women.  

 
 
PfSPZ Vaccine in WOCBP  
 
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• Explore the PfSPZ Vaccine protective efficacy and 
durability of protection in neonates/infants born to PfSPZ 
vaccinated mothers. 
 
4 STUDY DESIGN 
This study will enroll healthy Malian adult WOCBP between 18 and 38 years of age to 
participate in a randomized, double blind, placebo-controlled study to assess the safety, 
immunogenicity and protective efficacy of PfSPZ Vaccine across a year of follow up including 
malaria transmission season. Participants will be immunized with a 3-dose series of 9.0x105 
PfSPZ Vaccine or 3-dose series of 1.8x106 PfSPZ Vaccine or normal saline (placebo) at 1, 8, 29 
days (as seen below in Figure 5). Vaccinated subjects and controls will then be assessed for 
malaria infection during the ensuing malaria transmission season and subsequent dry season, 
including following prospectively women who become pregnant during follow up and their 
offspring. Volunteers will be randomized into three arms at a 1:1:1 ratio to receive PfSPZ 
Vaccine versus normal saline control.  
Approximately one year post receipt of vaccination #3 (2019), women, both pregnant and non-
pregnant, will be asked to continue on study for at least another 6 months. No additional study 
products will be given during this time. If a woman becomes pregnant during this extended 
follow-up, she will continue to be followed through the course of her pregnancy and shortly after 
delivery. Subsequent offspring born from pregnancies from this time period will only be 
followed for delivery outcomes.  
Approximately three years post receipt of last vaccine dose, women, both pregnant and non-
pregnant, will be asked to be followed for another 6 month period. No additional study products 
will be given during this time. If a woman is or becomes pregnant during this extended follow-
up, she will continue to be followed during the 24 week period, but not beyond that follow-up 
period. Subsequent offspring born from pregnancies from this time period will not be followed.  
 
 
 
 
 
 
 
 
 

 
 
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Figure 5: Study Schema (Year 1) 
 
 
  Study Arms 
Three study arms will be enrolled in this study, with two PfSPZ vaccination arms and one 
control arm. 
 
Arm 1: (n= 100) will receive 3 doses of PfSPZ Vaccine (9.0 x105) via direct venous inoculation 
(DVI) at 1, 8, 29 days.  
 
Arm 2: (n= 100) will receive 3 doses of PfSPZ Vaccine (1.8 x106) via DVI at 1, 8, 29 days. 
  
Arm 3: (n=100): will receive 3 doses of placebo saline injection via DVI at 1, 8, 29 days. 
 
All injections will be administered by DVI. All volunteers will receive antimalarial treatment 
with artemether/lumefantrine (AL) approximately two weeks prior to the 1st and 3rd injection. 
Post 3rd injection, participants will be followed through the malaria transmission (rainy) season, 
approximately 6 months, and then the ensuing dry season for an additional 6 months. Participants 
will be monitored for safety, immunogenicity, and protective efficacy (malaria infection) during 
the follow-up period.  
 
For any women who becomes pregnant during the first year of the trial, follow up will continue 
through the end of pregnancy, and any viable newborns/infants and their mothers will be 
followed through the first year of life. 
 
During the second year of follow-up, which will start immediately at the conclusion of the first 
year of follow-up, participants will be followed through the malaria transmission (rainy) season, 
24
28
32
36
40
APR 2020               
PfSPZ Vaccine 
9.0x10^5
AL
Malaria Transmission Season Follow-up
Arm 1 (N=100)
Screening
PfSPZ Vaccine 
1.8x10^6
AL
Malaria Transmission Season Follow-up
Arm 2 (N=100)
Screening
Normal Saline
AL
Malaria Transmission Season Follow-up
Arm 3 (N=100)
Screening
Pregnancy + Neonate/Infant Follow-up
Pregnancy + Neonate/Infant Follow-up
44
50
0
4
8
12
54
JUL 2020
16
20
JUL 2019
OCT 2019
JAN 2020
-4
Continued 
surveillance 
of mother + 
neonate/
infant up 
through 
May 2021
Post Vaccination Follow-up
Pregnancy + Neonate/Infant Follow-up
Pregnancy + Neonate/Infant Follow-up
Post Vaccination Follow-up
Pregnancy + Neonate/Infant Follow-up
Pregnancy + Neonate/Infant Follow-up
Post Vaccination Follow-up
AL
AL
AL
 

 
 
PfSPZ Vaccine in WOCBP  
 
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approximately 6 months. Participants will be monitored for safety (unsolicited AEs), 
immunogenicity, and protective efficacy (malaria infection) during the follow-up period. 
 
For any women who becomes pregnant during the second year of the trial (~September 2020 to 
March 2021), follow up will continue through the end of pregnancy and through ~1-2 months 
post delivery, but any viable newborns/infants will not be followed beyond delivery. 
 
Given continued protective efficacy seen during Malaria Season Year 2 (2020-2021), women 
(pregnant or non-pregnant) who have received at least two vaccinations will be asked to come 
back to be followed for a 24-week period during the 2022-2023 Malaria Season. No product (AL 
nor PfSPZ Vaccine nor Normal Saline) will be administered. 
 
5 STUDY ENDPOINTS 
 Primary Endpoints 
Safety: Incidence of local and systemic adverse events (AEs) graded by severity occurring 
within 7 days after each vaccine administration.  
 
 Secondary Endpoints  
 
 
 
 
 
 
 
 
 
Protective Efficacy: P. falciparum blood stage infection defined as time to first positive blood 
smear (detection of at least 2 P. falciparum parasites by microscopic examination of 0.5 µL) 
starting immediately following 3rd injection over 24 weeks (all Arms). 
 
 Exploratory Endpoints 
Protective Efficacy 
• Measurement and comparison of various malaria infection endpoints, such as PCR, 
gametocytemia, non-falciparum parasitemia, symptomatic malaria 
• P. falciparum blood stage infection defined as time to first positive blood smear 
(detection of at least 2 P. falciparum parasites by microscopic examination of 0.5 µL) 
starting approximately 1 year post receipt of 3rd injection for 24 weeks.  
• P. falciparum blood stage infection defined as time to first positive blood smear 
(detection of at least 2 P. falciparum parasites by microscopic examination of 0.5 µL) 
starting approximately 3 years’ post receipt of last injection for 24 weeks. 
 
Immunogenicity  
• Measurement and comparison of various immunological parameters: 
    
 - in the same subject prior to and after vaccination 
- between parasitemic and aparasitemic subjects 
• Determination of the genotype of parasites isolated from study subjects, using 
microsatellite typing, sequencing, and/or single-nucleotide polymorphism (SNP) chip 
assays. 
 

 
 
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Pregnant Women and Neonates 
 
 
Safety: 
• Incidence of maternal obstetric outcomes (miscarriage/stillbirth, intrauterine growth 
restriction, hypertensive diseases in pregnancy, preterm delivery) and neonatal 
outcomes (neonatal death, low birth weight, small for gestational age, major 
malformations, and microcephaly) 
 
 
Protective Efficacy: 
• P. falciparum blood stage infection defined as time to first positive blood smear 
(detection of at least 2 P. falciparum parasites by microscopic examination of 0.5 µL) 
during the pregnancy, during infancy, and starting immediately following 3rd injection 
• P. falciparum placental infection defined as any positive placental blood smear for P. 
falciparum.  
 
 Sample Size and Estimated Duration of the Study 
A total of 300 volunteers will be enrolled/randomized in this trial, 200 subjects in the vaccine 
arms (Arm 1, Arm 2) and 100 subjects in the control arm (Arm 3). WOCBP will be enrolled in 
the study for approximately 21 months if they do not become pregnant during the course of the 
study.  
If a woman becomes pregnant during the course of the first year of the study, they will not be 
removed from the study, but at the time of pregnancy determination will no longer receive 
investigational product, but will be followed throughout the course of their pregnancy and post-
delivery as outlined in Appendix A. Their offspring will also be followed as outlined in 
Appendix A for one year following birth.  
If a woman becomes pregnant, but pregnancy does not result in a live birth during the study, she 
will not be removed from the study as long as she agrees to continue on the study as a non-
pregnant participant. If a woman delivers and completes her post-delivery follow-up before the 
end of the second year of follow-up (~March 2021) she can be followed as a non-pregnant 
subject as long as she agrees to continue on the study.  
Definitions for the purpose of this study: 
• Screened – subjects will receive a study screening number when the informed consent is 
signed and will either be determined as “eligible” or “screen failure” as noted below. 
o Screening may be completed over the course of multiple visits. 
o Screening, in most cases, will occur within 56 days prior to administration of 
vaccine #1. 
 If the screening visit is >56 days before the administration of vaccine #1, 
then an updated medical review and laboratory testing (CBC with 
differential, ALT, Creatinine, ECG, Pregnancy test) + repeat malaria 
comprehension will be completed to determine eligibility for enrollment. 

 
 
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• Eligible – subjects will be considered eligible to enroll once they have completed the 
screening procedures and have met all inclusion criteria and not met exclusion criteria.  
They will be asked to provide baseline blood samples for the immunological assessment 
before the vaccination.  
• Screen Failure – subjects are considered screen failures when they meet one of the 
following criteria after signing consent: 
o Screening results reveal that the subject is ineligible. 
o Subject withdraws consent before being vaccinated and/or randomized.  
o Subject is determined eligible for enrollment after study completes enrollment. 
• Enrolled – subject will be considered enrolled if they: 
o Meet eligibility criteria,  
o Undergo first blood draw on study day -14 
• Discontinued/Withdrawn – subjects are considered discontinued when they meet one or 
more of the following criteria: 
o Subject withdraws consent after being vaccinated. 
o Subject is withdrawn by the Principal Investigator (PI)/Sponsor after being 
vaccinated.  
o If a subject is discontinued/withdrawn and unscheduled, intentional unblinding is 
not determined to be needed at the time of discontinuation/withdrawn she will be 
contacted on study day 561 for notification of her arm assignment (individual 
unblinding). 
• Completed – subjects are considered completed when they complete the final study visit. 
o Never pregnant women = study day 561 
o Pregnant women = study day P16 (~12 months following delivery) for Year 1; 
study day P11 (~2 months follow delivery) for Year 2 
 If pregnancy does not result in a live birth, will rejoin the non-pregnant 
follow-up schedule until either 1) Pregnant; 2) End of Study (study day 
561) for non-pregnant women 
o Offspring of WOCBP = study day C6 (~12 months of age) for Year 1 pregnancies 
only 
o Year 2 offspring will only have delivery outcomes (study day C0) collected 
6 STUDY AGENTS 

 
 
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 PfSPZ Vaccine 
The vaccine referred to as PfSPZ Vaccine contains aseptic, purified, vialed, cryopreserved, 
radiation attenuated NF54 P. falciparum sporozoites (PfSPZ) produced by Sanaria Inc. PfSPZ 
Vaccine is manufactured in compliance with Good Manufacturing Practice (GMP) regulations 
(21 Code of Federal Regulations [CFR] 21), that is described in detail in Investigational New 
Drug (IND) 13969. Manufacture of PfSPZ Vaccine is performed in Sanaria’s Clinical 
Manufacturing Facility (CMF) in Rockville, Maryland, USA. The PfSPZ Vaccine manufacture is 
an aseptic process that includes in process testing according to USP<71> sterility testing. In 
brief, manufacture includes disinfection of mosquito eggs performed by exposure to chemical 
agents. Disinfected eggs are inoculated into vented flasks containing growth medium. The eggs 
hatch and develop into pupae, which are transferred to an adult mosquito container where the 
adult mosquitoes emerge. In vitro culture of P. falciparum parasites is initiated from a working 
cell bank (WCB) vial of P. falciparum isolate NF54, which is described in detail in Biologics 
Master File BMF 13489. The asexual parasite stages are induced to produce gametocytes. The 
adult mosquitoes are fed P. falciparum gametocyte-infected blood in a high-security insectary in 
Rockville, Maryland, USA. Infected adult mosquitoes are maintained and sporozoites migrate to 
the salivary glands in two weeks from the time of infectious feed. The PfSPZ in the mosquito 
salivary glands are attenuated by irradiation at 150 Gy. The salivary glands from the P. 
falciparum sporozoite infected mosquitoes are harvested by manual dissection. Salivary glands 
are then triturated to release the PfSPZ that are then purified, counted, and, at a specified 
concentration, cryopreserved. Cryopreservation commences with the addition of cryoprotective 
additives to the PfSPZ bulk product to produce the PfSPZ Vaccine final product. The final 
product is dispensed into screw-cap vials that are stored in liquid nitrogen vapor phase (LNVP) 
at -150°C to -196°C. All the procedures are described in more detail in the cross-referenced IND 
13969. 
 Storage and Handling  
PfSPZ Vaccine is cryopreserved in aliquots of 20 μL in 0.5 mL cryovials and stored in LNVP at 
below -150°C. The cryovials are packaged in a latched box and transported from Sanaria, Inc. to 
the clinical study site in a LNVP dry shipper. The LNVP dry shipper has a holding time of at 
least 10 days. The PfSPZ Vaccine remains in the dry shipper at the clinical study site and 
individual cryovials are removed from the dry shipper and thawed as needed for PfSPZ Vaccine 
dilution, syringe preparations and immunizations. Each cryovial is labeled indicating that it 
contains PfSPZ Vaccine, together with the lot number and date of manufacture. The LNVP dry 
shipper is labeled to indicate it is approved by International Air Transport Association (IATA) 
for shipment by air, conforms to UN3373 for Biological Substance, Category B, and packing 
instructions 650 (US 49 CFR, Part 173.199).  
Transfer, receipt and maintenance of PfSPZ Vaccine from its storage site to the clinical trial site 
will follow SOP331 (Cryopreserved Material Transportation), provided by Sanaria, Inc. At the 
study site, the LNVP shipper will be continuously monitored by a data logger as well as a 
temperature probe according to Sanaria standard operating procedure (SOP). Receipt of the 
products will be documented on a tracking log by trained study staff according to Sanaria SOP. 

 
 
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 Disposition and Dispensation 
The clinical site must confirm that the vials of PfSPZ Vaccine have been transported and stored 
below -150°C according to SOP. Immediately prior to use, the cryovials will be thawed by 
partial submersion of the vials for 30 seconds in a 37°C ± 1°C water bath. Designated study staff 
will be trained by Sanaria, Inc. and then will - either alone or with Sanaria, Inc. staff - prepare, 
dilute (if necessary) and dispense PfSPZ Vaccine to clinical staff at the clinical study site 
according to SOP353 (Preparation of PfSPZ Vaccine and Diluent for Clinical Trial in Mali). 
The diluent is phosphate buffered saline (PBS) containing human serum albumin (HSA). PBS 
and 25% HSA will be provided to the clinical sites by Sanaria, Inc. for preparation of the diluent. 
All PfSPZ Vaccine vials, PBS and HSA that are used will be documented on inventory forms as 
well as documented disposition forms according to SOP. All unused PfSPZ Vaccine vials will be 
returned to Sanaria, Inc. 
 Administration  
PfSPZ Vaccine will be injected by needle and syringe into a peripheral vein by a qualified 
member of the clinical team. The diluted vaccine will be prepared such that a defined volume of 
the suspension (not more than 0.5mL) is administered by DVI.  
During administration of PfSPZ Vaccine, advanced-life-support drugs and resuscitation 
equipment will be immediately available for the management of anaphylaxis. The study staff 
administering PfSPZ Vaccine will wear gloves. The subject will stay in the clinical area for at 
least 30 minutes after vaccine administration. 
 PBS and HSA Diluent 
The diluent for PfSPZ Vaccine is composed of phosphate-buffered saline (PBS) and human 
serum albumin (HSA). Vials of sterile PBS and HSA will be shipped to the clinical site, where 
diluent composed of PBS and HSA is prepared according to SOP353 (Preparation of Challenge 
and Diluent for Clinical Trials in Mali) provided by Sanaria, Inc.  
PBS that will be used was manufactured in compliance with GMP by Sanaria, Inc. (9800 
Medical Center Dr., Rockville, MD, USA). A Certificate of Analysis (CoA) is generated for each 
lot of PBS that is released for use in clinical studies. In addition, the PBS lots are placed on 
stability.  
HSA is a licensed product which is approved for parenteral, IV administration to humans and is 
purchased by Sanaria, Inc. The HSA is repackaged at Sanaria. Repackaged HSA is released with 
a CoA.  
 Storage and Handling 
The PBS and HSA are stored at ambient temperature within specifications (between 15°C to 
30°C) that is monitored by a continuous data logger in a controlled access room. Receipt of the 
products will be documented on a tracking log by trained study staff according to Sanaria SOP. 

 
 
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 Disposition and Dispensation 
The clinical site must confirm and document that the vials of PBS and HSA have been 
transported and stored within specified ranges. All PBS and HSA that are used will be 
documented on inventory forms as well as documented disposition forms according to SOP.  
 Administration and Dosage 
PBS and HSA are components of PfSPZ Vaccine diluent. The use of PBS and HSA will be 
according to SOP. The PfSPZ Vaccine dose will be suspended in a diluent composed of PBS and 
about 1% HSA in a total of 0.5 mL.   
 Accountability 
PBS and HSA vial accountability will be maintained to document chain of custody from Sanaria, 
Inc., to study site. An inventory to account for number of vials used will be recorded and kept in 
the study file. 
 Control Product 
Sterile isotonic (0.9%) normal saline will be procured in the US and shipped to Mali at ambient 
temperature. Like the product, normal saline is a clear liquid, making it indistinguishable from 
the study product when drawn up into a syringe. Normal saline will be used as a placebo, rather 
than a comparator vaccine being used, as currently there are no licensed vaccines available as IV 
formulations.  
 Storage and Handling 
The normal saline is stored at room temperature in a controlled room per product standards. Each 
normal saline vial can either be single use or multi-use over a period of a few hours (i.e. the 
duration of vaccine preparation on a given day). 
 Disposition and Dispensation 
The clinical site must confirm and document that the vials of normal saline have been 
transported and stored within specified ranges.  
 Administration and Dosage 
Normal saline will be administered DVI as placebo in an equal volume to the study product. 
 Accountability 
Normal saline accountability will be maintained to document chain of custody from Sanaria, 
Inc., to study site. An inventory to account for number of vials dispensed for each subject 
injection will be recorded and kept in the study file. 
 Antimalarial Drugs  
All antimalarial medications used for the study will be maintained at the study site and 
administered by direct observational therapy. Artemether/lumefantrine (AL) tablets will be 

 
 
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purchased from commercial sources and provided by the MRTC study team to subjects. Drug 
accountability will be managed by the site clinical team. 
 Preparation and Administration 
AL will be provided as tablets for oral administration. Administration will be under direct 
observation by study staff according to dosing parameters; on a case by case basis a dose may be 
given outside of directly observed therapy (DOT; e.g. during nighttime dosing) as long as timing 
of dose and overall compliance can be confirmed. 
 Storage and Handling 
AL tablets will be maintained in the manufacturer’s original packaging and stored at the clinic 
under recommended storage conditions until prepared for dispensing. 
 Return of Study Product 
Final accountability of drug supplies will be performed at the conclusion of the study. Final 
disposition of any remaining AL will be determined and documented. 
 Drugs used for Pre-emptive Treatment of Malaria 
During this study, all Arms will receive pre-emptive antimalarial treatment prior to 3rd injection.  
AL (e.g, Coartem®) is a licensed antimalarial in the US and Mali for use for uncomplicated 
malaria. It has an excellent safety profile and is widely used to treat malaria. Subjects who may 
have any contraindications to the use of these drugs will be excluded at screening. The most 
common side effects reported in adults are: headache, anorexia, dizziness, asthenia, arthralgia 
and myalgia. 
 Drugs Used for Management of Symptomatic Malaria 
In accordance with the Malian Government treatment guidelines, volunteers will be treated with 
AL (e.g. Coartem®, 80mg/480mg per dose or equivalent). AL is a licensed antimalarial in the 
US and Mali for use for uncomplicated malaria. It has an excellent safety profile and is widely 
used to treat malaria. Subjects who may have any contraindications to the use of these drugs will 
be excluded at screening. The most common side effects reported in adults are: headache, 
anorexia, dizziness, asthenia, arthralgia and myalgia.  
Clinical or symptomatic malaria for this study is defined as the presence of asexual P. falciparum 
parasites at any parasitemia level and/or positive rapid diagnostic test with either an axillary 
temperature of 37.5 °C or more or one or more of the following symptoms: headache, myalgia, 
arthralgia, malaise, nausea, dizziness, or abdominal pain and will be reported as an AE. 
Pregnant subjects who develop clinical malaria will be treated following Mali National Policy on 
Malaria Control guidelines. Uncomplicated malaria and asymptomatic parasitemia in the 1st 
trimester is treated with quinine and during 2nd and 3rd trimesters, treatment is with AL. 
Complicated malaria in pregnancy is treated similarly to non-pregnant patients.  

 
 
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This study will not interfere with the routine standard-of-care. Pregnant women will receive 
medical care through the antenatal clinic (ANC) according to the standard of care in Mali. The 
study will support the public health clinic by providing pregnancy testing, pregnancy dating by 
ultrasound, ensuring supply of RDT and blood smears for malaria diagnosis, and drugs for 
malaria treatment and prevention, and training on accurate completion of antenatal cards. During 
the study visits, the team will encourage women who became pregnant to attend ANC. The 
research conducted in this study will not influence medical advice given to subjects and 
individuals engaged in the research will have no part in any decisions as to the timing, method, 
or procedures used to terminate a pregnancy. 
Neonates and infants will also be followed and treated for malaria in accordance with the Malian 
treatment guidelines. Uncomplicated malaria and asymptomatic parasitemia is treated with AL 
and complicated malaria is treated with arthemeter, artesune or quinine injection.   
  
 Contraindications to Vaccination  
The following criteria should be checked prior to each injection and are contraindications to 
further injections for the primary series:  
• Hypersensitivity reaction following administration of the study product (PfSPZ Vaccine 
or placebo) 
• Positive urine or serum β-hCG test prior to injection in women 
 
Subjects will be encouraged to remain in the study for safety evaluation and continued efficacy 
analysis (blood smears).  
For women who become pregnant during the course of the study, vaccination will be deferred at 
this time, but the women and their offspring will be followed according to Appendix A.  
 Indications for Deferral of Vaccination  
If any of the following AEs occurs at the time of the scheduled injection (vaccination with PfSPZ 
Vaccine or normal saline), the subject may be either vaccinated at a later date within the 
allowable visit window as specified in the protocol or withdrawn at the discretion of the 
Investigator: 
• 
Oral temperature >37.5˚C at the time of injection will warrant deferral of injection until 
fever resolves (within protocol-defined window). 
• 
Any other condition that in the opinion of the Investigator poses a threat to the individual 
if vaccinated or that may complicate interpretation of the safety of vaccine following 
vaccination. 
Such individual(s) will be followed in the clinic until the symptoms resolve or the window for 
injection expires. No further injections will be performed if the subject does not recover 
(temperature ≤ 37.5˚C and/or lack of symptoms) or develops a chronic condition deemed unsafe 
for future injections. The subject will be monitored for safety and immunogenicity for at least 3 

 
 
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months after their last injection (PfSPZ vaccine or normal saline), and if subject is willing 
longer, unless the subject has withdrawn consent. If the subject does not receive any further 
vaccinations, scheduled safety blood draws and malaria blood smear may not be performed at the 
discretion of the PI. Blood draws scheduled to measure immune response may be obtained if 
possible.  
If a subject misses vaccination #2, but is eligible for vaccination #3, they can proceed with 
receipt of vaccination #3 and be followed per protocol.  
 Prohibited Medications 
Treatment with some medications/procedures may potentially interfere with vaccine-induced 
immunity and/or interpretation of study endpoints. Use of any of the potentially interfering 
medications/procedures during the study may exclude a subject from receiving further doses of 
the study vaccine. However, the subject will be encouraged to remain in the study for safety 
evaluations. The following medications/procedures will not be permitted or may result in the 
withdrawal of the study subject: 
• Licensed killed vaccines in the 2-week period prior to and following each vaccination or 
licensed live vaccines in the 4-week period prior to and following each vaccination; 
• Receipt of immunoglobulins and/or any blood products up to six months prior to the first 
vaccination and for 30 days after administration of the last dose of vaccine; 
• Chronic oral or IV administration (≥ 14 days) of immunosuppressive doses of steroids, 
i.e., prednisone ≥20 mg per day, immunosuppressants, or other immune-modifying drugs 
from each day of vaccination to two weeks following each vaccination; 
• Any investigational drug or investigational vaccine other than the study vaccine during 
the study period; and 
• Surgical removal of the spleen or the development of a hematologic or other disease that 
would interfere with normal immunity. 
Medications, such as acetaminophen or ibuprofen, may be used to help relieve symptoms from 
vaccination and are not considered prohibited. All concomitant prescription medications, over-
the-counter medications and non-prescription medications taken at the time of adverse events (all 
grades) or for other reasons, will be documented into the case report form (CRF). 
Subjects are encouraged to contact study clinicians for any medical issues and consult with study 
clinicians prior to taking any medications not prescribed by the study clinician. Any medications 
taken by study subjects will be reviewed at every scheduled and unscheduled study visit with 
study staff. If a new medication has been started since the prior visit, then its potential to interact 
with any prescribed intervention in the study and/or interfere with the performance of the clinical 
trial will be assessed on a case by case basis.  
If the medication is needed for the health of the study subject and is contraindicated or cautioned 
with protocol-defined antimalarial treatment, alternative antimalarial treatments will be made 

 
 
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available to the study subject if clinically indicated. If the medication is needed for the health of 
the subject and might interfere with the vaccine by posing a safety risk to the subject, then the 
study subject should be withdrawn from further vaccinations and followed for safety. Use of 
antimalarial medications or antibiotics that have antimalarial activity administered during the 
study period is not exclusionary but will be documented by clinical staff and will be taken into 
consideration during data analysis.  
When possible, study subjects should review their plans to electively initiate a new medication 
with study staff before starting that medication; however, medical treatment will never be 
withheld or delayed due to concerns regarding its effect on the execution of the clinical trial.  
7 STUDY POPULATION 
The study population will consist of healthy adult females of child bearing potential aged 18–38 
years who reside in Ouelessebougou and surrounding villages in Mali.  
 Clinical Site 
The study will be carried out in collaboration between the LMIV/NIAID/NIH and the Malaria 
Research and Training Center (MRTC) in Bamako, Mali, and Sanaria, Inc. MRTC is 
experienced in conducting Good Clinical Practice (GCP) compliant clinical trials including two 
malaria vaccine and drug studies. 
Ouelessebougou is located about 80 km south of Bamako, the capital city of Mali. It contains the 
district health center and a Clinical Research Center located in the community health center 
where studies of malaria and other infectious disease have been ongoing since 2008.  
Based on our previous immunoepidemiology study in Ouelessebougou, malaria burden during 
pregnancy is high. Overall, at enrollment 28% of the pregnant women were infected with 
malaria, and infection was more frequent in primigravid women (43.5% compared to 19.8% of 
multigravid women). Among children less than 5 years of age, the incidence rate of clinical 
malaria was 1.99 episodes/child/year. Based on population census conducted under NIAID #17-
I-N018, 23.9% (7061/29,569) are women of child bearing age (aged 15-45 years), and 14% of 
these women (988) were pregnant.  
For the purpose of vaccine trials, adequate facilities for conducting an interventional trial have 
been put in place at Ouelessebougou within walking distance to the residents’ homes. The study 
site has a research clinic with an inpatient unit. Study physicians are available 24 hours a day, 
seven days a week.  
At Ouelessebougou, malaria transmission is highly seasonal, with the transmission season taking 
place from June until December, with peak transmission in August to November. 
Ouelessebougou is situated in a high transmission area, with entomological inoculation rates 
using CDC light traps of about seven infectious bites per person over the period of August to 
December (Dicko et al., 2011). Malaria parasite prevalence during the transmission season varies 
between 20-30% in adults (unpublished data).  

 
 
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 Recruitment 
Community permission will be obtained from village elders and other community members after 
explanation and discussion of the study at a community meeting (see Section 15.2.1). A general 
announcement inviting household and family members to the participating clinic to learn about 
the study will be made at the time of community permission, using local radio or any traditional 
channel of communication. 
 Inclusion Criteria 
Subjects must fulfill all the following criteria to be eligible for the study: 
1. Females of child bearing potential aged ≥ 18 and ≤ 38 years  
2. Able to provide proof of identity to the satisfaction of the study clinician completing the 
enrollment process 
3. In good general health and without clinically significant medical history 
4. Willing to have blood samples stored for future research 
5. Available for the duration of the study 
6. Must be willing to use reliable contraception (defined as: pharmacologic contraceptives 
[parental delivery] or pre-existing intrauterine or implantable device) from 21 days prior 
to study day 1 to 28 days after last vaccination  
7. Report being interested in becoming pregnant within the next 1 year  
 Rescreening Inclusion Criteria 
Subjects must fulfill all the following criteria to be eligible for the study: 
1. 
Females previously enrolled and received at least 2 vaccinations and followed both 
during 2019-2020 malaria transmission season AND 2020-2021 malaria transmission season 
 
2. 
Willing to have blood samples stored for future research 
 
 Exclusion Criteria 
A subject will be excluded from participating in the trial if any one of the following criteria is 
fulfilled: 
1. Pregnancy at the time of enrollment/vaccination, as determined by a positive urine or 
serum human chorionic gonadotropin (β-hCG) test  
2. Biologically unable to become pregnant secondary to: surgical sterilization, premature 
ovarian insufficiency (defined as no menses for ≥12 months without an alternative medical 
cause) 

 
 
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3. Behavioral, cognitive, or psychiatric disease that in the opinion of the investigator affects 
the ability of the participant to understand and comply with the study protocol 
4. Hemoglobin (Hgb), WBC, absolute neutrophils, and platelets outside the local 
laboratory-defined limits of normal and ≥ Grade 2 (subjects may be included at the 
investigator’s discretion for ‘not clinically significant’ abnormal values) 
5. Alanine transaminase (ALT) or creatinine (Cr) level above the local laboratory-defined 
upper limit of normal and ≥ Grade 2 (subjects may be included at the investigator’s 
discretion for ‘not clinically significant’ abnormal values) 
6. Infected with human immunodeficiency virus (HIV)  
7. Known or documented sickle cell disease by history (Note: known sickle cell trait is NOT 
exclusionary) 
8.   Clinically significant abnormal electrocardiogram (ECG) such as abnormal QTc. 
9.   Evidence of clinically significant neurologic, cardiac, pulmonary, hepatic, endocrine, 
rheumatologic, autoimmune, hematological, oncologic, or renal disease by history, physical 
examination, and/or laboratory studies including urinalysis 
10. History of receiving any investigational product within the past 30 days 
11. Participation or planned participation in a clinical trial with an investigational product 
prior to completion of the follow-up visit 28 days following last vaccination OR planned 
participation in an investigational vaccine study until the last required protocol visit 
12. Medical, occupational, or family problems as a result of alcohol or illicit drug use during 
the past 12 months 
13. History of a severe allergic reaction (Grade 2 or higher or per PI discretion) or 
anaphylaxis  
14. Severe asthma (defined as asthma that is unstable or required emergent care, urgent care, 
hospitalization, or intubation during the past two years, or that has required the use of oral or 
parenteral corticosteroids at any time during the past two years) 
15. Pre-existing autoimmune or antibody-mediated diseases including but not limited to: 
systemic lupus erythematosus, rheumatoid arthritis, multiple sclerosis, Sjögren’s syndrome, 
or autoimmune thrombocytopenia 
16. Known immunodeficiency syndrome 
17. Known asplenia or functional asplenia 
18. Use of chronic (≥14 days) oral or IV corticosteroids (excluding topical or nasal) at 
immunosuppressive doses (i.e., prednisone ≥20 mg/day) or immunosuppressive drugs within 
30 days of vaccination 

 
 
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19. Receipt of a live vaccine within the past four weeks or a killed vaccine within the past 
two weeks prior to Vaccination #1 and every subsequent vaccination day 
20. Receipt of immunoglobulins and/or blood products within the past six months 
21. Previous receipt of an investigational malaria vaccine in the last five years 
22. Known allergies or other contraindications against use of artemeter/lumefantrine 
23. Other condition(s) that, in the opinion of the investigator, would jeopardize the safety or 
rights of a participant participating in the trial, interfere with the evaluation of the study 
objectives, or would render the subject unable to comply with the protocol 
 Rescreening Exclusion Criteria 
A subject will be excluded from participating in the trial if any one of the following criteria is 
fulfilled: 
1. Enrollment in another malaria vaccine (outside of this protocol) or drug trial in the last 2 
years 
 
2. Development of behavioral, cognitive, or psychiatric disease that in the opinion of the 
investigator affects the ability of the participant to understand and comply with the study 
protocol 
 Justification for the Exclusion of Pregnant Women 
This study will not enroll pregnant woman at the start of the study since the effects of PfSPZ 
Vaccine on the developing human fetus will still be unknown at that time. No reproductive 
toxicity studies have been performed yet on PfSPZ Vaccine to assess preclinical safety and 
immunogenicity in pregnant animals, but is planned to occur in 2019. Once reproductive toxicity 
studies have been completed and reviewed and safety data has been reviewed from the first year 
of this study, as noted prior, our clinical development plan for PfSPZ Vaccine would include 
next studies of the safety and efficacy of a primary immunization series in all trimesters, and 
studies to evaluate the efficacy of boosting during pregnancy. 
If a woman becomes pregnant after enrollment, she may continue in the study for follow up only 
as outlined in Appendix A. AL is considered a category C medication, though AL is 
recommended as first line therapy in Mali and the U.S. for women with malaria in the second 
and third trimester of pregnancy.  There are no adequate studies in pregnant women during the 
first trimester. 
For prolonged follow-up (2020-2021, 2022-2023) pregnant women are able to participate in the 
study and are not excluded from participation. During this period of the study, no study product 
(vaccine, anti-malarial drug) will be administered.  
 Justification for Exclusion of Children 
Children are excluded from enrolling during the vaccination phase of this study given the focus 
of enrollment is on women who are looking to become pregnant in the next 1-2 years’ time.  

 
 
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Children will subsequently be enrolled, if consented by their parents, at birth until 12 months’ of 
age.  
8 SCHEDULE 
 Screening 
The purpose of the screening visit is to determine subject eligibility for study participation. 
Screening procedures include the informed consent process, Malaria Comprehension Exam, 
laboratory assessments (completed within 56 days of receipt of first vaccination) and clinical 
assessments. Screening activities can occur over multiple visits if necessary, including the day of 
enrollment.  
In the event that a chronic illness and/or HIV is discovered during the course of screening, long-
term treatment and care will not be reimbursed by the study, but referral for continuing care can 
be provided to subjects.  
 
Per national requirements for reporting communicable diseases, confirmed positive test results 
for HIV will be reported to the local health department according to applicable laws and 
appropriate medical referrals initiated. 
 
The following actions must be completed as part of the screening process for all subjects within 
the 56 days prior to first vaccination:  
 
• Explain the study and informed consent document to the subject; reconsenting if 
on the same prior version of the ICF is not required. 
• Ensure the subject has acknowledged consent by signing or fingerprinting the 
informed consent document. Ensure that the subject receives a signed copy of the 
informed consent. 
• Ensure the subject has correctly answered ≥80% of the questions (see Section 
15.2.2) on the Malaria Comprehension Exam.  
• Elicit a complete medical history, including menstrual and contraceptive history 
for females, and medication use. 
• Confirm that females of childbearing potential are willing to use reliable 
contraception from at least the period from screening (at least 21 days prior to 
first vaccination) through 28 days after the third vaccination.  
• Administer a complete physical examination, including vital signs (height, 
weight, blood pressure, temperature, and heart rate). 
• Complete HIV pre- and post-test counseling as indicated, including follow-up 
contact with subject to report the results and referral for appropriate medical care 
if indicated. 
• Obtain venous blood for complete blood count (CBC) with differential and 
platelet count, ALT, creatinine (Cr), HIV testing 

 
 
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• Obtain urine for urinalysis and/or urine dipstick 
• Obtain urine (or serum) for pregnancy testing. 
• Obtain a 12-lead ECG. 
 
Sickle cell testing will be completed retrospectively on subjects enrolled into the study. History 
of known sickle cell disease is an exclusion at the time of enrollment. Discovery of sickle cell 
disease (HbSS) on subsequent laboratory testing will not result in the subject being withdrawn 
from the study. 
 
Final eligibility will be determined at this point. The subject may be excluded by any of the 
above procedures if they meet the exclusion criteria. Acceptable ranges for hematological and 
biochemistry parameters defined for this study are given in Appendix B. (Note: parasitemia is 
not an exclusion criterion).  
 
If an abnormal finding is determined to be clinically significant, the subject will be informed, a 
referral letter will be issued, and the subject will be guided as to where to present for further 
investigation and medical care. Treatment for minor ailments may be provided by study 
clinicians at the study site. Decisions to exclude the subject from enrollment in the trial or to 
withdraw the subject from the trial will be at the discretion of the investigator. 
 
For continuation into Year 2 of follow-up, given no study product is being administered, women 
will be continued on study and no additional rescreening procedures, or inclusion/exclusion 
criteria will need to be completed. 
 
 Rescreening  
The purpose of the rescreening visit is to determine subject eligibility for study participation. 
Screening procedures include the informed consent process, review of eligibility, and a focused 
physical examination, if clinically indicated, to restart another 24 week period of follow-up 
(including blood draws). No screening labs, imaging, or ECG will be required given no 
additional study product is being administered.  
 Assignment of Groups 
Randomization of the subjects in Arm 1 or Arm 2 or Arm 3 will occur prior to first vaccination. 
Once a subject has received their first vaccination, they cannot be replaced.  
During the study, the list linking randomization numbers to study product (PfSPZ Vaccine or 
control) will be made available only to the study statistician and associated team members, 
pharmacy team/syringe preparers (at the start of the study), independent safety monitor (if 
needed to review), and DSMB chair (if needed for closed session unblinded review). On 
vaccination days, the vaccines associated with each randomization number will be obtained from 
the pharmacist. 

 
 
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To ensure proper identification of study subjects, following subject enrollment all subjects will 
receive an identification card with their photo on it to present at the clinic with each study visit. 
 Detailed Study Procedures 
Detailed study procedures are outlined in Appendix A of the protocol. 
9 STUDY PROCEDURES/EVALUATIONS 
 Photographs of Rash or Injection Site Reactions 
If a subject develops a rash or injection site reaction, photographs may be taken by the 
investigators. These photographs will not include the subject’s face or any identifying scars, 
marks, or tattoos. 
 Clinical Laboratory Testing 
Using standard techniques, the clinical laboratory will perform the following tests: 
1. Complete blood count (CBC) plus white blood cell (WBC) differential and platelet count 
• The following CBC parameters will be assessed for safety throughout the trial: WBC, 
absolute neutrophil count (ANC)/absolute granulocyte count (AGC), hemoglobin 
(Hgb), and platelet count. 
2. Serum creatinine (Cr) 
3. Alanine aminotransferase (ALT) 
4. HIV test (can include rapid diagnostics, ELISA, Western Blot if indicated) (at screening 
only) 
5. Urine and/or serum pregnancy testing (β-hCG) 
Additional clinical testing includes the following but will be completed retrospectively by 
other laboratories as noted below: 
1. Hemoglobinopathy testing - testing for normal adult hemoglobin (HbAA), hemoglobin c 
trait (HbCC), hemoglobin sickle cell trait (HbAS), hemoglobin sickle cell disease (HbSS)  
Additional clinical testing may be completed if a woman becomes pregnant (Appendix A): 
1. Blood type 
2. Serum glucose 
3. Serum Cr and ALT 
4. Urinalysis or urine dipstick 
5. CBC with differential 
6. Prenatal Ultrasound 
7. Rubella serology 
8. Hepatitis B serology 
9. Syphilis by treponemal or non-treponemal testing 
10. Toxoplasma IgG, IgM 
11. Malaria blood smear or rapid diagnostic test (RDT) 
12. Placental sample for parasitemia (blood smear, PCR) + histology  

 
 
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During pregnancy, some of the above safety clinical testing (see Appendix A) may be 
completed at least once per trimester at the women’s OB/GYN provider or during a clinical 
visit. In addition, specified research labs in Appendix A during pregnancy may also be 
completed at least once per trimester. 
Additional clinical testing may be completed in neonates/infants upon follow-up 
(Appendix A): 
1. Hemoglobin 
2. Malaria blood smear or RDT 
 
 Electrocardiogram 
Electrocardiograms (12-lead ECGs) will be performed during screening and as needed 
throughout the study by the study site team in Mali and read by a Mali cardiologist or NIH study 
cardiologist or their representative. Subjects with QT interval (QTc) > 460 ms will be excluded 
as AL may prolong QTc. Subjects with clinically significant abnormalities will also be excluded 
from the study. 
 Malaria Diagnostics 
 Malaria Blood Smears 
The gold standard for malaria diagnosis and evaluation of VE endpoints is the detection of 
malaria parasites on Giemsa-stained thick blood films. Blood smears are prepared in duplicate 
according to standard malaria challenge procedures and evaluated by trained study 
microscopists, and the results reported to the study PI. At least 0.5 µL are scanned for the 
presence of malaria parasites. This method allows for detection of a parasite density of 
approximately 3 parasites/µL and early diagnosis, often before subjects become symptomatic for 
malaria. For symptomatic subjects, at least 1.5 µL are evaluated. Slides are considered positive if 
at least two unambiguous P.falciparum parasites per slide are identified and confirmed by a 
second microscopist.  
Thick blood smears will be prepared from the blood remaining in the IV cannula, or (at time 
points when no IV blood collection is planned) from a finger prick sample. The smears will be 
examined microscopically. 
Thick blood smears will be used for diagnosis throughout the study. 
 Malaria qPCR 
While detection of parasites on thick blood smears remains the most common primary endpoint 
in human challenge trials, both PCR- and nucleic acid sequence-based amplification (NASBA)- 
based methods have been increasingly used to support blood smear data in malaria vaccine trials 
(M. Walther et al., 2005; M. Walther et al., 2006). These research molecular assays have 
significantly increased sensitivity for detection of P. falciparum blood-stage infection 
approaching 20 parasites/mL, often resulting in diagnosis 2-4 days earlier than by paired thick 

 
 
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blood smears (Hermsen et al., 2001; Schneider et al., 2004; M. Walther et al., 2005). 
Quantification of parasite density by these methods allows evaluation of parasite growth curves 
for assessing the utility of partially-effective vaccine candidates. LMIV has also developed a 
research qPCR that detects 18s of P. falciparum with a detection limit of at least 20 parasites/mL 
that will be used during the study for comparison to traditional thick blood smears.  
P. falciparum qPCR may be performed from all scheduled visits with a malaria blood smear 
noted (see Appendix A) to capture infections that remain below the detection limit for 
microscopy. For subject convenience, a finger prick sample can be used for both preparation of 
the microscopy slide and for DNA preservation. 
 Placental Malaria 
Blood smear (BS) microscopy, which is viewed as the gold standard for diagnosing placental 
malaria owing to longstanding clinical practice. Placental malaria will be detected by microscopy 
of Giemsa-stained thick and thin smears of blood extracted from placental tissue by mechanical 
grinding and will be quantified as percent of infected erythrocytes. Two readers will confirm 
each read. 
Whether applied to peripheral blood or placental blood samples, PCR methods yield positivity 
rates 20% or more above those of BS microscopy. For placental samples, qPCR will be used 
retrospectively using similar methods as outlined in Section 9.4.2. 
 Unscheduled Blood Smear Positive Visits 
After receipt of at least one vaccination, if a subject has detected P falciparum malaria parasites 
on peripheral thick blood smear (whether or not they were symptomatic; scheduled or 
unscheduled visits), she will be asked to the clinic to provide an additional blood sample within 
48 hours for the following as seen in Appendix A: 
• 0.5 mL ethylene diamine tetraacetic acid (EDTA) microtainer: for whole blood ex-
vivo assays if sample not obtained within the last two days with the positive blood 
smear  
• 4 mL EDTA tube: to obtain RNA and DNA for the study of host and parasite 
transcriptome (RNA) and parasite genotype (DNA) and to obtain plasma for 
proteomics studies  
o If 4mL EDTA sample has been collected in the last 28 days for this purpose, it 
can be deferred at the investigator’s or subject’s discretion.  
• 0.5 mL for qPCR if sample not obtained within the last two days with the positive 
blood smear 
 
The unscheduled blood smear positive blood draw does not need to be completed with every 
positive blood smear and subjects have the right, as with every blood draw, to refuse to return for 
this additional blood draw. Preference for unscheduled blood smear positive blood draws is for 
first positive blood smear post vaccination #3, subsequent positive blood smear after treatment 

 
 
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with anti-malarial treatment (>14 days after treatment), and new positive blood smear after 
having a negative blood smear >28 days.  
 Immunologic Laboratories 
As indicated in the objectives, assays will be conducted to assess immunogenicity in addition to 
safety as described above. Laboratory assays to assess immune response to PfSPZ Vaccine will 
be performed at the LMIV, NIAID, NIH, Sanaria Inc, and NIH Center for Human Immunology 
according to standard laboratory procedures. 
These assays include: 
1. Binding ELISA for antibodies to P. falciparum liver stage and blood stage antigens 
(which includes but not limited to: CSP, sporozoite surface protein 2, liver stage 
antigen 1, erythrocyte binding antigen 175, merozoite surface protein 1, merozoite 
surface protein 5, and exported protein 1 [PfCSP, PfLSA-1, PfEBA-175, PfMSP-1, 
PfMSP-5, malaria protein EXP-1] 
2. (IFN-γ) ELISPOT assay and multi-parameter flow cytometry with intracellular 
cytokine staining on peripheral blood mononuclear cells in P. falciparum liver- stage 
antigens (CSP, LSA-1) and PfSPZ  
3. B and T cells studies to analyze immunologic responses  
Sanaria, Inc. will also assess antibodies to whole PfSPZ by immunofluorescence assay (IFA) and 
inhibition of sporozoite invasion assay (ISI) and to asexual erythrocytic stage parasites by IFA as 
described (Epstein et al., 2011; Seder et al., 2013) and also by protein microarrays (Antigen 
Discovery Inc).  
In addition, using plasma, sera, peripheral blood mononuclear cells, or their component parts 
(e.g., purified IgG), Naval Medical Research Center will perform assays of humoral and cellular 
immunity that may be associated with protective activity. 
Laboratory assays to assess immune responses to novel pre-erythrocytic antigens will be 
performed in the PEVA Consortium laboratories at the LMIV, NIAID, and NIH according to 
standard laboratory procedures. The target proteins are novel antigens that confer protection 
against liver stage malaria in rodent malaria models (P. yoelii, P. berghei) according to 
vaccination studies conducted by Seattle BioMed and LMIV. The novel antigens to be used for 
these laboratory assays include PFL1995c, PFE0305w, LISP1 (PF14_0179), SAP1 (PF11_0480), 
MAL7P1.164, PF14_0113, using the identifiers in the PlasmoDB database (www.plasmodb.org). 
These antigens were initially selected on the basis of their gene expression during early liver 
stage development of P. falciparum, and preliminary testing shows that these antigens are 
immunologically recognized by individuals previously exposed to P. falciparum. The potential 
utility of these antigens as pre-erythrocytic vaccines has been supported by animal studies, 
wherein orthologues of these genes incorporated in DNA vaccines induce protective immunity in 
mice that significantly reduces the liver stage development of P. berghei and P. yoelii parasites. 
The assays included in this study can confirm that individuals receiving CVac with PYR develop 

 
 
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immune responses to pre-erythrocytic antigens and can provide additional data by which to 
assess the potential for these antigens to be developed as subunit vaccines to prevent infection. 
The long-term objective of the PEVA consortium is to identify antigens that individually, or in 
combination with CSP or other antigens, will induce a high level of pre-erythrocytic immunity 
that is protective against P. falciparum. 
VAR2CSA is a member of the PfEMP1 variant antigens that is preferentially expressed by 
placental parasites, and is currently the leading candidate for a vaccine to prevent malaria during 
pregnancy. During pregnancy parasites sequester in the placenta with and without parasites 
detected in peripheral blood. Increased antibody levels to VAR2CSA can indicate exposure to 
placental infection. Antibody levels to VAR2CSA will be compared between women who will 
become pregnant and received PfSPZ vaccine or placebo.  
The assays to be performed include: 
1. Binding ELISA for antibodies to P. falciparum pre-erythrocytic antigens (PFL1995c, 
PFE0305w, LISP1 (PF14_0179), SAP1 (PF11_0480), MAL7P1.164, PF14_0113) 
2. Binding ELISA for antibodies to VAR2CSA in samples from women that will become 
pregnant during the study 
3. IFN-γ ELISPOT/Intracellular cytokine staining (ICS) assay on peripheral blood 
mononuclear cells in P. falciparum pre-erythrocytic antigens (PFL1995c, PFE0305w, 
LISP1 (PF14_0179), SAP1 (PF11_0480), MAL7P1.164, PF14_0113)  
 Transcriptomic analysis  
Whole genome transcriptional profiling will be performed to explore possible gene expression 
profiles or pathways that predict optimal responses to vaccination. Gene expression profiling 
following vaccination will allow the predictive capacity of eventual protected and unprotected 
vaccinees, and thus will assist in defining the correlates of protection induced by vaccination. 
Transcriptional analyses will be performed on whole blood collected as outlined in Appendix A. 
Blood will be collected via venous puncture and placed in PAXGene tubes to preserve RNA 
integrity until the RNA is extracted. The molecular profiling encompasses the identification of 
RNA transcripts present in all humans, which are induced or repressed after each vaccination. 
This does not represent genetic testing of individuals or their DNA. 
 
 Maternal and Neonatal Clinical Outcomes 
Pregnancy and neonatal outcomes will include the collection of the following information  
1. Date of delivery, or date of the end of pregnancy in case of miscarriage/stillbirth  
2. Miscarriage 
3. Stillbirth 

 
 
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Macerated: fetus shows skin and soft-tissue changes (skin discoloration or 
darkening, redness, peeling and breakdown) suggesting death was well before delivery.  
Fresh: Fetus lacks skin changes and is presumed to have died intrapartum birth. 
4. Preterm delivery (based on ultrasound examination at recruitment at antenatal clinic, or 
recorded in the antenatal clinic card) or womb fundal height or last menstrual period.  
  
Defined as gestational age <37 weeks. 
5. Hypertensive disease in pregnancy (including gestational hypertension, preeclampsia, 
eclampsia, chronic hypertension with superimposed preeclampsia and HELLP (Hemolysis, 
Elevated Liver Enzymes, Low Platelets) syndrome) 
6. Birth weight, length, and head circumference (recorded in the antenatal clinic card 
within 24 hours of birth; evaluation for intrauterine growth restriction, microcephaly).  
7. Neonatal death  
               Early neonatal death: 0-7 days post delivery 
              Late neonatal death: 8-28 days post delivery 
8. Major malformations 
               Includes: central nervous system abnormalities, cleft lip/palate, congenital heart 
defects, gastrointestinal abnormalities, limb abnormalities, reproductive system abnormalities.  
Post-delivery questionnaire will provide the following information: maternal gravidity, history of 
pregnancy loss and socio-economic status, covariates that can influence the outcome of the 
current pregnancy.  
Following delivery in Year 1, mothers will be periodically followed as outlined in Appendix A. 
If women become pregnant during Year 2 follow-up, they will be followed as outline in 
Appendix A through visit P11.  
Infant follow-up, if pregnancy detected during Year 1 follow-up, will include regular 
measurement of weight, length, and head circumference as well as periodic blood draws as 
outlined in Appendix A. At 6- and 12-months of age, a developmental screening questionnaire 
will be completed. Infants born to women who become pregnant in Year 2 will only be followed 
for delivery outcomes. 
If a woman is pregnant or becomes pregnant during 2022-2023 follow-up period (3 years post 
initial vaccination series), she will be followed similar to the non-pregnant population. If she 
delivers while on study (during the 24-week period) we will collect limited information about the 
delivery outcome (estimated weeks of gestation (or full term versus preterm) and major 
complications or pregnancy outcomes) but we will not collect blood, placental, or cord blood 
samples and we will not follow the infants. During follow-up in both the pregnant and non-
pregnant population we will only report malaria and venipuncture related AEs and all SAEs. 

 
 
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10 RESEARCH USE OF STORED HUMAN SPECIMENS 
Intended Use: Samples and data collected under this protocol will be used to study malaria and 
related diseases and possible adverse reactions to vaccination.  
Storage: Access to stored research samples will be limited using either a locked room or a 
locked freezer. Temporary storage of samples collected in Mali, prior to shipment to LMIV, may 
occur at the Core Immunology Laboratory or the MRTC CAP laboratory. Samples will be stored 
at LMIV in Rockville, MD or at LMIV’s designated repository, Thermo Scientific, Rockville, 
MD, with the exception of retention specimens which may be kept at the MRTC in Mali for 
quality control. Samples and data will be stored using codes assigned by the investigators or their 
designees. Data will be kept in password-protected computers. Only investigators or their 
designees will have access to the samples and data.  
Tracking: Samples will be tracked using a sample-tracking software program, e.g., 
Freezerworks.  
Disposition at the Completion of the Protocol: In the future, other investigators (both at the 
NIH and outside) may wish to study these samples and/or data. In that case, Institutional Review 
Board (IRB) approval must be sought prior to any sharing of samples. Any clinical information 
shared about the sample with or without patient identifiers would similarly require prior IRB 
approval.  
At the completion of the protocol (termination), samples and data will either be destroyed or, 
after IRB approval, transferred to another existing protocol.  
Reporting the Loss or Destruction of Samples/Specimens/Data to the IRB: Any loss or 
unanticipated destruction of samples (for example, due to freezer malfunction) or data (for 
example, misplacing a printout of data with identifiers) that meets the definition of Protocol 
Deviation and/or compromises the scientific integrity of the data collected for the study, will be 
reported to the NIHIRB. 
Consent to allow long term storage of study samples is a part of the inclusion criteria for this 
study. However, if a subject decides following enrollment not to have their samples stored, the PI 
or designee will destroy all known remaining samples and report this destruction to the subject 
and the NIH IRB and Faculty of Medicine, Pharmacy and Odonto-Stomatology Ethics 
Committee (FMPOS EC). This decision will not affect the subject’s continued participation in 
this protocol or any other protocols supported by the NIH. 
11 DATA SHARING PLAN 
In NIH's view, all data should be considered for data sharing. Data should be made as widely and 
freely available as possible while safeguarding the privacy of subjects, and protecting 
confidential and proprietary data. We recognize that the public dissemination of our scientific 
results can facilitate the creation of collaborative efforts with domestic and international 
collaborators. Furthermore, we recognize that the proposed project may result in novel ideas for 
new methods, technologies, and data that could benefit the entire research community. 

 
 
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Therefore, final research data will be shared openly and timely in accordance with the most 
recent NIH guidelines (http://grants.nih.gov/grants/policy/data_sharing/) while being mindful 
that the confidentiality and privacy of participants in research must be protected at all times 
(Section 15.3). Timelines for distribution of data will vary depending on any required 
restrictions in accordance with federal and/or institutional policies and guidelines. In general, we 
expect de-identified data will be available through NIH-funded or approved public repository, 
speaking engagements and publications, presentations at scientific symposia and seminars. Effort 
will be made to publish our research findings in scientific journals. All final peer-reviewed 
manuscripts that arise from this proposal will be submitted to the digital archive PubMed 
Central. For tools, reagents, data and model organisms generated by the proposed study, pending 
third parties’ rights, LMIV will transfer materials to outside researchers in both the private and 
public sectors under a Material Transfer Agreement or Research Collaboration Agreement.  
12 ASSESSMENT OF SAFETY 
 Documenting, Recording, and Reporting Adverse Events 
At each contact with the subject, information regarding adverse events will be elicited by 
appropriate questioning and examinations and will be: 
• immediately documented in the subject’s medical record/source document, 
• recorded on the Adverse Event Case Report Form (AE CRF) or electronic database, 
and 
• reported as outlined below (e.g., IND sponsor, IRB, FDA). 
A study clinician will be available during the study period and will be available to the study 
subjects at all times. Should a subject call a study clinician to report an AE, it will be discussed 
with the PI and documented, recorded, and reported appropriately. 
  Definitions 
Adverse Event (AE): An AE is any untoward or unfavorable medical occurrence in a human 
subject, including any abnormal sign (e.g., abnormal physical exam or laboratory finding), 
symptom, or disease, temporally associated with the subject’s participation in the research, 
whether or not considered related to the research. 
Adverse Reaction (AR): An AR is an adverse event that is caused by an investigational agent 
(drug or biologic). 
Suspected Adverse Reaction (SAR): A SAR is an adverse event for which there is a reasonable 
possibility that the investigational agent caused the adverse event. ‘Reasonable possibility’ 
means that there is evidence to suggest a causal relationship between the drug and the adverse 
event. A suspected adverse reaction implies a lesser degree of certainty about causality than 
adverse reaction which implies a high degree of certainty. 

 
 
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Serious Adverse Event (SAE): A SAE is defined as an AE that results in any of the following 
outcomes: 
• 
death 
• 
life threatening (i.e., an immediate threat to life) 
• 
inpatient hospitalization or prolongation of an existing hospitalization 
• 
persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
• 
congenital anomaly/birth defect 
• 
medically important event 
Medical and scientific judgment will be exercised in deciding whether expedited reporting is 
appropriate in other situations, such as important medical events that may not be immediately 
life threatening or result in death or result in hospitalization but may jeopardize the subject or 
may require intervention to prevent one of the other outcomes listed above.  
Routine hospitalizations (mother and infant(s)) related to normal delivery and post partum care 
will not be reported as SAEs unless they meet an additional SAE criteria for reporting. Duration 
of hospitalizations and type of delivery (e.g. vaginal or C-section) will be routinely noted in the 
delivery reports. 
Unexpected Adverse Event: An AE is considered unexpected if it is not listed in the 
Investigator’s Brochure (IB) or Package Insert (for marketed products) or is not listed at the 
specificity or severity that has been observed. It is the responsibility of the IND sponsor to make 
this determination. 
Serious and Unexpected Suspected Adverse Reaction (SUSAR): A SUSAR is a SAR that is 
both serious and unexpected. 
Unanticipated Problem (UP): An UP is any event, incident, experience, or outcome that is 
1. unexpected in terms of nature, severity, or frequency in relation to 
a. the research risks that are described in the IRB-approved research protocol and 
informed consent document, IB, or other study documents; and 
b. the characteristics of the subject population being studied; and 
2. possibly, probably, or definitely related to participation in the research; and 
3. places subjects or others at a greater risk of harm (including physical, psychological, 
economic, or social harm) than was previously known or recognized.  
Serious Unanticipated Problem (UP):  A UP that meets the definition of a Serious Adverse 
Event or compromises the safety, welfare or rights of subjects or others. 

 
 
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Unanticipated Problem that is not an Adverse Event (UPnonAE): An UPnonAE is an UP 
that does not fit the definition of an adverse event, but which may, in the opinion of the 
investigator, involve risk to the subject, affect others in the research study, or significantly 
impact the integrity of research data. Such events would be considered a non-serious UP. For 
example, we will report occurrences of breaches of confidentiality, accidental destruction of 
study records, or unaccounted-for study drug. 
New Onset of Chronic Illness (NOCI): A NOCI is defined as a diagnosis of a new medical 
condition that is chronic in nature, including those potentially controllable by medication (e.g., 
diabetes, asthma). Any NOCI will be recorded in the same manner as unsolicited AEs. 
Protocol Deviation: Any change, divergence, or departure from the IRB-approved research 
protocol.  
Major Deviations: Deviations from the IRB approved protocol that have, or may have 
the potential to, negatively impact, the rights, welfare or safety of the subject, or to 
substantially negatively impact the scientific integrity or validity of the study.   
Minor Deviations: Deviations that do not have the potential to negatively impact the 
rights, safety, or welfare of subjects or others, or the scientific integrity or validity of the 
study.  
Non-Compliance: Failure of investigator(s) to follow the applicable laws, regulations, or 
institutional policies governing the protection of human subjects in research, or the requirements 
or determinations of the IRB, whether intentional or not. Failure of subjects to comply with the 
research protocol does not represent non-compliance unless that failure is due to an action or 
omission of a member of the research team, for example, the failure to give adequate instruction 
to the subject 
Serious non-compliance: Non-compliance, whether intentional or not, that results in 
harm or otherwise materially compromises the rights, welfare and/or safety of the subject. 
Non-compliance that materially effects the scientific integrity or validity of the research 
may be considered serious non-compliance, even if it does not result in direct harm to 
research subjects.  
Continuing non-compliance: A pattern of recurring non-compliance that either has 
resulted, or, if continued, may result in harm to subjects or otherwise materially 
compromise the rights, welfare and/or safety of subjects, affect the scientific integrity of 
the study or validity of the results. The pattern may comprise repetition of the same non-
compliant action(s), or different noncompliant events. Such non-compliance may be 
unintentional (e.g. due to lack of understanding, knowledge, or commitment), or 
intentional (e.g. due to deliberate choice to ignore or compromise the requirements of any 
applicable regulation, organizational policy, or determination of the IRB). 

 
 
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 Investigator Assessment of Adverse Events 
If a diagnosis is clinically evident (or subsequently determined), the diagnosis rather than the 
individual signs and symptoms or lab abnormalities will be recorded as the AE.  
All solicited (see Table 8 below) and unsolicited AEs will be recorded through Day 7 after each 
injection. Injection site reactions will be assessed until Day 7 after injection (PfSPZ Vaccine or 
normal saline) or until resolved.  
After the periods specified above only unsolicited AEs, SAEs, UPs, and NOCIs will be recorded. 
Table 8: Solicited Adverse Events 
Laboratory adverse events1 
Hemoglobin (decreased hemoglobin) 
Platelet count (thrombocytopenia or 
thrombocytosis) 
WBC (leukopenia or leukocytosis) 
Creatinine (Cr) (increased Cr) 
ANC (neutrophil count decreased) or AGC 
(granulocyte count decreased) 
ALT (increased ALT) 
Local reactogenicity (secondary to PfSPZ Vaccine/normal saline) – through Day 7 post 
injection 
Injection site pain/tenderness 
Injection site induration 
Injection site erythema/redness 
Injection site swelling/edema 
Injection site pruritus 
Injection site bruising 
Systemic reactogenicity (secondary to PfSPZ Vaccine/normal saline) – through Day 7 
post injection 
Rash 
Urticaria 
Generalized pruritus 
Generalized Edema 
Headache 
Fever or feverish 
Chills 
Malaise/Fatigue 
Myalgia 
Arthralgia 
Sweats 
Diarrhea 
Back Pain 
Chest Pain (non-musculoskeletal) 
Nausea/Vomiting 
Abdominal Pain 
 
1 Note absolute lymphocyte counts will be capture on CRFs for use for research assessments. If clinically significant 
changes as determined by PI, these may also be reported as AEs as noted below. 
Any laboratory abnormalities (other than those specified as safety labs in the protocol as defined 
by the values in the toxicity table) should be reported as AEs if they require intervention. 
Interventions include, but are not limited to, discontinuation of treatment, dose reduction/delay, 
additional assessments, or concomitant treatment. In addition, any medically important 
laboratory abnormality may be reported as an adverse event at the discretion of the investigator. 
This could include a laboratory result for which there is no intervention, but the abnormal value 
suggests a disease or organ toxicity. In addition, similar to solicited AEs, all laboratory AEs as 
defined in Appendix B, will be collected and graded for severity through 7 days after each 
vaccination until resolved. 

 
 
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For follow-up completed in 2022-2023 (3-years post receipt of last study product) only malaria 
related AEs (e.g. clinical malaria, blood smear positive) and venipuncture AEs and all SAEs will 
be captured.  
The Investigator will assess all AEs with respect to Seriousness (criteria listed above), Severity 
(intensity or grade), and Causality (relationship to study agent and relationship to research) 
according to the following sections in the protocol. 
 Severity 
Severity of AEs will be assessed by the investigator as described in Appendix B. AEs not 
included in the Appendices will be graded for severity using the followings definitions as seen in 
Table 9. 
Table 9: AE Severity Grading Definitions 
Severity 
Definition 
Grade 1 (Mild) 
No interference with activity, may use one 
dose of an over the counter medication 
Grade 2 (Moderate) 
Repeated use of non-narcotic pain reliever > 
24 hours or some interference with activity 
Grade 3 (Severe) 
Activities of daily living limited to <50% of 
baseline, medical evaluation/therapy required 
Grade 4 (Life-Threatening) 
Extreme limitation in activity, significant 
assistance required; immediate medical 
intervention or therapy required to prevent 
death 
Grade 5 
Death 
 
 Causality 
Causality (likelihood that the event is related to the study agent) will be assessed considering the 
factors listed under the following categories: 
Definitely Related 
• reasonable temporal relationship 
• follows a known response pattern 
• clear evidence to suggest a causal relationship 
• there is no alternative etiology 
Probably Related 

 
 
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• reasonable temporal relationship 
• follows a suspected response pattern (based on similar agents) 
• no evidence of a more likely alternative etiology 
Possibly Related 
• reasonable temporal relationship 
• little evidence for a more likely alternative etiology 
Unlikely Related 
• does not have a reasonable temporal relationship  
 
OR 
• good evidence for a more likely alternative etiology 
Not Related 
• does not have a temporal relationship 
 
OR 
• definitely due to an alternative etiology 
Note: Other factors will also be considered for each causality category when appropriate. 
Causality assessment is based on available information at the time of the assessment of the AE. 
The investigator may revise the causality assessment as additional information becomes 
available. 
The degree of certainty with which an AE can be attributed to administration of the study 
vaccine will be determined by how well the event can be understood in terms of one or more of 
the following: 
• The event being temporally related with vaccination or reproduced on re-vaccination; 
• A reaction of similar nature having previously been observed with this type of vaccine and/or 
formulation; 
• The event having been reported in the literature for similar types of vaccines; and/or 
• Whether or not there is another identifiable cause. 
All local (injection site) reactions will be considered causally related to vaccination. All malaria 
cases will be reported as not related to vaccination unless results indicate otherwise. 
Asymptomatic parasitemia (positive blood smears without related malaria clinical symptoms) 
will not be reported as an AE. Clinical malaria will be reported as an AE. 
Reports will further classify AEs as follows:  

 
 
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• Related - all AEs that are assessed as definitely, probably, or possibly related. 
• Unrelated - all AEs assessed as unlikely or definitely not related. 
When reporting to regulatory authorities and IRBs is needed, AE relationship will be determined 
as noted above. 
 Investigator Reporting Responsibilities to the Sponsor 
 Adverse Events 
Line listings, frequency tables and other summary AE data will be submitted to the IND sponsors 
when needed for periodic safety reviews, review of IND annual reports, review of IND safety 
reports, and preparation of final study reports. 
 Serious Adverse Events 
All SAEs (regardless of relationship and whether or not they are also UPs) will be reported and 
sent to the IND sponsor by fax (SAE fax line: 240-306-0596) or email attachment. Deaths, 
immediately life threatening and all possibly, probably or definitely related SAEs will be 
communicated by telephone, fax, email or automated report via the data management system by 
the PI within 24 hours of site awareness of occurrence to the IND sponsor. All other SAEs will 
be reported to the IND sponsor within three business days after the site becomes aware of the 
event. The PI must document that the communication is received and acknowledged. 
Sanaria, Inc.  
SAE Fax: 240-306-0596 
 
Individuals: 
1. Stephen L. Hoffman, M.D. 
  Tel: 240-403-2701(office)  
Tel: 240-299 3178 (mobile) 
Email: slhoffman@sanaria.com 
 
  2. Thomas L Richie, M.D., Ph.D. 
  Tel: 240-403-2727 (office) 
  Tel: 301-466-7943 (mobile) 
  Email: trichie@sanaria.com 
 
3. L.W. Preston Church, M.D. 
  Tel: 240-403-2714 (office) 
  Tel: 843-814-0888 (mobile) 
  Email: lwpchurch@sanaria.com 
 
4. Tooba Murshedkar, MS 
  SAE Fax: 240-306-0596 
Email: tmurshedkar@sanaria.com 
 

 
 
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In Mali – the clinical site investigator will also notify the LMIV PI and the site medical monitor 
in Mali by email, fax, or telephone within one working day of notification of an SAE occurrence. 
LMIV Contact Information: 
PI: Patrick Duffy, M.D. 
Tel:   301-761-5089 
Fax:   301-480-1962 
Email: patrick.duffy@nih.gov 
 
Independent Safety Monitor: 
Oumar Moussokoro Traore, MD 
Reference Health Center of Commune V 
Bamako, Mali 
+ 223 76 18 72 71 
Email: baroutraore@yahoo.fr 
 
 Unanticipated Problems (UPs) 
All UPs that are also adverse events will be reported to the IND sponsor on the NIH Reportable 
Events Form sent by fax or email attachment no later than 7 calendar days of site awareness of 
the event.  
UPs that are not AEs will also be reported to the IND sponsor. 
 Pregnancy 
Pregnancies are anticipated to occur during follow up of this population of WOCBP, and our 
ongoing pregnancy registry data suggest this may occur at a rate of ~6% per month in the target 
demographic once active pregnancy prevention stops. Pregnancy itself is not an AE. However, 
complications of pregnancies are AEs and may be SAEs; despite these events being reported as 
AEs or SAEs, based on our initial pregnancy registry data, we expect these events to occur at a 
relative frequency as noted below (Table 10 and 11).  
Table 10: Rate of Adverse Outcomes from Pregnancy Registry (NIAID Protocol #17-I-
N018) 
 
Primigravid, % (n) 
Secundigravid, % (n) 
Multigravid, % (n) 
Miscarriage + stillbirth 
2.2% (8) 
2.2% (7) 
2.0% (16) 
Preterm delivery 
7.5% (27) 
4.1% (13) 
2.6% (21) 
 
Table 11: Rate of Early and Late Neonatal Death from Pregnancy Registry (NIAID 
Protocol #17-I-N018) 
 
Preterm Delivery, 
% (proportion) 
Term Delivery, 
% (proportion) 
Early neonatal death 
11% (7/61) 
1.6% (23/1404) 
Late neonatal death 
1.6% (1/61) 
0.3% (4/1404) 

 
 
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Pertinent obstetrical information for all pregnancies will be reported to the IND sponsor and 
LMIV via fax or email within three business days from the site awareness of the pregnancy 
during vaccination. At >1 month post third (or last) vaccination, given the number of expected 
pregnancies on this study, all pregnancies will be reported monthly to the IND sponsor and 
LMIV via fax or email with quarterly detailed updates as noted below. 
Pregnancy outcome data (e.g., delivery outcome, spontaneous, or elective termination of the 
pregnancy) will be reported to the IND sponsor and LMIV within three business days of the 
site’s awareness via fax or email. At >9 months post third (or last) vaccination, given the number 
of expected deliveries on this study, all births will be reported monthly to the IND sponsor and 
LMIV via fax or email with quarterly detailed updates as noted below. 
In the event of pregnancy during the period of vaccine administration (including 21 days prior to 
vaccination #1 to 1 month post vaccination #3), the following steps will be taken: 
• 
The subject will be withdrawn from receiving any further investigational products 
but will continued to be followed actively in the study per Appendix A; alternative 
pregnant woman schedule but continued blood smear evaluation and safety lab 
evaluations per vaccine cohort (Appendix A) 
• 
Report to FMPOS EC as an informational item  
• 
Report to NIH IRB at the time of continuing review  
• 
Report to DSMB, Sponsor Medical Monitor, and Site Medical Monitor 
• 
Advise research subject to notify the obstetrician of possible study vaccine 
exposure 
In the event of pregnancy or delivery after the period of vaccine administration (starting >1 
month post dose #3 for pregnancies and >9 months post dose #3 for deliveries/miscarriages) and 
follow up, the following steps will be taken: 
• 
The subject will continue in follow-up according to the alternative study schedule 
outlined in Appendix A. 
• 
Reported to FMPOS EC and NIH IRB at time of continuing review.  
• 
Report to DSMB, Sponsor Medical Monitor, and Site Medical Monitor quarterly. 
• 
Advise research subject to notify the obstetrician of possible study vaccine 
exposure 
Given women reconsenting to participate in an additional year of follow-up (2022-2023) may be 
pregnant to participate and it has been >3 years since last product administration, documentation 
of new pregnancies and/or birth outcomes will not be reported and will just be captured on the 
study CRF.  

 
 
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 Reporting Procedures to NIH IRB and FMPOS EC 
 Expedited Reporting to the NIH IRB and FMPOS EC 
Non-compliance: Any actual or suspected non-compliance by any investigator or entity 
associated with the protocol must be reported by the NIH PI/designee within 7 calendar days of 
any investigator or individual associated with the protocol first becoming aware, unless 
otherwise indicated in this policy.  
Non-NIH IRB determinations of serious and/or continuing noncompliance about an NIH 
investigator: If the NIH is relying on a non-NIH IRB and the Reviewing IRB makes a 
determination of serious and/or continuing non-compliance regarding an NIH investigator, then, 
even if the determination has already been provided to OHSRP either directly or via the NIH 
Institutional Official (IO)/designee, the NIH PI/designee must report this in iRIS within 7 
calendar days of any member of the research team being notified of the determination by the 
Reviewing IRB. The NIH PI must provide the OHSRP office of Compliance and Training with 
documentation from the Reviewing IRB unless this documentation has already been provided 
directly to the office by the Reviewing IRB or via the IO.  
Major Deviation: A deviation must be reported within 7 calendar days of an investigator 
becoming aware of an actual or suspected deviation. Although protocol deviations are also non-
compliance, these should only be reported once as deviations.  
Unanticipated Problem (UP): A UP must be reported within 7 calendar days of an investigator 
becoming aware of the actual or suspected UP.  
Death: Any death of a research subject that is possibly, probably or definitely related to the 
research must be reported within 24 hours of an investigator becoming aware of the death.  
New information that might affect the willingness of a subject to enroll or remain in the study 
should be reported within 7 calendar days of an investigator first becoming aware.  
Any suspension or termination of research activities, including holds on new enrollment, placed 
upon the research by the study sponsor, NIH or IC leadership, or any regulatory agency must be 
reported within 7 calendar days of an investigator becoming aware.  
Investigators must provide the following information to the IRB in summary format at the time 
of continuing review: Minor protocol deviations; Adverse events and Serious Adverse Events 
that do not meet the definition of an UP.  
Investigators are required to immediately (i.e., no longer than 10 days) report SAEs or UADEs to 
the study sponsor and, if also an actual or suspected UP, to the IRB within 7 calendar days of an 
investigator becoming aware. 
 Annual Reporting to the NIH IRB and FMPOS EC 
The following items will be reported to the NIH IRB and FMPOS EC in summary format at the 
time of Continuing Review: Minor protocol deviations; Adverse events and Serious Adverse 
Events that do not meet the definition of an UP.  

 
 
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 Additional Investigator Reporting Responsibilities to the Local IRB (NIH IRB 
and FMPOS EC) 
Investigators are responsible for submitting any IND FDA Safety Reports and UP summaries 
that are received from the IND sponsor to their local IRB/EC. Investigators must also comply 
with all local IRB/EC reporting requirements. 
 Reporting to the Data and Safety Monitoring Board 
As agreed with the Office of Clinical Research Policy and Regulatory Operations (OCRPRO), a 
DSMB chartered by the IND sponsor, Sanaria, Inc. will be used for this study instead of the 
NIAID Intramural DSMB. 
The DSMB will review the study prior to initiation, after completion of the vaccination series 
and at study close. Quarterly summaries regarding pregnancy (maternal and neonatal outcomes) 
will be submitted to the board for review on an ongoing basis.  The board may convene 
additional reviews as necessary, and will issue recommendations concerning continuation, 
modification, or termination of the study. All SAEs will be reported by the PI to the sponsor 
immediately upon becoming aware of them. All SAEs that are possibly, probably or definitely 
related to the study agent, Ups, and safety reports (as available) will be reported by the sponsor 
to the DSMB. 
The DSMB will review the study data to evaluate the safety, efficacy, study progress, and 
conduct of the study. The sponsor will notify the DSMB of any cases of intentional or 
unintentional unblinding as soon as possible. The sponsor will notify the DSMB at the time 
pausing criteria are met and obtain a recommendation concerning continuation, modification, or 
termination of the study. The PI will submit the written DSMB summary reports with 
recommendations to the IRB(s). 
 Follow-up Adverse Events and Serious Adverse Events 
AEs that occur following receipt of a single vaccination are followed until the final outcome is 
known or until the end of the study follow-up period.  
SAEs that have not resolved by the end of the follow-up period will be followed until the final 
outcome is known. If it is not possible to obtain a final outcome for an SAE (e.g., the subject is 
lost to follow-up), the reason a final outcome could not be obtained will be recorded by the 
investigator on the AE CRF (if the CRF is still open) and the SERF.  
SAEs that occur after the study follow-up period (six months following the last vaccination) that 
are reported to and assessed by the Investigator to be possibly, probably, or definitely related 
must be reported to the study IND sponsor as described above. 
 Sponsor’s Reporting Responsibilities 
SUSARs as defined in 21 CFR 312.32 and determined by the IND sponsor will be reported to 
FDA and all participating Investigators of related Sanaria trials as IND Safety Reports.  

 
 
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The IND sponsor will also submit an IND Annual Report of the progress of the investigation to 
the FDA as defined in 21 CFR 312.33.  
 Pausing Criteria for the Main Vaccine Phase 
The PI will closely monitor blinded study data as they become available and will make 
determinations regarding the presence and grading of Aes. The Aes will be evaluated with regard 
to the known complications associated with administration of vaccine components. If a dose of 
vaccine is considered unacceptably reactogenic (as described in the following criteria), the study 
will be paused. No new enrollments and no further vaccinations will be administered by the 
investigators until reviewed by the DSMB and study IND sponsor. A report of DSMB 
recommendations will be submitted to the IRBs. The following criteria will be used to define 
unacceptable reactogenicity of the malaria vaccine (Aes that are possibly, probably, or definitely 
related to the vaccine will be considered “Related” and will be summarized as such): 
1. One or more subjects experience an SAE as defined in Section 11.4.2 of this protocol 
that is determined to be possibly, probably, or definitely related to the vaccine or placebo 
or 
2. One or more subjects experience a hypersensitivity reaction (e.g. anaphylaxis, diffuse 
urticaria) that is probably or definitely related to the vaccine or placebo; or 
3. Any severe clinical illness occurs that is not explained by a diagnosis that is unrelated to 
injection; or 
4. Thirty percent of subjects in any dose arm experience the same Grade 2 or higher 
laboratory abnormality (see Appendix B), or Grade 3 systemic AE that is determined to 
be possibly, probably, or definitely related to the injection (PfSPZ Vaccine or placebo) as 
defined in this protocol or  
5. Ten percent of subjects in any arm experience Grade 3 or higher local reactogenicity; or 
6. Any safety issue that the study PI or IND sponsor determines should pause the study. 
 
The IRBs, the NIAID, the FDA, or other government agencies may discontinue the study at any 
time. Subsequent review of serious, unexpected, and related Aes by the DSMB or IRB, the IND 
sponsor, the FDA, and other regulatory authorities may also result in suspension of further 
administration of vaccine at the clinical site (or, in the case of the DSMB, a recommendation to 
the Sponsor that the study should be suspended). The FDA, other regulatory authorities, and the 
study sponsor(s) retain the authority to suspend additional enrollment and administration of 
vaccine for the entire study as applicable.  
 Pausing Criteria for the Pregnancy and Offspring Follow-up Phase 
The PI will closely monitor blinded study data as they become available and will make 
determinations regarding the presence and grading of Aes, in particular defined safety and 
protective efficacy outcomes in pregnant women and their offspring, as defined by the protocol. 
These Aes and safety and protective efficacy outcomes will be evaluated by the study team, 
Sponsor, and DSMB on a regular basis defined at the start of the study, for occurrence of events 
outside of the expected background rate in the community.   

 
 
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If a concern arise during the course of vaccination, all vaccinations will be halted until DSMB 
review has been held. Post vaccination, an aggregate report of these events will be provided on a 
quarterly basis for review by the Sponsor, IRB/EC, and DSMB. If there’s an identified concern 
about pregnancy outcomes, all enrolled women will be provided an update of the concern and 
any additional recommendations associated with the concerns as the information becomes 
available.  
 Reporting of Study Pausing 
If a pausing requirement is met, a description of the event(s) or safety issue will be reported by 
the PI or Site Investigator within one business day of awareness of, to the IND sponsor by fax or 
email. 
The site investigator will inform the LMIV PI, the ISM, and the local IRB that a pausing rule has 
been met according to their requirements. The LMIV PI will notify the NIH IRB. The IND 
sponsor will notify the DSMB as well as all sites conducting Sanaria-sponsored studies, or 
studies using Sanaria related products that the study has been paused. 
 Resumption of a Paused Study 
The IND sponsor, in collaboration with the PI and DSMB, will determine if it is safe to resume 
the study. The IND sponsor will notify the site investigators of this decision. The conditions for 
resumption of the study will be defined in this notification. The site investigator will notify their 
local IRB(s) of the study pause and of the decision to resume the study. 
 Pausing Criteria for a Subject  
The decision to suspend administration of the study agent(s) for a single subject or for all 
subjects in a specific group requires discontinuation of use of the study agent to any study 
subject(s) until a decision is made whether or not to continue study agent in the study.  
The pausing criteria for a single subject or for the subjects in this study include:  
• A subject experiences an SAE or ≥ 2 or more Grade 3 or greater AE (excluding 
laboratory assays) that is unexpected (as determined by the IND sponsor) and is possibly, 
probably, or definitely related to the study agent;  
OR 
• Any safety issue that the Site Investigator determines should pause administration of the 
study agent to a single subject.  
The IND sponsor, in collaboration with the PI, may also pause for an individual subject if a 
safety concern is identified during routine aggregate data analysis. 
 Reporting of Pausing for a Subject  
If a pausing requirement is met, a description of the AE(s) or safety issue must be reported by the 
site Investigator by fax or email within one business day to the IND sponsor and LMIV PI. The 

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

 
 
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(other than local reactions lasting <72 hours, or systemic reactions lasting <48 hours) will 
result in pausing of the subject from further vaccinations until the subject is reviewed by 
the study Sponsor, DSMB .. Subjects may also be withdrawn for any AE that would 
cause continued participation in the study to not be in the best interest of the subject, as 
per the investigator’s judgment. Any subject who will not receive any further vaccination 
because of an AE related to study agent will be followed for safety until at least 
resolution of that AE and will be encouraged to remain in the safety evaluation for the 
duration of the study. 
 
5. Other – is used when previous categories do not apply and a written explanation is 
required. 
If a subject withdraws or is withdrawn prior to completion of the study, the reason for this 
decision will be recorded in the source documents and CRFs. Any subject who has received at 
least one dose of vaccine will be encouraged to remain in the safety evaluation for the duration 
of the study. The subject’s data will be included in the safety and immunogenicity analysis. If a 
subject fails to complete all planned vaccinations because of an AE or SAE, the subject will be 
followed until resolution or stabilization of the event. If a subject withdraws, the investigator will 
make a reasonable effort to determine the reason. 
 Replacement of Withdrawn Subjects 
Subjects who have received at least one vaccination and who withdraw or are terminated from 
the study prior to completion will not be replaced. Subjects withdrawn before the first 
vaccination may be replaced. 
  Unblinding for the Study 
Intentional, unscheduled unblinding may occur if a subject experiences a SAE that the treating 
clinician and/or site PI believes warrants unblinding to provide appropriate clinical management 
of the subject. The request for unblinding may be requested by the site PI or designee, sponsor, 
sponsor medical monitor, independent medical monitor, and DSMB. If non-emergent, all parties 
should be notified to discuss prior to unblinding taking place. If unblinding is requested, an 
“Unblinding Report” should be documented per standard operating procedures and submitted to 
the study statistician for formal unblinding.  
If emergency unblinding is required, the PI or designee will contact the study statistician or study 
pharmacist for unblinding. The sponsor will be informed within one business day that the 
unblinding was necessary and a submitted “Unblinding Report” will be provided within 2 
business days.  
In general, unless requested by the PI or designee, sponsor, sponsor medical monitor, 
independent medical monitor, or DSMB, pregnancies will not result in unblinding of subjects 
involved in the study. 

 
 
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Subjects who are unblinded will be encouraged to remain in the study to be followed for safety 
regardless of their indication for unblinding. 
Scheduled unblinding, for all study participants – pregnant or not pregnant, will occur at the 
completion of the subject’s final malaria follow-up visit in Year 2 (study visit 561; final study 
visit of Year 2 exploratory efficacy endpoint) as outlined in Appendix A.  Individuals directly 
continuing AE assessment or performing assays for exploratory endpoints will remain blinded to 
individual randomization until assessment or assays are completed.  
The study Sponsor, Sanaria, Inc., requested in writing an unscheduled unblinding, to support 
future PfSPZ Vaccine studies, to occur prior to planned unblinding of the protocol on study day 
561 (anticipated Feb 2021). This unblinding was requested to only include Year 1 data from 
screening to study day 197 (from July 2019 to Feb 2020) (final study visit of Year 1 secondary 
efficacy endpoint/malaria follow-up) and include the following information: enrollment data, 
demographics, drop outs (through study day 197), solicited (local and systemic) AEs 
through study day 36, unsolicited AEs through study day 57, laboratory AEs through study day 
57, and SAEs through study day 197.  Summary of pregnancies and miscarriages through study 
day 197 were provided by the study team. This request was reviewed by the scientific review 
committee, DSMB, NIH IRB, and FMPOS EC prior to implementation. LMIV data manager 
provided a blinded report for collation of this data. MRTC and LMIV staff were not involved in 
the transmission, review, or discussion of any unblinded results. Unblinding data was transmitted 
directly from the unblinded study statistician (or designee not involved with direct study 
participant care or evaluation) to the Sponsor for submission to the FDA.  
Given that no additional study product will be administered in the continued follow-up of 
previous participants, no scheduled DSMB meeting will be set up unless necessary as outlined in 
Section 12.16.3 or at the request of the DSMB, but during the final DSMB meeting for the 
overall study, results from this extension will also be presented.  
 Safety Oversight 
 Sponsor Medical Monitor 
A medical monitor, representing the IND sponsor (Sanaria, Inc) has been appointed for oversight 
of safety in this clinical study. The sponsor medical monitor will be responsible for performing 
safety assessments. 
 Independent Safety Monitor (ISM) in Mali 
An independent safety monitor (ISM) in Mali will review the study prior to initiation and will be 
available to advise the investigators on study-related medical issues and to act as a representative 
for the welfare of the subjects. The ISM will conduct independent safety monitoring and 
recommend appropriate action regarding adverse events and other safety issues. The ISM is an 
expert in the field of oversight of clinical trials conducted in Mali and internal medicine, 
specifically in the population under study in Mali. The ISM does not have direct involvement in 
the conduct of the study and does not have other interests with any collaborating pharmaceutical 
firms or their competitors.  

 
 
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All serious adverse events, all UPs, and all FDA IND Safety Reports will be reported by the PI to 
the ISM prior to or at the same time they are submitted to the IRB or IND sponsor. The ISM will 
be notified immediately if any pausing rule is met and the ISM will provide recommendation for 
continuation, modification, or termination of the study. The PI will also notify the medical 
monitor if intentional or unintentional unblinding occurs. 
 Data and Safety Monitoring Board (DSMB) 
As agreed with OCRPRO, for this study a DSMB chartered by the IND sponsor, Sanaria, Inc. 
will be used instead of the NIAID Intramural DSMB. 
The DSMB will review the study prior to initiation and as outlined in Section 12.7. The board 
may convene additional reviews as necessary, and will issue recommendations concerning 
continuation, modification, or termination of the study. All SAEs, UPs, and all IND Safety 
Reports will be reported by the sponsor to the DSMB.  
The DSMB will review the study data to evaluate the safety, efficacy, study progress, and 
conduct of the study. The sponsor will notify the DSMB at the time pausing criteria are met and 
obtain a recommendation concerning continuation, modification, or termination of the study. The 
PI will submit written DSMB summary reports with recommendations to the IRB(s).  
13 CLINICAL MONITORING 
 Site Monitoring Plan 
As per International Conference on Harmonization (ICH)-GCP 5.18 and FDA 21 CFR 312.50, 
clinical protocols are required to be adequately monitored by the study sponsor. This study 
monitoring will be conducted according to the “NIAID Intramural Clinical Monitoring 
Guidelines.” Monitors under contract to the NIAID/OCRPRO will visit the clinical research site 
to monitor aspects of the study in accordance with the appropriate regulations and the approved 
protocol. The objectives of a monitoring visit will be: 1) to verify the existence of signed 
informed consent documents and documentation of the informed consent process for each 
monitored subject; 2) to verify the prompt and accurate recording of all monitored data points, 
and prompt reporting of all SAEs; 3) to compare abstracted information with individual subjects’ 
records and source documents (subjects’ charts, laboratory analyses and test results, physicians’ 
progress notes, nurses’ notes, and any other relevant original subject information); and 4) to help 
ensure investigators are in compliance with the protocol. The monitors also will inspect the 
clinical site regulatory files to ensure that regulatory requirements: for the Office for Human 
Research Protections (OHRP), FDA, and applicable guidelines (ICH-GCP) are being followed. 
During the monitoring visits, the investigator (and/or designee) and other study personnel will be 
available to discuss the study progress and monitoring visit. 
The investigator (and/or designee) will make study documents (e.g., consent forms) and pertinent 
hospital or clinical records readily available for inspection by the local IRB, the FDA, the IND 
Sponsor (Sanaria), the site monitors, and the NIAID staff for confirmation of the study data.  

 
 
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A specific protocol monitoring plan will be discussed with the PI and study staff prior to 
enrollment. The plan will outline the frequency of monitoring visits based on such factors as 
study enrollment, data collection status and regulatory obligations. 
14 STATISTICAL CONSIDERATIONS 
 Endpoints and Statistical Methods 
 Safety Analysis 
Safety will be assessed by line listing and tables at the individual level. Safety will be 
additionally assessed over women who become pregnant during the study and their newborns. 
These safety profiles will be reviewed in light of baseline rates in the targeted population for 
pregnancy outcomes defined in an ongoing pregnancy registry at the study site. Other concerning 
trends will be investigated as needed or requested by the PI, ISM, IND sponsor, and/or DSMB.  
Group comparisons, between each vaccine arm and the control arm, may be performed in terms 
of the proportion of AE and SAE adopting the as-treated analysis and the per protocol analysis.  
 Vaccine Efficacy Analysis 
Primary efficacy analysis will be based on time to infection during the first year post vaccination. 
The time to infection, which is defined as the time to the first positive blood smear. Each vaccine 
arm will be compared with the control arm by logrank test for interval-censored data (using the 
interval package in R). Vaccine efficacy (VE) will be estimated assuming a Weibull model and 
allowing for interval censoring (survival package in R).  
The proportions of infection will be also compared between each vaccine arm with the control 
arm by the exact binomial test, or the Exact Cochran-Mantel-Haenszel test (using the 
mantelhaen.test in R with the exact option set to true, this is a conditional exact test). Subjects 
that are censored prior to the last day of planned follow up will be removed from the analysis and 
censoring will be assumed to be completely at random. A sensitivity analysis may be performed 
where all censored subjects are treated as either cases or non-cases in either arm.  
Under either of these analyses, we will perform a modified ITT and a per-protocol analysis. 
Under the modified ITT analysis, subjects receiving at least one vaccination will be included and 
will be analyzed according to the assigned arm. Under the per-protocol analysis, subjects that 
drop out prior to receiving the full number of vaccinations will not be included in the analysis 
and they will be analyzed according to the regimen actually received.  
Exploratory analysis on efficacy will also be conducted on the subset of women who become 
pregnant during followup with respect to P.falciparum blood stage infection and P.falciparum 
placental infection. The timing of pregnancy and number of prior pregnancies may be included 
as a confounder in the efficacy analysis. Exploratory efficacy analysis may also be performed to 
compare the two vaccine dose arms. 
Additional exploratory analyses may be completed looking at other malaria infection endpoints, 
such as symptomatic malaria episodes, malaria infection detected by PCR, gametocytemia, and 
non-P. falciparum infections.  

 
 
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Similar efficacy analyses as above will be performed over the Year 2 data at the end of Year 2 
follow-up. In addition, we will assess the protective efficacy over Year 1 and Year 2 combined. 
 Immunogenicity analysis 
We will characterize and compare immunogenicity responses between vaccine and placebo arms 
by Wilcoxon rank sum test or two-sample t-test after proper transformation. We will also 
compare the immunogenicity response before and after vaccination by Wilcoxon signed rank test 
or paired t-test after proper transformation. Figures of immune responses in each study arm will 
be provided to depict the pattern of change in immune responses. 
We will explore the impact of PfSPZ Vaccine on the genotype and transcriptome profile of 
parasites isolated from study subjects using a linear regression or a generalized linear regression. 
 Pregnancy and Neonatal Outcomes  
As noted, prior special attention will be given to outcomes for women who become pregnant 
during the study and their newborns, and will be reviewed in light of background rates for 
pregnancy outcomes defined in an ongoing pregnancy registry at the study site. Given the 
pregnancy rates seen thus far during the Pregnancy Registry (#17-I-N018), we expect the 
following occurrences of pregnancies and deliveries over the course of the study as outlined in 
Table 12 and Table 13. 
Table 12: Number of Expected Pregnancies Post PfSPZ Vaccine or Normal Saline 
Vaccination 
 
Aug 
2019 
Sep 
2019 
Oct 
2019 
Nov 
2019 
Dec 
2019 
Jan 
2020 
Feb 
2020 
Mar 
2020 
Apr 
2020 
May 
2020 
Jun 
2020 
Jul 
2020 
Aug 
2020 
Total 
Estimated 
PfSPZ 
Vaccine 
(n=200) 
1 
(0.5%) 
2        
(1 %) 
1 
(0.5%) 
2       
(1 %) 
3 
(1.6%) 
4 
(2.1%) 
6 
(3.3%) 
8 
(4.6%) 
10 
(6.1%) 
9 
(5.8%) 
9 
(6.2%) 
8 
(5.8%) 
8 
(6.2%) 
71 
(35.5%) 
Estimated 
Normal 
Saline 
(n=100) 
0 
(0.0%) 
1 
(1%) 
0 
(0.0%) 
1 
(1%) 
1 
(1%) 
2  
(2.1%) 
3 
(3.3%) 
4 
(4.5%) 
5  
(6%) 
5 
(6.4%) 
4 
(5.5%) 
4 
(5.8%) 
4 
(6.2%) 
35  
(35%) 
Actual 
Totals from 
Current 
ProtocolA 
0/288 
(0.0%) 
0/288 
(0.0%) 
6/288 
(2.1%) 
5/282 
(1.8%) 
10/277 
(3.6%) 
14/267 
(5.2%) 
15/254 
(5.9%) 
19/245 
(7.8%) 
19/232 
(8.2%) 
8/214 
(3.7%) 
6/209 
(2.9%) 
14/203 
(6.9%) 
13/191 
(6.8%) 
129/288B 
(44.8%) 
Actual 
Number of 
Pregnancy 
Loss from 
Current 
Protocol 
0 
0 
0 
0 
0 
1 
6 
6 
1 
3 
0 
2 
1 
19C 

 
 
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+Depo-Provera = median delay before conception was 5.5 months + 4 months after discontinuing; IUD = median 
delay before conception was 4.5 months after discontinuing.  
AEligible Women = 288 women received Vaccination #3. Not included are: 4 enrolled, but not vaccinated, women 
who became pregnant and 1 woman who became pregnant post Vaccination #2. 
B129 pregnancies occurred in 120 individual women during this time period. 9 women became pregnant twice 
during this time period 
C20 miscarriages occurred in 19 individual women during this time period  
Table 13: Number of Expected Children Post PfSPZ Vaccine or Normal Saline Vaccination 
 
May 
2020 
Jun 
2020 
Jul 
2020 
Aug 
2020 
Sep 
2020 
Oct 
2020 
Nov 
2020 
Dec 
2020 
Jan 
2021 
Feb 
2021 
Mar 
2021 
Apr 
2021 
May 
2021 
Total 
Estimated 
PfSPZ 
Vaccine 
(n=200) 
1  
2        
1  
1        
3 
 
3  
5  
7  
7  
8 
 
7 
7 
6 
58  
Estimated 
Normal 
Saline 
(n=100) 
0 
 
1 
 
0 
 
2 
 
1 
 
1   
3 
 
3  
4 
 
4 
3  
4  
3  
29 
Actual 
Deliveries 
from 
Current 
Protocol 
0 
4 
7 
13 
10 
9* 
14 
17 
10 
6 
10 
15 
15 
130 
+Assuming ~15-20% baseline pregnancy loss; note this estimated loss may be underrepresented but will be adjusted 
as more data is collected under #17-I-N018.  
AOnly women who became pregnant post Vaccination #3 included in this table. Not included are: 4 enrolled, but not 
vaccinated, women who became pregnant and 1 woman who became pregnant post Vaccination #2. 
*Excludes two stillbirths. 
 Sample Size Consideration 
Three hundred subjects will be enrolled and randomized 1:1:1 to the control and the two 
vaccination arms. All subjects will contribute to safety evaluation at least up to certain time 
points.  For safety evaluation, with 100 subjects in each arm, there is >90% probability of 
observing at least one adverse event if the adverse event rate is no less than 0.023. Previous 
studies on the study vaccine have indicated low adverse event rate associated with the vaccine. 
The goal of safety analysis is to establish the safety profile of vaccine arm.  
Sample size consideration primarily targets vaccine efficacy evaluation basing on the 
comparison of each vaccine arm with the control arm.  The null hypothesis is VE=0 and the 
alternative hypothesis is VE is not equal to zero.  If the annual drop-out rate is between 15% and 
25%, there will be 75 to 85 subjects available in each arm for efficacy evaluation one year after 
study initiation. With 80 samples in each arm, the study is capable of detecting the protective 
efficacy of vaccine with over 80% power if VE is 45% or higher and the background infection 
rate is ≥0.5 (see Table 10). These calculations are based on Cox proportional-hazard model at 
two-sided significance level of 0.05, which follows a normal approximation to the logrank test 

 
 
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without adjustment for interval censoring [Reference: Fundamentals of Biostatistics, Bernard 
Rosner, 2006].  
Table 14: Power for group-wise comparison based on logrank test on time to infection 
Sample size 
per arm 
Background 
infection rate 
Vaccine 
Efficacy 
Power 
75 
0.5 
0.45 
81 
75 
0.5 
0.3 
46 
75 
0.5 
0.25 
34 
75 
0.6 
0.45 
92 
75 
0.6 
0.3 
60 
75 
0.6 
0.25 
45 
75 
0.7 
0.45 
98 
75 
0.7 
0.3 
75 
75 
0.7 
0.25 
60 
80 
0.5 
0.45 
84 
80 
0.5 
0.3 
48 
80 
0.5 
0.25 
36 
80 
0.6 
0.45 
94 
80 
0.6 
0.3 
63 
80 
0.6 
0.25 
48 
80 
0.7 
0.45 
98 
80 
0.7 
0.3 
78 
80 
0.7 
0.25 
62 
85 
0.5 
0.45 
86 
85 
0.5 
0.3 
51 
85 
0.5 
0.25 
37 
85 
0.6 
0.45 
95 
85 
0.6 
0.3 
65 
85 
0.6 
0.25 
50 
85 
0.7 
0.45 
99 
85 
0.7 
0.3 
80 
85 
0.7 
0.25 
65 
 
 Randomization and Blinding 
Eligible participants will be randomized to study arms using block randomization of 
sequentially-numbered study ID numbers that are generated sequentially for those participants 
who meet inclusion criteria after screening. Randomization codes will be generated by study 
statisticians and provided to the pharmacist by direct delivery in sealed, opaque envelopes or 

 
 
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electronically using a secure email server. The study is blinded to participants and study staff 
involved with assessing all clinical and laboratory outcomes. 
 Interim Analysis 
No interim analysis will be performed in this trial. The primary analysis on efficacy will be 
performed after the first peak transmission season, approximately in January 2020. The same 
efficacy analysis methods will be applied to the interim analysis in both modified ITT and the 
per protocol cohorts. This analysis will be performed to assist regimen selection in future studies. 
The analysis will completed by the study statistician and will be reviewed by LMIV senior 
investigators and PI, MRTC senior investigator, the Sponsor and DSMB.  Subjects, site 
clinicians and site personnel conducting clinical assessments and LMIV and MRTC laboratory 
personnel conducting study related assays will remain blinded until after scheduled unblinding at 
the completion of the study and completion of study related assays. In this way, they analysis 
results will not affect the secondary analysis on efficacy that will be performed after the end of 
the second transmission season.  
In October 2020, the study Sponsor (Sanaria, Inc) requested an unblinded analysis on safety, 
immunogenicity, efficacy, and pregnancy rates/outcomes be made available from Year 1 of the 
study (through primary efficacy endpoint, study day 197) to share with the FDA which was 
approved by Scientific Review, NIH IRB, FMPOS EC, and DSMB and was submitted to the 
FDA by the Sponsor.   
15 Human Subject Protections and Ethical Obligations 
This research will be conducted in compliance with the protocol, GCPs, and all applicable 
regulatory requirements. 
 Institutional Review Board 
A copy of the protocol, informed consent forms (ICFs), and other study-related information such 
as questionnaires, diary cards, medical history forms, and any proposed advertising/recruitment 
materials or letters to the subjects will be submitted to the reviewing IRBs for written approval. 
The investigator must submit and obtain approval from the IRBs for all subsequent amendments 
to the protocol, informed consent documents, and other study documentation referenced above. 
The investigator will be responsible for obtaining IRB approval of the annual Continuing Review 
throughout the duration of the study. The investigators will notify the reviewing IRBs of protocol 
violations and SAEs as specified in the relevant sections of the protocol. The results of the study 
will be shared with the IRBs. 
 Informed Consent Process 
Informed consent is a process where information is presented to enable persons to voluntarily 
decide whether or not to participate as a research subject. It is an on-going conversation between 
the human research subject and the researchers which begins before consent is given and 
continues until the end of the subject’s involvement in the research. Discussions about the 
research will provide essential information about the study and include: purpose, duration, 

 
 
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experimental procedures, alternatives, risks and benefits. Subjects will be given the opportunity 
to ask questions and have them answered.  
Consent forms will be approved by all participating IRBs. The subjects will sign the informed 
consent document prior to undergoing any research procedures. The subjects may withdraw 
consent at any time throughout the course of the trial. The informed consent process will be 
documented in the subject’s research chart, as required by 21 CFR 312.62. The ICF will be 
signed (or fingerprinted) and personally dated by the subject and the person who conducted the 
informed consent discussion. The original signed ICF will be retained in the subject’s chart and a 
signed and dated copy will be provided to the subject. The rights and welfare of the subjects will 
be protected by emphasizing to them that the quality of their medical care will not be adversely 
affected if they decline to participate in this study.  
 Community Permission in Mali 
Community permission will be obtained from village elders, family heads, and other community 
members after explanation and discussion of the study (Diallo et al., 2005). The community 
permission process goes through the following steps: 
• Study investigators/personnel explain the study to village leaders, including the village 
chief, family heads, women association, and elders. 
 
• The village leaders then discuss the study with family heads and community members 
and relay any additional questions or concerns they may have to study personnel. 
 
 
• The study and the informed consent process are explained in detail to heads of families 
by study investigators/personnel.   
 
At the time of community permission, the need for both husband and wife to agree to avoid 
pregnancy for the specified period if a wife chooses to volunteer will also be addressed. 
The individual informed consent process and form will be translated into French. The study team 
conducts careful word-for-word review of the study consent form, and will translate the consent 
orally into local languages, as the majority of potential study subjects do not read or speak 
French. Verification that the oral translations are accurate and that the potential subjects 
understand the contents of the informed consent form will be done by an independent witness 
who is not a member of the study team.  
 Individual Informed Consent in Mali 
WOCBP will be invited to come to the study clinic for review of the informed consent, and if the 
subject agrees to participate, the subject will sign or fingerprint the consent form.  
At the consenting visit, the subject will read the consent form, or have it explained orally in cases 
of illiteracy. WOCBP will be separately consented and not all individuals from a household need 
to participate.  

 
 
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Subjects will be encouraged to ask questions, and then take a multiple-choice questionnaire 
(true/false) to evaluate consent comprehension. All incorrect responses will be reviewed with the 
subject, and she must verbalize understanding of all incorrect responses. A score of ≥80% correct 
is required for enrollment. For subjects scoring less than 80%, study staff may choose to review 
study details again with subject and reassess comprehension with a repeat Malaria 
Comprehension Exam. At the discretion of the investigator, any subject whose comprehension is 
questionable, regardless of score, may be excluded from enrollment.  
The Malaria Comprehension Exam will be translated into French and administered orally in the 
native dialect in the case of potential subjects who cannot read. Study staff will use incorrect 
answers from the questionnaire to identify those areas of the informed consent that need further 
review with subject. This will help ensure that the subject has sufficient understanding before the 
consent form is signed. The subject may either sign the consent form immediately or later after 
further consideration. Subjects unable to read will place a fingerprint in the place of a signature. 
In addition, an independent witness will sign the consent form to attest that the consent was fully 
explained and all questions were answered. 
For rescreening, no Malaria Comprehension Exam will be required, but individual informed 
consent will be obtained from each participant choosing to continue as described above.   
 Subject Confidentiality 
Subjects will not be identified in any publicly released reports of this study. All records will be 
kept confidential to the extent provided by federal, state, and local law. The study monitors and 
other authorized representatives of the sponsor may inspect all documents and records required 
to be maintained by the investigator. The investigator will inform the subjects that the above-
named representatives will review their study-related records without violating the 
confidentiality of the subjects. All laboratory specimens, evaluation forms, reports, and other 
records that leave the site will be identified only by a coded number in order to maintain subject 
confidentiality. All records will be kept locked and all computer entry and networking programs 
will be done with coded numbers only. Clinical information will not be released without written 
permission of the subject, except as necessary for monitoring by IRB, FDA, NIAID, OHRP, or 
the sponsor’s designee. 
16 POTENTIAL RISKS AND BENEFITS 
For any clinical trial, the risk for potential subjects should be weighed against the benefit. PfSPZ 
Vaccine has been shown in previous studies to provide protection from malaria infection in 
vaccinated individuals at similar dosing regimens and schedules as proposed here. It is unknown 
if there is continued protective efficacy or clinical benefit in a woman who becomes pregnant 
following vaccination and within their offspring. 
Risks to the subjects are associated with venipuncture, immunization, or drug administration.  
These risks are outlined below: 

 
 
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 Venipuncture 
Risks occasionally associated with venipuncture include pain, bruising, bleeding, and infection at 
the site of venipuncture, lightheadedness, and rarely, syncope. 
The total amount of blood collected is well within the American Association of Blood Banks 
recommendations and the current NIH guidelines, and will not compromise these otherwise 
healthy subjects (Howie, 2011). Any minor bruising, local tenderness or pre-syncopal symptoms, 
or rarely, infection associated with venepuncture, will be documented as AEs. 
For follow-up into 2022-2023 malaria transmission season, venipuncture is the only risk to 
women re-enrolled.   
 DVI Immunizations (either PfSPZ Vaccine or Normal Saline) 
Possible local injection reactions resulting from DVI include pain, swelling, erythema, 
induration, limitation of limb movement for several days, lymphadenopathy, bruising, or pruritus 
at the injection site. Systemic reactions such as fever, chills, headache, fatigue, malaise, myalgia, 
and joint pain may also occur, and may range from mild to severe. These side effects will be 
monitored but are generally mild and self-limiting. 
As with any investigational product, immediate hypersensitivity reactions including urticaria, 
anaphylaxis, or other IgE-mediated responses are possible. There is a theoretical possibility of 
risks about which we have no present knowledge. Subjects will be informed of any such risks 
should further data become available. 
Subjects may be asked to defer routine immunization until 14 – 28 days following vaccination.  
 PfSPZ Vaccine 
Based on vaccinations administered thus far, the most frequent Aes reported have been headache 
and malaise, with the majority mild to moderate in nature. Laboratory abnormalities seen include 
mild, transient, and asymptomatic change in liver enzymes (ALT and/or aspartate 
aminotransferase [AST]), WBC (leukopenia), and absolute granulocyte counts.  
Possible local reactions include pain, swelling, erythema, induration, limitation of limb 
movement for several days, lymphadenopathy, or pruritus at the injection site. Systemic 
reactions such as fever, chills, headache, fatigue, malaise, myalgia, and joint pain may 
also possibly occur, with some reactions moderate or severe. 
Other than mild and transient local (site of administration) reactions, the listed adverse 
reactions remain theoretical.  
In the course of conducting PfSPZ Vaccine trials 7 participants have become pregnant during the 
course of the study. Two pregnancies were carried to term; although one of the 2 pregnancies 
was complicated by intrauterine growth retardation (IUGR) and some subsequent fetal 
abnormalities, these complications were not thought to be related to vaccine. One pregnancy 
resulted in early fetal demise – in this case the date of vaccine administration was approximately 
the same as the estimated date of conception and the event was considered possibly related to 

 
 
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vaccine. Two pregnancies were electively terminated by the study participant. Two additional 
pregnancies are ongoing and appear to be progressing normally.  
Details of each pregnancy are provided below. 
1. Bethesda, MD (USA):  
G1P0 woman who had a positive screening serum pregnancy test on 1 July 2014 
(43 days after last immunization), confirmed by a repeat test on 2 July 2014. Her 
LMP was 12 June and reportedly normal. Her 4th of 4 immunizations with 2.7x105 
PfSPZ of PfSPZ Vaccine was 19 May 2014. Her previous pregnancy test on 2 
June was negative and she underwent controlled human malaria infection (CHMI) 
on 3 June. She remained negative for P. falciparum parasitemia by blood smear 
and PCR throughout the subsequent 28-day monitoring period. As this was an 
unplanned pregnancy, the participant elected to terminate the pregnancy on 7 July 
2014. 
2. Equatorial Guinea:  
19 year old G3P2 woman was found to have a positive urine pregnancy test on 4 
January 2017 after reporting her LMP was 13 November. Her previous urine 
pregnancy test was negative on 1 December 2016. She had initiated oral 
contraceptives after the 1 December visit and also received her first dose of 
2.7x106 PfSPZ of PfSPZ Vaccine. After her positive pregnancy test no further 
vaccine was administered. On 17 January 2017 (estimated gestational age 9 2/7 
weeks) she underwent transvaginal ultrasound which showed a 6-week embryo 
without cardiac activity; these findings were confirmed on a repeat ultrasound a 
week later. The products of conception were evacuated using misoprostol without 
further complication. 
18 yo G1P0 woman who presented to her local clinic on 30 August 2017 with 
nausea, vomiting, generalized weakness and a last menstrual period on 18 July 
2017 (90 days after her last dose of vaccine). Her urine pregnancy test was 
positive. She reported no use of contraception. Her third and final dose of 1.8x106 
PfSPZ of PfSPZ Vaccine was administered 19 April 2017. The participant’s 
vomiting progressed and she was admitted for IV fluids and symptom control 
with a diagnosis of hyperemesis gravidarum of moderate severity.  Her symptoms 
were successfully managed and there were no further complications during the 
pregnancy. She delivered a healthy baby girl at 37 4/7 weeks weighing 2880 
grams. Examination of the infant at 1 month was normal except for an umbilical 
granuloma. 
15 yo G1P0 woman was found at a prevaccination assessment visit 18 April 2017 
to have a positive urine pregnancy test. She had previously received 1.8x106 
PfSPZ of PfSPZ Vaccine on 8 December 2016 and 25 February 2017. By 
ultrasound her estimated date of conception was 7 April 2017 (41 days after 
vaccination) with estimated delivery date of 29 December 2017. Fetal ultrasounds 
were normal at 16 and 24 weeks. At 30 5/7 weeks there was evidence of IUGR 
followed by onset of gestational hypertension and proteinuria at 33 weeks. The 

 
 
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infant was delivered by cesarian section at 33 2/7 weeks with a weight of 1300 
grams, Apgar scores of 8 and 9. The volunteer had no further complications and 
recovered fully. The infant was initially hypoglycemic but responded to 
treatment; no evidence of neonatal sepsis was found. The baby was discharged 
after 3 days and gained weight appropriately at home. A patent ductus arteriosus 
(PDA) was identified on echocardiogram on 4 December and treated with 2 days 
of ibuprofen; repeat echocardiograms dated 31 January and 30 April 2018 showed 
the PDA had decreased in size. Also noted were moderate tricuspid insufficiency 
and a patent foramen ovale. Cardiac chamber sizes and systolic function were 
normal. The child also had a protuberant right inguinal hernia and underwent 
bilateral inguinal herniorrhaphies under general anesthesia on 26 December 2017 
without complication.  
3. Tanzania:  
26 year old G1P0 woman who had a positive urine pregnancy result on a home 
test kit approximately 20 days after starting a 4-dose series of immunizations with 
9x105 PfSPZ every other day. Urine pregnancy testing prior to immunizations had 
been negative. She subsequently self-administered misoprostol vaginal 
suppositories. When she presented for her booster immunization pre-assessment 
on day 26 her urine pregnancy test was positive and she was found by ultrasound 
to have had an incomplete abortion. She subsequently underwent a dilatation and 
evacuation without further complications. 
 
4. Mali:  
25 year old G4P3 woman who presented to the clinic on 8 January 2019 with 
nausea, dizziness, headache, myalgias and a missed menstrual period. A serum 
pregnancy test was positive. Her third and final dose of investigational product 
was administered 18 September 2018 (112 days previously); her last injection of 
medroxyprogesterone was 19 July 2018. No further problems have been reported 
for this participant. The estimated due date is 4 August 2019. 
21 year old G4P3 woman who presented to the clinic on 19 January 2019 with 
mild abdominal pain, headache, dizziness, maylgias and feverishness x 3 days 
plus 2 months of amenorrhea. Malaria RDT was negative; a serum pregnancy test 
was positive. Her third and final dose of investigational product was 12 
September 2018 (129 days previously); her last injection of medroxyprogesterone 
was 13 August 2018. No further problems have been reported for this participant. 
The estimated due date is 26 August 2019.Of note from the obstetric history – all 
3 prior births were live births but the first child died after 1 day of unknown 
causes and the 2nd child died after 5 days of unknown causes.  
Miscarriages frequently occur without known causes and although it is unlikely the vaccine 
caused the miscarriage, the temporal relationship meant this was a possibility. All women of 
child-bearing age are required to take birth control measures as specified within the protocol 
and/or consent form to avoid getting pregnant while participating in trials of PfSPZ-based 

 
 
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products. In this protocol, women of child bearing potential must use parental injectable 
contraceptive or have a pre-existing implantable or intrauterine device at least 21 days prior to 
receipt of Sanaria® PfSPZ Vaccine injection.  
A 15-year-old boy who received PfSPZ Vaccine, had a generalized seizure 3 ½ hours after 
receiving his third dose. The boy fully recovered from the seizure. The EEG showed that he was 
predisposed to having seizures. It is unlikely the vaccine caused the seizure, but like all vaccines, 
PfSPZ Vaccine causes an immune response in the body which may increase the chance that 
those individuals predisposed to seizures experience one. 
As with any infusion, immediate hypersensitivity reactions including urticaria, anaphylaxis, or 
other IgE-mediated responses are possible. There is a theoretical possibility of risks about which 
we have no present knowledge. Subjects will be informed of any such risks should further data 
become available. 
Subjects may be asked to defer routine immunization (such as influenza) until 14 – 28 days 
following vaccination.  
 Normal Saline 
The amount of normal saline used in this study is small (< 1 mL) and has been well tolerated, 
including in previous PfSPZ Vaccine studies. Overall, most Aes reported with the use of normal 
saline have been reactions that may have occurred because of administration technique and have 
been local injection reactions as noted above in Section 15.2.  
 Antimalarial Medication 
Subjects will be treated with a registered, oral, proven, and highly efficacious treatment during 
the course of this study per standard clinical practice. These medications will be tracked closely, 
similar to study specific products, but are not considered investigational for this study as they are 
standard of care treatments for uncomplicated and complicated malaria. 
 Artemether/Lumefantrine 
For artemether/lumefantrine, the most commonly reported side effects in adults are: headache, 
anorexia, dizziness, asthenia, arthralgia and myalgia. Generally, these effects do not require 
discontinuation of the drug. 
Artemether/lumefantrine has an acceptable safety profile. Individuals who may have any 
contraindication for the use of this drug (e.g. prolonged QTc or taking other medications that can 
prolong QTc, history of myocardial infarction) will be excluded at screening. The most common 
side effects (i.e., >30%) in adults are: headache, anorexia, dizziness, asthenia, arthralgia, and 
myalgia. Discontinuation of artemether/lumefantrine due to AE is rare (0.2%) in adults. Rare but 
serious hypersensitivity reactions (urticarial and angioedema) and skin reactions (bullous 
eruption) have been reported post marketing.  
Artemether/lumefantrine is a Category C pregnancy drug, though it is currently recommended by 
WHO for treatment of uncomplicated malaria during the second and third trimester. Thus, all 

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

 
 
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Pregnancy testing is performed during screening and throughout the vaccination period, 
including prior to each PfSPZ Vaccine or placebo vaccine via DVI and prior to AL dosing. 
Pregnancy prevention counseling and compliance is reinforced at every clinic visit (see 
Appendix A) throughout the vaccination period and for 28 days post vaccination #3. 
If clinical history indicates recent sexual activity that may lead to pregnancy, or history or 
symptoms suggestive of pregnancy, a serum β-HCG test will be performed and results reviewed 
by a study investigator prior to the subject continuing in the study.  
If a subject becomes pregnant during the first year of the study (2019; through study day 365), 
the subject will not be withdrawn from the study but no further investigational products will be 
administered. The Sponsor and NIH IRB/FMPOS EC will be notified of the pregnancy as 
outlined in Section 12.7. We will confirm the pregnancy by urine (or serum) pregnancy test. The 
subject will be advised to follow up for antenatal care per Mali Ministry of Health guidelines. 
This may include receipt of intermittent preventive treatment for prevention of malaria in 
pregnancy. 
The subject will then be provided with an alternative study schedule, as outline in Appendix A, 
which will include obtaining blood for safety labs (if indicated), blood smear +/- PCR samples, 
and periodic research samples. This study schedule may be altered at the investigator’s discretion 
if any concern that the blood draws would impact the health of the mother or the fetus. The 
mother will be invited to continue follow up until the end of pregnancy, and to enroll her 
newborn and herself in one year of additional follow up, in order to document the pregnancy and 
neonatal outcomes. Pregnant women will be seen at antenatal consultation including at least one 
visit during the first, second, and third trimester. In addition to their usual prenatal care, pregnant 
women will be invited to consult with study clinicians on a monthly basis for a clinical 
assessment including blood pressure measurement.  
The newborn will followed-up actively and passively. Active surveillance will be completed 
with in-person visits every two months for 12 months as well as additional telephone 
consultations completed every two weeks through 6-months of life. Passive follow-up will be 
done through the availability of the study clinicians 24 h/day and 7 days as week to assess the 
pregnant women and newborn through the follow-up period. For new pregnancies detected in 
Year 2 of follow-up (study day 393 onwards), newborns will only have delivery outcomes 
collected (study visit C0) and will not be followed beyond this visit. 
If a woman miscarries, she will be permitted to continue on the study as a non-pregnant subject 
and will join that study schedule on the closest estimated upcoming visit. If she becomes 
pregnant again while on study, she will then follow the study schedule depending on the timing 
of the detection of her pregnancy (Year 1, prior to study day 393, versus Year 2, study day 393 
onwards).  
Post-partum, women whose pregnancy was determined in Year 1 will be followed for ~12 
months post delivery. For women who become pregnant in Year 2, she will only be followed for 
~1-2 month’s post delivery. 

 
 
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Pregnant subjects who develop clinical malaria will be treated following Mali National Policy on 
Malaria Control guidelines. Uncomplicated malaria and asymptomatic parasitemia in the 1st 
trimester is treated with quinine and during 2nd and 3rd trimesters, treatment is with AL. 
Complicated malaria in pregnancy is treated similarly to non-pregnant patients.  
 Risk to the Community  
PfSPZ Vaccine is not known to cause any risk to the community. 
17 COMPENSATION 
Subjects will be given in kind (such as rice and/or millet) or cash equivalent, that can be given in 
multiple installments as outlined in Table 15, to compensate for the time taken to come to the 
study clinic for study-related visits. Preferred compensation will be decided in consultation with 
village elders, but case-by-case exceptions to receive the cash equivalent may be acceptable. The 
Mali EC recommends compensating the study subject for their time lost for study procedures. 
The amount equals US $ 6 or US $ 3 for each visit depending on the time spent by the volunteer. 
Volunteers will receive US $ 6 when they have to do more evaluation process so spend more 
time at the center, and US $ 3 when the process and time are less. Volunteer compensation 
payments will be made periodically throughout of the test. 
Table 15: Estimated Compensation for the Study 
Study Group(s) 
US Dollar Equivalent 
Rice or Millet Dispensed 
(Local Currency [CFA] 
WOCBP 
Vaccine Phase 
$186 
93000 F CFA 
Pregnant 
Women1 
$69 
34500 F CFA 
Offspring 
$27 
13500 F CFA 
Non-pregnant 
Year 2 
$78 
39000 F CFA 
Non-pregnant + 
Pregnant Women 
Year 4 
$78 
39000 F CFA 
 
*Assuming currency exchange rate of USD $1= 500 CFA; this may be adjusted due to economic 
conditions.  
1Compensation during pregnancy may be more if pregnant women agree to non-pregnant visits 
(every 2 weeks) during the malaria season. 

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

 
 
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19 Role of NIH Investigators 
MRTC and NIH/NIAID/LMIV investigators work collaboratively on this clinical trial, however, NIH 
investigators are not directly engaged in clinical research, such as recruiting, consenting, 
assessing adverse events, and/or administering drug or vaccine. NIH investigators do have 
access to personal identifying information from this trial.  
20 Role of Collaborators 
Dr. Blair Wylie will be providing her experience and expertise to assist with study design, 
protocol training and implementation, standardization of obstetric related evaluations, and 
discussion with the study team regarding adverse events (on a de-identified basis). 
 
 

 
 
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21 APPENDICES 
Appendix A: Study Schedule 
 
 
Clinic visits 
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Unscheduled -- Blood Smear 
Positive (B)
Study Day 
-56
-14
1
2
4
8
9
11
15
22
29
30
32
36
N/A
Days post-PfSPZ Vaccine
-56
-14
0
1
3
0
1
3
7
14
0
1
3
7
N/A
Weeks post-PfSPZ Vac #1
-8
-2
0
1
2
3
4
5
N/A
Visit windows (days)
±7
0
±1
±2
0
±1
±7
±3
±3
0
±1
±2
Screen
Enroll 
PfSPZ Vac #1
Safety F/U
Safety F/U; Pre-
Vac
PfSPZ Vac #2
Safety F/U
Safety F/U
AL
Pre-vac
PfSPZ Vac #3
Safety F/U
Safety F/U
Safety F/U
Unscheduled Visit Positive BS
CLINICAL PROCEDURES
Complete medical history/ physical
X
Informed consent
X
Malaria Comprehension Exam
X
Pre-test/Post-test HIV counseling
X
Pregnancy Prevention Counseling
X
X
X
X
X
X
X
X
X
X
X
X
X
X
(X)
Interim clinical evaluation
X
X
X
X
X
X
X
X
X
X
X
X
X
X
AE/SAE assessment
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Conmed review
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Unblinding
AL dose
X
X
X
PfSPZ Vaccine or Placebo
X
X
X
LABORATORY PROCEDURES
Designated Laboratory
Tube Type
Screening/Safety Labs and procedures
CBC with differential + sickle cell screening (day -14 
only)
MRTC CAP lab/UB
EDTA
2
2
2
2
2
2
2
2
2
2
ALT, Cr + HIV
SST
3
3
3
3
3
3
3
3
3
3
Urine dipstick or UA
Urine Container
X
Urine/Serum Pregnancy Test (A) 
Urine Container or SST
X
X
X
X
X
X
(X)
ECG
NIH/Mali Cardiology
N/A
X
Malaria Infection Assays
qPCR
MRTC CAP lab/LMIV 
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Peripheral Blood Smear
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
Research Assays
Humoral Assays
MRTC/ LMIV
SST
10
5
Cellular Assays
NaHep
10
10
10
Ex Vivo Assays
EDTA
0.5
0.5
0.5
0.5
0.5
Parasite Purification (CF11)
EDTA
4
Transcriptional Assays
Nucleic Acid Stabilizer
1
1
1
Daily total
5
27.5
6
0
5.5
6
0
5
22.5
0
6
0
6
16.5
5
Study cumulative total
5.0
32.5
38.5
38.5
44.0
50.0
50.0
55.0
77.5
77.5
83.5
83.5
89.5
106.0
Appendix A: Clinic and Laboratory Procedures for Main Vaccination Phase 
(A) If serum pregnancy testing required, an additional 3mL of blood may need to be drawn
(B) For unscheduled blood smear positive visits -- for first positive blood smear, subjects should return within 48 hours to blood draw; no need to repeat blood smear given positive BS prompting visit unless clinically indicated; first positive BS = first positive post vaccination (preference given post vaccination #3) or new positive BS occurring >14 days after recent anti-malarial treatment or new positive BS occurring >28 
days after negative BS regardless of treatment; visit is optional, with priority for completing visit for first positive BS post vaccination #3

 
 
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Clinic visits 
15
16
17
18
19
20
21
22
23
24
25
26
26
27
28
29
30
31
Unscheduled -- Blood Smear 
Positive (B)
Study Day 
43
57
71
85
99
113
127
141
155
169
183
197
225
253
281
309
337
365
N/A
Days post-PfSPZ Vaccine
14
28
42
56
70
84
98
112
126
140
154
168
196
224
252
280
308
336
N/A
Weeks post-PfSPZ Vac #1
6
8
10
12
14
16
18
20
22
24
26
28
32
36
40
44
48
52
N/A
Visit windows (days)
±3
±3
±3
±3
±3
±3
±3
±3
±3
±3
±3
±3
±7
±7
±7
±7
±7
±7
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Post Vax F/U
Post Vax F/U
Post Vax F/U
Post Vax F/U
Post Vax F/U
Post Vax F/U
Unscheduled Visit Positive BS
CLINICAL PROCEDURES
Complete medical history/ physical
Informed consent
Malaria Comprehension Exam
Pre-test/Post-test HIV counseling
Pregnancy Prevention Counseling
X
X
(X)
Interim clinical evaluation
X
X
X
X
X
X
X
X
X
X
x
x
X
X
X
X
X
X
X
AE/SAE assessment
X
X
X
X
X
X
X
X
X
X
x
x
X
X
X
X
X
X
X
Conmed review
X
X
X
X
X
X
X
X
X
X
x
x
X
X
X
X
X
X
X
Unblinding
AL dose
PfSPZ Vaccine or Placebo
LABORATORY PROCEDURES
Designated Laboratory
Tube Type
Screening/Safety Labs and procedures
CBC with differential + sickle cell screening (day -14 only)
MRTC CAP lab/UB
EDTA
ALT, Cr + HIV
SST
Urine dipstick or UA
Urine Container
Urine/Serum Pregnancy Test (A) 
Urine Container or SST
X
X
X
X
x
X
X
X
X
X
X
(X)
ECG
NIH/Mali Cardiology
N/A
Malaria Infection Assays
qPCR
MRTC CAP lab/LMIV 
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Peripheral Blood Smear
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Research Assays
Humoral Assays
MRTC/ LMIV
SST
5
2.5
2.5
2.5
Cellular Assays
NaHep
10
10
10
10
Ex Vivo Assays
EDTA
0.5
0.5
0.5
0.5
Parasite Purification (CF11)
EDTA
4
Transcriptional Assays
PaxGENE
1
1
Daily total
16.5
15
1
1
1
13.5
1
1
1
15
1
1
1
1
1
1
1
1
5
Study cumulative total
122.5
137.5
138.5
139.5
140.5
154
155
156
157
172
173.5
174.5
175.5
176.5
177.5
178.5
179.5
180.5
(A) If serum pregnancy testing required, an additional 3mL of blood may need to be drawn
(B) For unscheduled blood smear positive visits -- for first positive blood smear, subjects should return within 48 hours to blood draw; no need to repeat blood smear given positive BS prompting visit unless clinically indicated; first positive BS = first positive post vaccination (preference given post vaccination #3) or new positive BS occurring >14 days after recent anti-malarial treatment or new positive BS occurring >28 days after negative BS regardless of treatment; visit is optional, with priority for completing visit for first positive BS post vaccination #3

 
 
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100 
 
 
 
 
 
 
Trimester (A)
TBD
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Month post Delivery
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
0 (Delivery)
2
4
6
8
10
12
Study Day 
P0
P1
P2
P3
P4
P5
P6
P7
P8
P9
P10
P11
P12
P13
P14
P15
P16
Visit windows (days)
0
±14
±14
±14
±14
±14
±14
±14
±14
±14
±2
±21
±14
±14
±14
±14
±14
Enroll
Preg F/U
Preg F/U
Preg F/U
Preg F/U
Preg F/U
Preg F/U
Preg F/U
Preg F/U
Preg F/U
Delivery
Post Delivery F/U
Post Delivery F/U
Post Delivery F/U
Post Delivery F/U
Post Delivery F/U
Post Delivery F/U
CLINICAL PROCEDURES
Complete medical history/ physical
X
Informed consent for pregnancy follow-up
X
Interim clinical evaluation
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Pregnancy outcome assessment
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
AE/SAE assessment
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Conmed review
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Informed consent for offspring follow-up
(X)
(X)
(X)
(X)
(X)
(X)
(X)
(X)
(X)
(X)
(X)
(X)
Unblinding ©
LABORATORY/IMAGING PROCEDURES
Designated Laboratory
Tube Type
 Labs and procedures
CBC with differential
MRTC CAP lab/UB
EDTA
2
2
2
2
ALT, Cr
SST
Glucose
SST
Blood type
EDTA
X
Serologies (syphilis, rubella, toxoplasmosis)
SST
3
Urine dipstick or UA
Urine Container
X
X
X
Urine/Serum Pregnancy Test 
Urine Container or Lithium Hep
X
X
X
X
X
Prenatal Ultrasound
Mali
N/A
(X)
Malaria Infection Assays
qPCR
MRTC CAP lab/LMIV 
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Peripheral Blood Smear
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Research Assays (D)
Humoral Assays
MRTC/ LMIV
SST
5
5
5
5
5
Cellular Assays
NaHep
Ex Vivo Assays
EDTA
0.5
0.5
0.5
0.5
0.5
Parasite Purification (CF11)
EDTA
Transcriptional Assays
PaxGENE
1
1
1
1
1
Placenta
Other
X
Cord Blood
SST, EDTA, PaxGene
X
Total
0
15.5
1
1
6
1
1
12.5
1
1
9.5
1
1
7.5
1
1
7.5
Study cumulative total
0
15.5
16.5
17.5
23.5
24.5
25.5
38
39
40
49.5
50.5
51.5
59
60
61
68.5
(C) Unblinding will occur on estimated study day 561 for all study participants regardless where they are in the time course of their pregnancy
(D) If a woman delivers early and research labs during third trimester have been collected within 8 weeks' prior to delivery, at the investigator discretion, those research labs do not need to be repeated at time delivery (excluding placenta and cord blood collection); CBC with differential, qPCR and peripheral BS will be collected.
(B) Standard pregnancy labs will be coordinated with the subject's identified OB/GYN; if not drawn at OB/GYN labs will be drawn in the clinic and shared with the OB/GYN + patient. If drawn at OB/GYN, we will not repeat the labs but ask for copy of results from subject's OB/GYN
Appendix A: Clinic and Laboratory Procedures for Pregnant Women
3
(A) Depending on the timing of pregnancy diagnosis, at least 1 but up to 3 scheduled visits may be completed per trimester. Procedures and labs as noted will be completed at each visit during that trimester unless otherwise noted; if visits occur during the 24 week malaria infection follow-up, women will be asked to provide safety and malaria labs per Vaccine schedule 
3
3
1st  (B)
2nd
3rd
X
X
X
(X)

 
 
PfSPZ Vaccine in WOCBP  
 
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101 
 
 
 
 
 
 
 
Unscheduled -- Blood Smear 
Positive
Months post Birth
N/A
0.5, 1, 1.5
2
2.5, 3, 3.5
4
4.5, 5, 5.5
6
8
10
12
Study Day 
C0
CT1, CT2, CT3
C1
CT4, CT5, CT6
C2
CT7, CT8, CT9
C3
C4
C5
C6
N/A
Visit windows (days)
0
±7
±21
±7
±14
±7
±14
±14
±14
±14
Enroll (B)
Phone F/U
F/U
Phone F/U
F/U
Phone F/U
F/U
F/U
F/U
F/U
Unscheduled Visit Positive BS
CLINICAL PROCEDURES
Complete medical history/ physical
X
Interim clinical evaluation  (including weight, length, 
head circumference)
X
X
X
X
X
X
X
Neonatal/Infant outcome assessment
X
X
X
X
X
X
X
X
X
X
X
AE/SAE assessment
X
X
X
X
X
X
X
X
X
X
X
Conmed review
X
X
X
X
X
X
X
X
X
X
X
EPI vaccine review
X
X
X
X
X
X
X
Developmental screening
X
X
LABORATORY/IMAGING PROCEDURES
Designated Laboratory
Tube Type
 Labs and procedures
Hemoglobin
EDTA
0.5
0.5
Hemoglobin typing
EDTA
0.5 (A)
Malaria Infection Assays
qPCR
MRTC CAP lab/LMIV 
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Peripheral Blood Smear
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
Research Assays
Humoral Assays
MRTC/ LMIV
SST
3
3
Cellular Assays
NaHep
Ex Vivo Assays
EDTA
0.5
0.5
0.5
Parasite Purification (CF11)
EDTA
4
Transcriptional Assays
PaxGENE
1
1
Total
0
0
1
0
1
0
6
1
1
6.5
5
Study cumulative total
0
0
1
0
2
0
8
9
10
16.5
Appendix A: Clinic and Laboratory Procedures for Neonates/Infants
MRTC CAP lab/UB
(B) Infants enrolled from pregnancies detected in Year 2 (study day 393 onwards) will only complete study visit C0
(A) Hemoglobin typing can be collected at any time point; preference is for visit with venous blood draws (C3, C6 with C6 preferred given older age/weight). But if a subject may be moving or leaving the study area, this can be collected prior to departure at any visit

 
 
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Year 2 Follow-up: Non-pregnant Follow-Up 
 
Year 4 Follow-up/3-Years Post Initial Vaccination: Non-pregnant + Pregnant Follow-Up 
Clinic visits 
32
33
34
35
36
37
38
39
40
41
42
43
44
Unscheduled -- Blood Smear 
Positive (B)
Study Day 
393
407
421
435
449
463
477
491
505
519
533
547
561
N/A
Days post-PfSPZ Vaccine
364
378
392
406
420
434
448
462
476
490
504
518
532
N/A
Weeks post-PfSPZ Vac #1
56
58
60
62
64
66
68
70
72
74
76
78
80
N/A
Visit windows (days)
±56
±3
±3
±3
±3
±3
±3
±3
±3
±3
±3
±3
±3
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U and 
Unblinding Visit 
Unscheduled Visit Positive BS
CLINICAL PROCEDURES
Informed consent/ Addendum Consent
X
Focused clinical evaluation (if clinically indicated) 
(A)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
AE/SAE assessment
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Conmed review
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Unblinding
X
LABORATORY PROCEDURES
Designated 
Laboratory
Tube Type
Urine/Serum Pregnancy Test (B) 
Urine Container or SST
X
X
X
X
X
X
X
X
X
X
X
X
X
(X)
Malaria Infection Assays
qPCR
MRTC CAP lab/LMIV 
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Peripheral Blood Smear
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Research Assays
Humoral Assays
MRTC/ LMIV
SST
2.5
5
2.5
2.5
2.5
2.5
Cellular Assays
NaHep
10.0
10
10
10
10
10
Ex Vivo Assays
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
Parasite Purification (CF11)
EDTA
4
Transcriptional Assays
PaxGENE (or similar tube 
type)
1
Daily total
14
16.5
14
1
1
1
13.5
1
1
1
14
1
15
5
Study cumulative total
180.5
197
211
212
213
214
227.5
228.5
229.5
230.5
244.5
245.5
260.5
Appendix A: Clinic and Laboratory Proceduresfor Year 2
(A) Given >1 year since study product, clinical exam including vital signs will only be completed if clinically indicated.
(B) If serum pregnancy testing required, an additional 3mL of blood may need to be drawn
(C) For unscheduled blood smear positive visits -- for first positive blood smear, subjects should return within 48 hours to blood draw; no need to repeat blood smear given positive BS prompting visit unless clinically indicated; first positive BS = first positive post start of Year 2 or new positive BS occurring >14 days after recent anti-malarial treatment or new positive BS occurring >28 days after negative BS 
regardless of treatment; visit is optional, with priority for completing visit for first positive BS post start of Year #2
Clinic visits 
45
46
47
48
49
50
51
52
53
54
55
56
57
Unscheduled -- Blood Smear 
Positive (B)
Study Day 
1121
1135
1149
1163
1177
1191
1205
1219
1233
1247
1261
1275
1289
N/A
Days post-PfSPZ Vaccine
1120
1134
1148
1162
1176
1190
1204
1218
1232
1246
1260
1274
1288
N/A
Weeks post-PfSPZ Vac #1
160
162
164
166
168
170
172
174
176
178
180
182
184
N/A
Visit windows (days)
±56
±3
±3
±3
±3
±3
±3
±3
±3
±3
±3
±3
±3
Screen for 
Extension/Malaria 
F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Malaria F/U
Unscheduled Visit Positive BS
CLINICAL PROCEDURES
Informed consent/ Addendum Consent
X
Focused clinical evaluation (if clinically indicated) 
(A)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
AE/SAE assessment (if indicated)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Conmed review (if indicated)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
LABORATORY PROCEDURES
Designated 
Laboratory
Tube Type
Malaria Infection Assays
qPCR
MRTC CAP lab/LMIV 
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Peripheral Blood Smear
EDTA
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5
Research Assays
Humoral Assays
MRTC/ LMIV
SST
2.5
2.5
Cellular Assays
NaHep
10.0
10
Ex Vivo Assays
EDTA
0.5
0.5
0.5
Parasite Purification (CF11)
EDTA
4
Daily total
14
1
1
1
1
1
1
1
1
1
1
1
14
5
Study cumulative total (Extension)
14
15
16
17
18
19
20
21
22
23
24
25
39
Appendix A: Clinic and Laboratory Proceduresfor Year 4
(A) Given >3 year since study product, clinical exam including vital signs will only be completed if clinically indicated.
(B) For unscheduled blood smear positive visits -- for first positive blood smear, subjects should return within 48 hours to blood draw; no need to repeat blood smear given positive BS prompting visit unless clinically indicated; first positive BS = first positive post start of Year 2 or new positive BS occurring >14 days after recent anti-malarial treatment or new positive BS occurring >28 days after negative BS 
regardless of treatment; visit is optional, with priority for completing visit for first positive BS post start of Year #2

 
 
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Appendix B: Toxicity Table 
Local Reactogenicity Grading 
Local Reaction to 
Injectable Product 
Mild  
(Grade 1) 
Moderate (Grade 2) Severe  
(Grade 3) 
Potentially Life 
Threatening 
(Grade 4) 
Pain/Tenderness/Pruritus 
Does not 
interfere 
with activity 
Repeated use of 
non-narcotic pain 
reliever > 24 hours 
or interferes with 
activity 
Any use of 
narcotic pain 
reliever or 
prevents daily 
activity 
Emergency room 
(ER) visit or 
hospitalization 
Erythema/Redness/Bruising1 2.5 – 5 cm 
5.1 – 10 cm 
> 10 cm 
Necrosis or 
exfoliative 
dermatitis 
Induration/Swelling2  
2.5 – 5 cm 
and does not 
interfere 
with activity 
5.1 – 10 cm or 
interferes with 
activity 
> 10 cm or 
prevents daily 
activity 
Necrosis 
1 In addition to grading the measured local reaction at the greatest single diameter, the measurement should be 
recorded as a continuous variable.  
2 Induration/Swelling should be evaluated and graded using the functional scale as well as the actual measurement. 
Vital Sign AE Grading 
Vital Signs1  
Mild  
(Grade 1) 
Moderate 
(Grade 2) 
Severe  
(Grade 3) 
Potentially Life Threatening 
(Grade 4) 
Fever2 (°C) 
              (°F) 
38.0 – 38.4 
100.4 – 101.1 
38.5 – 38.9 
101.2 – 102.0 
39.0 – 40 
102.1 – 104 
> 40 
> 104 
Tachycardia - 
bpm 
101 – 115 
116 – 130 
> 130 
ER visit or hospitalization 
for 
arrhythmia 
Bradycardia - 
bpm3 
50 – 54 
45 – 49 
< 45 
ER visit or hospitalization 
for 
arrhythmia 
Hypertension 
(systolic) - 
mm Hg 
141 – 150 
151 – 155 
> 155 
ER visit or hospitalization 
for 
malignant hypertension 
Hypertension 
(diastolic) - 
mm Hg 
91 – 95 
96 – 100 
> 100 
ER visit or hospitalization 
for 
malignant hypertension 
Hypotension 
(systolic) – 
mm Hg 
85 – 89 
80 – 84 
< 80 
ER visit or hospitalization 
for 
hypotensive shock 
1 Subject should be at rest for all vital sign measurements.  
2Oral temperature; no recent hot or cold beverages or smoking.  
3When resting heart rate is between 60 – 100 beats per minute. Use clinical judgment when characterizing  
bradycardia among some healthy subject populations, for example, conditioned athletes. 
 

 
 
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104 
 
Systemic AE Grading 
Systemic adverse 
events1 
Mild  
(Grade 1) 
Moderate 
(Grade 2) 
Severe  
(Grade 3) 
Potentially Life 
Threatening 
(Grade 4) 
Feverish 
No interference 
with 
activity 
Some interference 
with activity not 
requiring medical 
intervention or use of 
1-2 doses of 
antipyretics 
Prevents daily activity or 
use of >2 doses of 
antipyretics in 24 hours 
ER visit or 
hospitalization  
Chills/Rigors 
No interference 
with activity or 1 
– 2 
episodes/24 hours 
Some interference 
with activity or > 2 
episodes/24 hours 
Prevents daily 
activity 
 
ER visit or 
hospitalization 
for 
hypotensive 
shock 
Sweats 
No interference 
with 
activity 
Some interference 
with activity not 
requiring medical 
intervention 
Prevents daily activity  
ER visit or 
hospitalization  
Diarrhea 
2 – 3 loose stools 
or 
< 400 gms/24 
hours 
4 – 5 stools or 
400 – 800 gms/24 
hours 
6 or more watery stools or 
> 800gms/24 hours 
or requires outpatient IV 
hydration 
ER visit or 
hospitalization 
Headache 
No interference 
with 
activity 
Repeated use of non- 
narcotic pain 
reliever > 24 hours or 
some interference 
with activity 
Significant; any use of 
narcotic pain reliever or 
prevents daily 
activity 
ER visit or 
hospitalization 
Fatigue/ 
Malaise 
No interference 
with 
activity 
Some interference 
with activity not 
requiring medical 
intervention 
Prevents daily activity 
ER visit or 
hospitalization 
Back Pain 
No interference 
with 
activity 
Some interference 
with activity; use of 
1-2 doses of 
medication 
Prevents daily activity   
ER visit or 
hospitalization  
Chest Pain (non-
musculoskeletal) 
Transient (< 24 
hours) or 
intermittent chest 
pain with no or 
minimal 
interference 
 
 
Persistent chest pain 
resulting in greater 
than minimal 
interference with 
usual activities  
Persistent chest pain 
resulting in inability to 
perform usual activities 
secondary to chest pain 
ER visit or 
hospitalization  
Myalgia 
No interference 
with 
activity 
Repeated use of non- 
narcotic pain 
reliever > 24 hours or 
some interference 
with activity 
Any use of narcotic 
pain reliever or 
prevents daily 
activity 
ER visit or 
hospitalization 

 
 
PfSPZ Vaccine in WOCBP  
 
February 13, 2023; V6.1 
105 
 
Systemic adverse 
events1 
Mild  
(Grade 1) 
Moderate 
(Grade 2) 
Severe  
(Grade 3) 
Potentially Life 
Threatening 
(Grade 4) 
Arthralgia 
No interference 
with 
activity 
Repeated use of non- 
narcotic pain 
reliever > 24 hours or 
some interference 
with activity 
Any use of narcotic 
pain reliever or 
prevents daily 
activity 
ER visit or 
hospitalization 
Nausea/ 
Vomiting 
No interference 
with activity or 1 
– 2 
episodes/24 hours 
Some interference 
with activity or > 2 
episodes/24 hours 
Prevents daily 
activity, requires 
outpatient IV 
hydration 
ER visit or 
hospitalization 
for 
hypotensive 
shock 
Abdominal Pain 
No interference 
with 
activity 
Repeated use of non- 
narcotic pain 
reliever > 24 hours or 
some interference 
with activity 
Any use of narcotic 
pain reliever or 
prevents daily 
activity 
ER visit or 
hospitalization 
Urticaria/Rash 
No interference 
with 
activity 
Requiring PO or 
topical treatment  > 
24 hours or IV 
medications or 
steroids for ≤24 hours 
Requiring IV medication 
or steroids for >24 hours 
ER visit or 
hospitalization 
Edema 
No interference 
with 
activity 
Some interference 
with activity not 
requiring medical 
intervention 
Prevents daily activity   
ER visit or 
hospitalization 
Pruritus  
No interference 
with 
activity 
Requiring PO or 
topical treatment  > 
24 hours or IV 
medications or 
steroids for ≤24 hours 
Requiring IV medication 
or steroids for >24 hours 
ER visit or 
hospitalization 
1 For other symptoms not listed, they should be graded as outlined in Section 10.3.1 
***Adapted from Guidance for Industry: Toxicity Grading Scale for Healthy Adult and Adolescent Volunteers Enrolled in 
Preventative Vaccine clinical Trials. 
 

 
 
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February 13, 2023; V6.1 
106 
 
Mali Laboratory AE Grading 
Hematology/Chemistry 
 
Hematology and 
Biochemistry 
values1, 2 
Mild 
(Grade 1) 
Moderate 
(Grade 2) 
Severe 
(Grade 3) 
Potentially Life 
Threatening 
(Grade 4) 
Hemoglobin 
(Female) -- gm/dL  
8.00 – 9.00 
7.00 – 7.99 
6.00 – 6.99 
< 6.00 and /or 
requiring 
transfusion 
WBC Increase – 
103/µL 
11.50 – 15.09 
15.10 – 20.09 
20.10 – 25.00 
> 25.00 
WBC Decrease - 
103/µL 
2.50 – 3.30 
1.50 – 2.49 
1.00 – 1.49 
< 1.00 with 
fever 
Granulocyte or 
Neutrophil 
Decrease - 103/µL 
0.80 – 1.00 
0.50 – 0.79 
< 0.50 
< 0.50 with 
fever 
Platelets Decreased 
– 103/µL 
100.0 – 110.0 
70.0 – 99.9 
25.0 – 69.9 
< 25.0 
Creatinine 
(Female) µmol/L 
107.00 – 
132.99 
133.00 – 159.99 
160.00 – 
215.99 
> 216.00 and 
requires dialysis 
Liver Function 
Tests –ALT U/L 
75.0 – 150.9 
151.0 – 300.9 
301.0 – 600.0 
> 600.0 
1The laboratory values provided in the tables serve as guidelines and are dependent upon institutional normal parameters. 
Institutional normal reference ranges should be provided to demonstrate that they are appropriate.  
2The clinical signs or symptoms associated with laboratory abnormalities might result in characterization of the laboratory 
abnormalities as Potentially Life Threatening (Grade 4). For example, a low sodium value that falls within a grade 3 parameter 
should be recorded as a grade 4 hyponatremia event if the subject had a new seizure associated with the low sodium value.  
 
 
 
 
 
 

 
 
PfSPZ Vaccine in WOCBP  
 
February 13, 2023; V6.1 
107 
 
Mali Adult Normals 
Chemistry 
Serum1 
Reference Range 
Creatinine (Female) 
- µmol/L 
< 72 
 
ALT – U/L 
< 41 
1The laboratory values provided in the table are based on Bancoumana, Malian adults (age 18-45 years old) 
Hematology 
Hematology1 
Reference Range 
Hemoglobin (Female) - gm/dL 
9.1 – 13.8 
Hemoglobin (Infant) - gm/dL 
 
0-30 days 15.0-22.0 
1 month 10.5-14.0 
2-6 months 9.5-13.5 
≥7 months 10.5-14.0 
WBC – 103/µL 
3.6 – 9.0 
Absolute Granulocyte or 
Neutrophil Count - 103/µL 
1.3 – 4.4 
Absolute Lymphocyte Count - 
103/µL 
1.3 – 4.4 
Platelet Count (Female)- 103/µL 
144 – 413 
1The laboratory values provided in the table are based on Bancoumana, Malian adults (age 18-45 years old) and 
infant parameters collection from healthy Oulessebougou infants. 
 
 

 
 
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Toxicity Tables for Neonates/Infants (referenced from Munoz et al. 2014)(Munoz, Weisman et al. 2014)  
 
 

 
 
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