Induced Blood-Stage Plasmodium Vivax Infection With HMPBS02-Pv Challenge Agent in Healthy Malaria-Naive Adults to Produce a Plasmodium Vivax Parasite Cell Bank for Future Studies
Phase: PHASE1
Conditions: Malaria
Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)

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Abbreviated Title: Blood-stage Plasmodium vivax cell bank
Version Date:  17 May 2022
Sars
Abbreviated Title: Blood-stage Plasmodium vivax cell bank
Protocol #: 000212
Version Date: 17 May 2022
Title: Induced blood-stage Plasmodium vivax infection with HMPBS02-Pv Challenge Agent in 
healthy malaria-naïve adults to produce a Plasmodium vivax parasite cell bank for future studies
NIH Principal Investigator:
Patrick E. Duffy, MD
Laboratory of Malaria Immunology and Vaccinology (LMIV) 
National Institute of Allergy and Infectious Diseases (NIAID) 
Building 29, Rm 4NN06
9000 Rockville Pike
Bethesda, MD 20892
Phone: 301-761-5089
Email: duffype@niaid.nih.gov
Investigational Agents:
Drug Name:
HMPBS02-Pv Challenge Agent
IND Number:
IND 27245
Sponsor:
Office of Clinical Research Policy and Regulatory 
Operations (OCRPRO), Division of Clinical 
Research (DCR), NIAID, NIH
Manufacturer:
Queensland Institute of Medical Research, 
Berghofer (QIMRB) and NIH Department 
of Transfusion Medicine

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Abbreviated Title: Blood-stage Plasmodium vivax cell bank
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TABLE OF CONTENTS
TABLE OF CONTENTS ..............................................................................................................2
LIST OF FIGURES.......................................................................................................................4
LIST OF TABLES.........................................................................................................................4
STATEMENT OF COMPLIANCE .............................................................................................5
1
PROTOCOL SUMMARY ....................................................................................................6
1.1
SYNOPSIS........................................................................................................................6
1.2
SCHEMA..........................................................................................................................7
1.3
SCHEDULE OF ACTIVITIES (SOA) .............................................................................8
2
INTRODUCTION ...............................................................................................................10
2.1
STUDY RATIONALE....................................................................................................10
2.2
BACKGROUND ............................................................................................................10
2.2.1
Previous Human P. vivax CHMI Experience..........................................................11
2.2.2
Previous Human P. vivax IBSM Experience...........................................................12
2.3
RISK/BENEFIT ASSESSMENT ...................................................................................20
2.3.1
Known Potential Risks ............................................................................................20
2.3.2
Known Potential Benefits........................................................................................23
2.3.3
Assessment of Potential Risks and Benefits............................................................24
3
OBJECTIVES AND ENDPOINTS....................................................................................24
4
STUDY DESIGN .................................................................................................................25
4.1
OVERALL DESIGN ......................................................................................................25
4.2
SCIENTIFIC RATIONALE FOR STUDY DESIGN.....................................................25
4.3
JUSTIFICATION FOR DOSE .......................................................................................26
5
STUDY POPULATION ......................................................................................................26
5.1
INCLUSION CRITERIA................................................................................................26
5.2
EXCLUSION CRITERIA...............................................................................................27
5.3
INCLUSION OF VULNERABLE PARTICIPANTS ....................................................31
5.3.1
Justification for Exclusion of Pregnant Women......................................................31
5.3.2
Justification for Exclusion of Children....................................................................31
5.3.3
Justification for Exclusion of Adults Who Cannot Consent....................................31
5.3.4
Justification for Exclusion of Participants Older than 50........................................31
5.3.5
Participation of NIH Staff or Family Members of Study Team ..............................32
5.4
LIFESTYLE CONSIDERATIONS................................................................................32
5.5
SCREEN FAILURES .....................................................................................................32
5.6
STRATEGIES FOR RECRUITMENT AND RETENTION .........................................32
5.6.1
Costs ........................................................................................................................33
5.6.2
Compensation..........................................................................................................33
6
STUDY INTERVENTION .................................................................................................34
6.1
STUDY INTERVENTIONS ADMINISTRATION .......................................................34
6.1.1
P. vivax Challenge Agent ........................................................................................34
6.1.2
Dosing and Administration......................................................................................34
6.1.3
Antimalarial Treatment............................................................................................34
6.2
PREPARATION/HANDLING/STORAGE/ACCOUNTABILITY...............................35
6.2.1
Acquisition and Accountability ...............................................................................35
6.2.2
Formulation, Appearance, Packaging, and Labeling...............................................36

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6.2.3
Product Storage and Stability ..................................................................................36
6.2.4
Preparation...............................................................................................................36
6.3
MEASURES TO MINIMIZE BIAS: RANDOMIZATION AND BLINDING .............36
6.4
STUDY INTERVENTION COMPLIANCE..................................................................37
6.5
CONCOMITANT THERAPY........................................................................................37
7
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL..................................................................................37
7.1
DISCONTINUATION OF STUDY INTERVENTION .................................................37
7.1.1
Withdrawal Criteria for an Individual Subject ........................................................38
7.2
LOST TO FOLLOW-UP ................................................................................................38
8
STUDY ASSESSMENTS AND PROCEDURES..............................................................39
8.1
SCREENING PROCEDURES .......................................................................................39
8.1.1
Screening activities performed prior to obtaining informed consent.......................39
8.1.2
Screening activities performed after a consent for screening has been signed........39
8.2
STUDY EVALUATION & PROCEDURES .................................................................41
8.2.1
Clinical Evaluations.................................................................................................41
8.2.2
Biospecimen Evaluations ........................................................................................43
8.2.3
Correlative Studies for Research/Pharmacokinetic Studies.....................................45
8.2.4
Samples for Genetic/Genomic Analysis..................................................................46
8.3
SAFETY AND OTHER ASSESSMENTS.....................................................................46
8.3.1
Day -3 to Day -1 Eligibility Confirmation Visit......................................................46
8.3.2
Enrollment ...............................................................................................................47
8.3.3
Administration of the Challenge Agent (IBSM Day 0) ...........................................47
8.3.4
Malaria Monitoring..................................................................................................48
8.4
ADVERSE EVENTS, AND SERIOUS ADVERSE EVENTS ......................................52
8.4.1
Definition of an Adverse Event ...............................................................................52
8.4.2
Definition of Serious Adverse Events (SAE) ..........................................................52
8.4.3
Classification of an Adverse Event..........................................................................54
8.4.4
Time Period and Frequency for Event Assessment and Follow-Up........................58
8.4.5
Adverse Event Reporting.........................................................................................59
8.4.6
Serious Adverse Event Reporting............................................................................59
8.4.7
NIH Intramural IRB Reporting of IND Safety Reports...........................................60
8.4.8
Events of Special Interest ........................................................................................61
8.4.9
Reporting of Pregnancy ...........................................................................................61
8.5
UNANTICIPATED PROBLEMS ..................................................................................61
8.5.1
Definition of Unanticipated Problems (UP) ............................................................61
8.5.2
Unanticipated Problem Reporting............................................................................62
8.6
ADDITIONAL REPORTING REQUIREMENTS.........................................................62
8.6.1
Safety Oversight and Reporting ..............................................................................62
8.6.2
Reporting to the NIH IRB........................................................................................63
8.6.3
Reporting to the NIAIAD Clinical Director ............................................................63
8.7
HALTING RULES FOR THE PROTOCOL..................................................................63
8.7.1
Reporting a study halt..............................................................................................63
8.7.2
Resumption of a halted study ..................................................................................63
8.7.3
Discontinuation of study agent/intervention............................................................63
9
STATISTICAL CONSIDERATIONS ...............................................................................64

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9.1
SAFETY ANALYSES....................................................................................................64
9.2
BASELINE DESCRIPTIVE STATISTICS....................................................................64
10
REGULATORY AND OPERATIONAL CONSIDERATIONS.....................................64
10.1
INFORMED CONSENT PROCESS ..............................................................................64
10.1.1
Consent/Assent Procedures and Documentation .....................................................64
10.1.2
Participation of Subjects Who Are/Become Decisionally Impaired........................65
10.1.3
Considerations for Consent of NIH Staff.................................................................65
10.2
STUDY DISCONTINUATION AND CLOSURE.........................................................65
10.3
CONFIDENTIALITY AND PRIVACY.........................................................................66
10.4
FUTURE USE OF STORED SPECIMENS AND DATA .............................................66
10.5
SAFETY OVERSIGHT..................................................................................................67
10.6
CLINICAL MONITORING ...........................................................................................67
10.7
QUALITY ASSURANCE AND QUALITY CONTROL..............................................67
10.8
DATA HANDLING AND RECORD KEEPING...........................................................68
10.8.1
Data Collection and Management Responsibilities .................................................68
10.8.2
Study Records Retention .........................................................................................68
10.9
PROTOCOL DEVIATIONS ..........................................................................................68
10.9.1
NIH Definition of Protocol Deviation .....................................................................68
10.10 PUBLICATION AND DATA SHARING POLICY ......................................................68
10.11 COLLABORATIVE AGREEMENTS ...........................................................................69
10.12 CONFLICT OF INTEREST POLICY............................................................................69
11
ABBREVIATIONS..............................................................................................................70
12
REFERENCES ....................................................................................................................72
LIST OF APPENDICES
Appendix A: Cardiovascular Risk Assessment .............................................................................75
Appendix B: Clinical Score for Malaria........................................................................................77
Appendix C: Toxicity Grading Scales...........................................................................................78
Appendix D: Total Whole Blood Volume for Collection During Study .......................................84
Appendix E: Symptoms and Signs of Malaria...............................................................................85
Appendix F: The Patient Health Questionnaire-2 (PHQ-2)...........................................................86
LIST OF FIGURES
Figure 1: Liver Function Tests in Six Volunteers who Received HMPBS-Pv Challenge Agent 
(ANZCTR Trial ID: 12613001008718) ........................................................................................14
Figure 2. Asexual Parasitemia and Gametocytemia......................................................................46
LIST OF TABLES
Table 1. Challenge Agent-Related Adverse Events for HMPBS02-Pv and HMPBS-Pv Isolate..17
Table 2. Compensation Table........................................................................................................33
Table 3. Standard Event Recording, Assessment, and Reporting Timeframes.............................55
Table 4. Solicited Adverse Events.................................................................................................56
Table 5. Definitions for Severity of AE Grading ..........................................................................57

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STATEMENT OF COMPLIANCE
The trial will be carried out in accordance with International Council for Harmonisation of 
Technical Requirements for Pharmaceuticals for Human Use (ICH) Good Clinical Practice (GCP) 
and the following:
United States (US) Code of Federal Regulations (CFR) applicable to clinical 
studies (45 CFR Part 46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, 
and/or 21 CFR Part 812)
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who are 
responsible for the conduct, management, or oversight of NIH-funded clinical trials have 
completed Human Subjects Protection and ICH GCP Training.
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the institutional review board (IRB) for review and approval. Approval of both 
the protocol and the consent form must be obtained before any participant is enrolled. Any 
amendment to the protocol will require review and approval by the IRB before the changes are 
implemented to the study. In addition, all changes to the consent form will be IRB-approved; an 
IRB determination will be made regarding whether a new consent needs to be obtained from 
participants who provided consent, using a previously approved consent form.

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Abbreviated Title: Blood-stage Plasmodium vivax cell bank
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1
PROTOCOL SUMMARY
1.1
SYNOPSIS
Title:
Induced blood-stage Plasmodium vivax infection with HMPBS02-
Pv Challenge Agent in healthy malaria-naïve adults to produce a 
Plasmodium vivax parasite cell bank for future studies
Study Description:
This is a single-center, open-label study to infect healthy volunteers 
using induced blood-stage malaria (IBSM) so that blood can be 
collected to enable production of a human malaria parasite (HMP) 
bank for use in future studies. This study will be conducted in up to 
two participants, with an accrual ceiling of 50. Participants will be 
inoculated intravenously (IV) with human malaria parasite blood 
stage P. vivax parasite–infected erythrocytes (HMPBS02-Pv) 
challenge agent (Day 0) and then monitored closely via outpatient 
clinic visits, phone visits, and while inpatient at the NIH Clinical 
Center (CC) for symptoms and signs of malaria to characterize the 
safety, tolerability, and infectivity in healthy malaria-naïve 
participants inoculated with P. vivax. Blood sampling will be done 
periodically to measure parasitemia via quantitative polymerase 
chain reaction (qPCR) targeting the P. vivax 18S rRNA gene.
The threshold for the commencement of collection of blood for 
production of the HMP bank and subsequent antimalarial rescue 
treatment with artemether/lumefantrine will occur when the Malaria 
Clinical Score is >6 (admission within 24 hours of notification), or 
parasitemia is >20,000 parasites/mL, or at the investigator’s 
discretion. When this threshold is reached, the participant will be 
admitted to the NIH CC for further safety assessments before 
undergoing the blood collection procedure.
After blood collection, the first dose of artemether/lumefantrine will 
be administered and the participant will remain inpatient for 48-72 
hours to monitor for safety and tolerability of rescue therapy, and to 
ensure adequate clinical and parasitological response to treatment. In 
the unlikely and unprecedented event that artemether/lumefantrine 
fails to clear parasitemia, participants will be treated with 
chloroquine. If oral administration of either artemether/lumefantrine 
or chloroquine is not possible (e.g., the participant is vomiting), the 
participant will receive IV treatment with artesunate. After discharge, 
participants will be followed on an outpatient basis for monitoring of 
safety and parasite clearance. Follow-up for safety assessments will 
be performed on Day 28±3, Day 56±7 (phone call only), and Day 
90±7 (End of Study).

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Participants may also be evaluated for the presence of sexual parasite 
stages (gametocytes) and other parasite lifecycle stages in the blood 
during the study using quantitative reverse transcriptase PCR (qRT-
PCR).
Objectives:
Primary Objective: The collection of blood from healthy 
participants experimentally infected with P. vivax isolate 
HMPBS02-Pv for the production of a P. vivax blood-stage parasite 
bank for use in future studies.
Secondary Objective: To assess the safety and tolerability of the P. 
vivax IBSM model following inoculation of healthy malaria-naïve 
participants with P. vivax.
Exploratory Objective: To further characterize blood- and sexual-
stage parasite growth profiles following inoculation with P. vivax 
isolate and treatment with artemether/lumefantrine.
Endpoints:
Primary Endpoint: Collection of blood for the production of a P. 
vivax blood-stage parasite bank from study participants following 
experimental infection with P. vivax isolate HMPBS02-Pv.
Secondary Endpoint: Occurrence of solicited and unsolicited adverse 
events (AEs) following P. vivax inoculation prior to the initiation of 
antimalarial treatment.
Exploratory Endpoint: The rate of growth of blood- and sexual-stage
P. vivax isolate following inoculation and treatment with 
artemether/lumefantrine as determined by blood smear and/or 
qPCR.
Study Population:
Healthy malaria-naïve US adults between 18 and 50 years of age
Phase:
1
Description of Sites/Facilities Enrolling Participants: NIH CC, Bethesda, Maryland, USA
Description of Study Intervention:
A single dose of HMPBS02-Pv Challenge Agent will be 
administered IV.
Study Duration:
Approximately five months
Participant Duration:
Three months
1.2
SCHEMA

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1.3
SCHEDULE OF ACTIVITIES (SOA)
Procedures
Screening
Eligibility 
Confirmationa
Malaria 
Inoculation
Phone
Contactb
Malaria 
Monitoringc
Blood Collection for Banking 
and Rescue Treatmentd
Outpatient 
Monitoringe
Safety 
Visit
Follow-up 
Phone Call
EOS Visit
Study Day
D-56 to 
D-1
D-3 to D-1
D0
D1 to 
D3
D4 to blood 
collection for 
banking
Day of collection
Post-admission to 
D28 Safety visite
D28±3b
D56±7
D90±7
Eligibility and Safety Assessments
Assessment for HMP bank
X
Informed consent
X
PHQ-2 questionnaire
X
Malaria Comprehension Exam
X
Assessment of CV disease risk
X
Medical history & prior medications
X
X
Drug & alcohol screeng
X
X
Xh,
Full physical examination
X
X
Symptom-directed physical 
examinationi
X
X
X
X
Xe
X
Vital signs assessment
X
X
X
X
X
Xe
X
X
ECG
X
X
Xj
Urinalysis
X
X
Xh
X
Hematology & biochemistryk
X
X
X
X
Xe
Xl
Xm
Pregnancy testn
X
X
Xh
Blood type and alloantibodiesv
X
X
Xm
HIV pre-test counseling
X
Bloodborne infection screeningw
X
X
DTM NIH CC donor assessment
Xf
SARS-Cov-2Y
X
Safety serum storage
X
X
Safety EDTA storage
X
AEs & concomitant medications
X
X
X
X
Xe
X
X
X
Malaria clinical score
X
X
Xe,o
Solicited (local/systemic) reactogenicity
X
X
Verify ongoing eligibility
X
Confirm pregnancy prevention 
compliance
X
X
X
X
X
Blood collection for banking
Xp
Research sample collectionx
X
X
X
X
Malaria Monitoring
Malaria 18S qPCR blood sampling
X
Xq
X
Xe
Xl
Xm
Parasite lifecycle stage qRT-PCR 
blood sampling
X
X
X
Xe
Xl
Malaria blood smearr
X
X
Xs
X
X
X
Rescue Drug Treatment
Artemether/lumefantrine treatment
Xk
Chloroquine treatment
Xt
Artesunate treatment
Xu

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Abbreviated Title: Blood-stage Plasmodium vivax cell bank
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AEs: Adverse events; CV: cardiovascular; DTM NIH CC: Department of Transfusion Medicine NIH Clinical Center; ECG: Electrocardiogram; EOS: End of 
Study; HIV: human immunodeficiency virus; HMP: human malaria parasite; PHQ-2: Patient Health Questionnaire-2; qPCR: quantitative polymerase chain 
reaction; qRT-PCR: quantitative reverse transcriptase polymerase chain reaction; RBC: red blood cell
a This visit is not required in the event that the screening visit is conducted within this period.
b A phone call will also be made on Day 56±7 to monitor participant well-being and to solicit any AEs.
c Daily visits until Day 9. Up to 3 visits per day may be required, at the discretion of the investigator, between Day 9 and treatment day.
d Admission is expected to start on Day 9, 10, 11 or 12 and last 48 to 72 hours.
e If participant is released from confinement before 72 hours post–artemether/lumefantrine treatment.
f Routine donor screening visit by DTM NIH CC service providers may occur any time between screening visit and day of eligibility confirmation visit. 
g Urine drug screen, serum ethanol test. Blood ethanol at screening only. Urine drug screen at screening, Day 0, Admission. Day 0/admission results assessed 
retrospectively. 
h At time of admission to clinical unit only.
i Physical examinations should be performed at screening and at Day 28±3. At all other times, symptom-directed physical examinations will only be performed when signs 
or symptoms of malaria are identified, and it is clinically indicated at the investigator’s discretion. Before discharge, nursing staff must confirm with the study doctor or 
investigator if any participant requires symptom-driven examination.
j ECG may be performed at any time during the rescue treatment and observation period
k Required laboratory testing for hematology and biochemistry as per Section 8.2.2.1, Section 8.3.
l At the discretion of the investigator and if required for safety reasons.
m If not performed on Day 28±3.
n Serum pregnancy test at screening. Urine pregnancy test may be performed at malaria inoculation and time of admission to clinical unit.
o Only if vital signs are abnormal, or at the investigator’s discretion.
p Collection of a target minimum 200 mL blood sample for cell bank processing. At the discretion of the investigator, extra volume may be collected, within 
maximum whole blood volume collection limit of 550 mL in any 8-week period.
Q Blood sampling for malaria may be done up to 3 times a day from Day 9 to treatment day (at the discretion of the investigator).
R Blood smear collection may occur in parallel with other malaria monitoring, at the discretion of the investigator.
S Blood smear collection prior to blood collection for banking.
T Chloroquine will only be administered to participants in the case of failure of artemether/lumefantrine therapy.
U Intravenous artesunate treatment will only occur in the event that a participant is unable to complete oral treatment with either artemether/lumefantrine or 
chloroquine (e.g., the participant is vomiting).
V Blood type including ABO, Rh status, Duffy antigen at screening only. Alloantibodies at screening and at Day 28 or 90/EOS visit.
W Eligibility screening for bloodborne infections at screening visit. Further screening for acute transfusion-transmissible agents at admission.
X A PaxGene (or equivalent) tube for transcriptional studies may be collected during the course of the study at Day 0, Day 4 (approximate), Admission, and 
Day 28.
Y A SARS-CoV-2 screening test will be performed at the eligibility confirmation visit (or at the screening visit if within -3 to-1 day before inoculation) and 
at future visits based on investigator discretion/ NIH CC policies. 

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2
INTRODUCTION
2.1
STUDY RATIONALE
Although P. falciparum is the most virulent Plasmodium species, P. vivax is the second-most 
prevalent, occurs over a wider geographical area, is the dominant species in Oceania and Asia, and 
altogether is estimated to cause 80 to 300 million clinical cases per year. Despite this high burden, 
the tools available to study P. vivax malaria are sparse and the prospects for elimination are more 
daunting than for P. falciparum. In addition, following inoculation of sporozoites by mosquitoes, 
P. vivax forms a hypnozoite that can lay dormant in hepatocytes for months or years and then cause 
a relapse of infection. Most    of the studies aimed at investigating mosquito infection from 
human volunteers with P. vivax have been undertaken using P. vivax sporozoites. However, 
sporozoite inoculation in healthy volunteers carries the additional risk of relapse of P. vivax 
infection due to the formation of hypnozoites. This risk can be eliminated using the IBSM model 
that uses a blood-stage parasite challenge. To date, a total of 45 healthy volunteers have been 
challenged with two P. vivax blood-stage malaria isolates. The results of these studies have 
demonstrated that this approach is safe with no signs of relapse of P. vivax infection detected in 
any of the challenged volunteers. The availability of a P. vivax blood-stage challenge model and 
optimal use of such a model provides a unique opportunity to rapidly and cost-effectively test the 
efficacy of P. vivax vaccines and drugs in healthy volunteers, accelerating clinical development of 
new interventions for P. vivax malaria.
2.2
BACKGROUND
Despite the decrease in malaria incidence achieved in the last 15 years, this parasitic disease still 
threatens almost half of the world’s population. According to a recent World Health Organization 
(WHO) report, in 2017 there were 219 million cases of malaria and 435,000 deaths. [1] Most 
malaria cases occurred in sub-Saharan Africa. However, Asia, Latin America, the Middle East and 
parts of Europe are also at risk. Whilst P. falciparum is the most prevalent malaria parasite in 
Africa, P. vivax has a wider geographical distribution. In 2017, 44% of the malaria cases that 
occurred outside the African continent were caused by P. vivax.[1] Moreover, 70 to 80 million 
cases per year of relapsing malaria occur due to infection with P. vivax.
The WHO has declared that the response to malaria is a global development priority and has 
changed their recommendation from control to eradication programs. A robust development 
pipeline of potential drug and vaccine candidates is required in order to meet this target. The 
development process for determining safety and clinical efficacy of potential antimalarial 
interventions requires fast, efficient test systems.
Controlled human malaria infection (CHMI) is increasingly being used to evaluate antimalarial 
drug and vaccine candidates.[2-9] Most CHMI studies use sporozoite parasite forms to induce 
infection. However CHMI studies with P. falciparum and P. vivax have also been conducted with 
the IBSM model, whereby participants are infected with blood-stage malaria parasites.[5, 7, 10] 
The IBSM models offer a pathway to test efficacy of P. falciparum and/or P. vivax vaccines and 
drugs in healthy volunteers in a rapid and cost effective manner. One of the advantages of the 
IBSM model is its ability to facilitate analysis of antimalarial and vaccine  efficacy against 
blood-stage  parasite growth  by
providing a standardized inoculum of blood-stage parasites. Validation studies have shown a high 
correlation between natural and experimental infections, which further justifies the use of IBSM 

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for testing new vaccines and drugs.[4, 8] The safety and utility of this approach for assessment of 
antimalarial and vaccine efficacy has been augmented by the implementation of rapid, sensitive, 
and robust real-time PCR assays for quantification of parasitemia.[4, 11]
Another significant benefit of the IBSM model for P. vivax studies is the exclusion of the liver 
stage of the parasite that is the source of relapses. Until recently, primaquine was the only Food 
and Drug Administration (FDA)-approved medication available for preventing relapse of malaria, 
but poor regimen adherence and other factors can lead to relapse rates of up to 32% in patients 
treated with the standard 15 mg daily dose of primaquine for 14 days.[12] In addition, 
primaquine is not fully metabolized to its active form in persons with low activity of cytochrome 
P450 isozyme (CYP) 2D, which can also lead to treatment failure. Persons with glucose-6-
phosphate-dehydrogenase deficiency are at elevated risk of hemolysis when taking primaquine, 
limiting its usefulness. Since July 2018, tafenoquine has also been approved by the FDA for the 
prevention and treatment of hypnozoites.[13] The major advantage of tafenoquine over primaquine 
is single-dose treatment of hypnozoites, but otherwise many of the drawbacks of primaquine 
remain. Therefore, excluding the liver stage of the parasite by using an IBSM model removes the 
risk of recurring P. vivax infection from occult hypnozoites. As such, the approach of experimental 
infection using the IBSM model provides a system for assessing the efficacy and safety of novel 
antimalarial drugs and vaccines against P. vivax infection with significantly reduced safety issues 
associated with recurrent P. vivax infections in the healthy participants.
In the absence of a method of in vitro culture of P. vivax, the only way to source parasites is ex 
vivo. This hampers all aspects of development of tools to eliminate this parasite. For example, to 
test and develop candidate P. vivax vaccines or hypnozoiticidal drugs, a reliable source of P. vivax 
sporozoites is required. Currently this entails an expensive, logistically complex and unreliable 
process of sourcing P. vivax-infected mosquitoes from endemic areas of Asia. In addition to these 
logistical issues, the parasites are not genetically homogenous. As a result, the dose and 
composition of P. vivax sporozoite challenge material is extremely difficult to standardize. The 
establishment of a ready supply of homogenous P. vivax parasites in a blood-stage challenge model 
would facilitate rapid and cost-effective studies of P. vivax vaccines and drugs in healthy 
volunteers, accelerating clinical development of new interventions for P. vivax malaria.
2.2.1
Previous Human P. vivax CHMI Experience
Challenge models have previously been developed for assessment of the efficacy of vaccine or 
drug candidates against P. vivax. Initial studies entailed challenge of healthy volunteers with live 
P. vivax sporozoites. Herrera et al. reported challenge of  18 malaria-I volunteers via 
mosquito bites.[14] The mosquitoes were first infected by feeding with blood donated by P. vivax 
infected patients: 17 out of 18 volunteers developed malaria as determined by thick blood smear 
and PCR. All l7 infected volunteers developed symptoms consistent with malaria on day 9 post-
challenge and all volunteers were treated with chloroquine and primaquine. All volunteers 
cleared parasitemia between 24 and
48 hours after initiating antimalarial treatment and recovered within 2 to 3 days without any severe 
or serious adverse reactions. Furthermore, the authors reported that none of the volunteers 
developed parasite relapses within an 18 month follow up.
Similarly, Herrera et al. reported 17 malaria-naive volunteers receiving sporozoite challenge with 
all volunteers developing symptoms and signs consistent with malaria infection between day 8 and 
15 post-challenge.[6] Malaria infection was also confirmed by thin blood smears. The prepatent 

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periods recorded in this study varied between 9 and 16 days with a median of 9 days. Volunteers 
were treated with chloroquine and primaquine one month after the day of challenge. Although no 
serious adverse events (SAEs) were reported in this study and all of the volunteers recovered after 
the antimalaria treatment, one of the volunteers developed symptoms consistent with a relapse of 
malaria infection 2 months after treatment. This infection was also confirmed with thin blood 
smear. The re- treated volunteer recovered completely.
These studies have reported that the sporozoite challenge model is safe and can be used for assessing 
the efficacy of antimalarial vaccines.[6, 14] However, the use of a mosquito challenge system in 
P. vivax has the additional risk of relapse of malaria infection despite primaquine therapy. In 
addition to the experience of Herrera et al. above, the relapse of P. vivax malaria infection during 
P. vivax sporozoite challenge studies was also recorded in a similar trial conducted at the Walter 
Reed Army Medical Research in the US, in which 33 participants underwent sporozoite challenge. 
All participants developed parasitemia by day 13 and parasitemia was cleared following treatment 
with chloroquine and primaquine. However, two participants had multiple relapses of malaria, and 
both were subsequently found to have low CYP2D6 activity compared with the participants who 
did not suffer relapses.[3]
2.2.2
Previous Human P. vivax IBSM Experience
A cryopreserved P. vivax isolate manufactured by QIMRB will be used to manufacture the P. vivax 
challenge agent at the NIH for this study. P. vivax parasite banks (HMPBS-Pv and HMPBS02-Pv) 
from QIMRB have been previously used to inoculate 45 malaria study participants.[15-21]
2.2.2.1
QIMRB Isolate HMPBS-Pv
The naturally occurring or wild type P. vivax master cell bank (MCB) containing HMPBS- Pv, was 
produced using blood collected from an individual with malaria infection presenting to hospital 
after travel to the Solomon Islands. The donor was an adult with laboratory-confirmed P. vivax 
malaria who consented to the proposed study. Once the patient consented, blood was collected, 
and the patient was successfully treated with artemether/lumefantrine.
A total of 8 healthy participants have been infected with P. vivax isolate HMPBS-Pv.[10, 22] The 
most frequent symptoms reported in P. vivax challenge studies have been those consistent with 
early malaria infection, including headache, malaise, chills, myalgia, fatigue, sweats and rigors. 
Less commonly reported symptoms include muscular pain, sensitive skin, paresthesias, nausea, 
and vomiting. In one volunteer who received HMPBS-Pv challenge agent, mild non-tender 
splenomegaly was also recorded 24 hours following initiation of the antimalarial treatment. This 
completely resolved by day 28 post-inoculation.[22] Four of the eight volunteers also experienced 
transient significant derangements of liver function tests (LFTs).[10] These derangements 
appeared as elevations greater than five times the upper limit of normal (ULN) of both 
alanine transaminase (ALT) and aspartate transaminase (AST). No volunteer reported any 
symptoms arising from or accounting for the LFT derangement. The derangements all resolved 
completely with no specific intervention by day 50 post-inoculation. Thorough investigation that 
included viral serologies for human immunodeficiency virus (HIV), hepatitis B and C, 
cytomegalovirus (CMV), Epstein-Barr virus (EBV), alphaviruses, and flaviviruses, as well as 
acetaminophen levels, creatine kinase (CK), and liver ultrasound screen indicated that the observed 
derangement was likely caused by the inoculum itself. External hepatologists were also consulted 
and no other possible cause could be identified. The recorded derangements were reviewed at the 
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(particularly a significant elevation of bilirubin, see Figure 1), these abnormalities were deemed to 
not preclude proceeding with subsequent cohorts nor with further studies utilizing this inoculum. 
In addition to the LFT derangements, the only other laboratory abnormalities observed were 
expected derangements of full blood count parameters, which were consistent with malaria 
infection.[10]

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Figure 1: Liver Function Tests in Six Volunteers who Received HMPBS-Pv Challenge Agent (ANZCTR Trial ID: 12613001008718)
Adapted from Griffin et al. (2016). Liver function tests. Levels of (A) ALT (alanine transaminase), (B) AST (aspartate transaminase), and (C) total bilirubin 
versus study day for each of the six subjects. The horizontal dotted line indicates normal range. Challenge agent was administered on Day 0. Antimalarial 
treatment was administered on Day 14. Abbreviations: ULN: upper limit of normal; LLN: lower limit of normal).[10]

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2.2.2.2
QIMRB Isolate HMPBS02-Pv
The blood-stage P. vivax MCB containing HMPBS02-Pv was also produced using blood collected 
from a consenting patient with naturally acquired malaria infection. The malaria infection was 
confirmed to be P. vivax by species-specific PCR at Pathology Queensland (accredited by the 
Australian National Association of Testing Authorities) and further confirmed by deep sequencing 
at the Sanger Institute. The clinical response to antimalarial chemotherapy was also demonstrated 
with this donor, who was successfully cured with artemether/lumefantrine.
This second P. vivax isolate, HMPBS02-Pv, has been used to inoculate 37 healthy volunteers to 
date in four studies.[15, 18-21] In the first study where two volunteers were inoculated with the 
HMPBS02-Pv isolate, the recorded AEs were all mild in severity with the exception of one 
moderate headache that was reported by one volunteer.[18] No significant liver enzyme 
derangements were recorded in either of these two volunteers.
Comparison of the parasitemias that developed in the participants following inoculation revealed 
no significant differences between the cohorts. The results showed consistency of the dosage 
strength and no evidence for reduction in the potency of the bank during storage. The results also 
demonstrated rapid and complete parasitological response following treatment with either 
artemether/lumefantrine or chloroquine. Parasitemia cleared within 2 to 3 days following the 
initiation of the treatment. The AEs recorded in these studies were consistent with malaria infection 
and included headache, fever, myalgia, arthralgia, presyncope, and rigors. The majority of the 
recorded AEs were transient in nature, mild in severity, and resolved either with antimalarial 
treatment alone or with doses of acetaminophen or ibuprofen. There were no clinically significant 
changes in hematology, biochemistry, or urinalysis over time in any participants on these studies.
Asymptomatic derangement in LFTs, however, have been recorded in some study participants 
inoculated with HMPBS02-Pv challenge agent. In one of the studies, one out of the eight 
challenged participants showed an increase in AST/ALT/lactate dehydrogenase >1.25 times the 
ULN, with peak ALT of 2.6 times the ULN on day 15 and day 18, resolving by day 22.[16] This 
participant used ibuprofen on days 9 and 10 of the study. Moderate transient neutropenia, mild 
transient lymphopenia, and mild transient thrombocytopenia on day 13 were also recorded in this 
participant.
In another recent study, seven out of eight participants within a single cohort who were treated 
with an investigational drug following inoculation with HMPBS02-Pv challenge agent developed 
elevated LFTs >1.25 times the ULN (ALT>AST with no elevation in bilirubin). In this cohort, 
four participants had peak malaria clinical scores ≥10.[21] All participants with elevated LFTs 
received symptomatic treatment with ibuprofen and acetaminophen. All participants had 
normalization of LFTs, seven by day 28 and one by day 44, the latter owing to delayed follow up.
All of the volunteers who have received HMPBS-Pv or HMPBS02-Pv challenge agent fully 
recovered and remained well when reviewed at their end of study visits. The recorded AEs for 
both HMPBS-Pv and HMPBS02-Pv challenge agent are summarized in Table 1.

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Table 1. Challenge Agent-Related Adverse Events for HMPBS02-Pv and HMPBS-Pv 
Isolate
Malaria-Related 
Symptoms and 
Signs
Study 
QP12C
14
[22] 
HMPBS-
Pv (n = 2)
Study 
QP13C0
9
[10] 
HMPBS-
Pv (n = 6)
Study 
QP14C1
0
[18] 
HMPBS0
2-Pv
(n = 2)
Study 
QP15C1
1
[21] 
HMPBS0
2-Pv
(n = 8)
Study 
QP15C1
9
[19] 
HMPBS02
-Pv
(n = 24)
Study 
QP17C1
4
[20] 
HMPBS0
2-Pv 
(n=3)
Abdominal 
discomfort
1(1)
7(2)
1(1) -–co1
6(4) -–co2
4(4) - co3
Abdominal 
tenderness–
1(1) - co3
Anorexia/ 
Decreased appetite
2(2)
3(3)
2(2) – co1
7(3) – co2
5(4) – co3
2(2)
ALT increased
8(4)
10(5)
2(2) – co2
3(2) – co3
1(1)
AST increased
7(4)
5(5)
1(1) – co3
Arthralgia
4(2)
1(1)
9(6)
1(1) – co1
11(4) – co2
7(4) – co3
1(1)
Chills / Rigor
2(2)
5(5)
1(1)
7(5)
1(1) – co1
8(4) – co2
8(4) – co3
4(3)
Dehydration
2(2) – co2
Diarrhea
1(1)
1(1)
1(1) – co2

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Dizziness
1(1)
1(1)
1(1)
2(2) – co2
1(1) – co3
1(1)
Feeling Hot
1(1)
Fatigue/Lethargy
3(1)
3(2)
19(8)
5(3) – co1
7(4) – co2
14(7) - co3
2(2)
Headache
7(2)
10(6)
5(2)
2(8)
8(5) - co1
30(7) - co2
15(7) – co3
5(2)
Hot Flush
1(1)
Hyperhidrosis 
/ sweat
1(1)
1(1)
5(4)
2(2)
Hypocalcemia
1(1) – co2
Hypophosphatemia
2(2)
Influenza 
like illness
1(1)
4(4)
2(1) – co1
7(4) – co2
4(2) –co3
Insomnia
1(1)
Lactate 
dehydrogenas
e increased
2(2)
Lymphocyte 
count decreased
8(8)
6(6) – co2
5(5) – co3
5(4)
Malaise
1(1)
8(6)
6(4) – co2
6(6) – co3
2(2)
Muscle rigidity
2(2)

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Myalgia
2(2)
2(2)
2(1)
16(7)
6(4) – co1
11(6) – co2
9(6) – co3
3(3)
Nausea
1(1)
6(6)
6(4)
6(3) – co1
7(3) – co2
11(6) – co3
1(1)
Neutrophil 
count decreased
2(2)
4(3) – co2
2(2) – co3
4(2)
Oral Herpes
1(1)
Oropharyngeal 
pain
1(1)
1(1) – 
co3
Paresthesia
1(1)
Platelet count 
decreased
1(1) – 
co2
Presyncope
1(1)
Pyrexia
22(6)
2(2)
30(8)
4(3) – co1
10(7) – co2
15(7) – co3
19(4)
Rhinorrhea
1(1) – 
co3
Sensitive skin
1(1)
Splenomegaly
2(2) – co2
1(1) – co3
Tachycardia
2(2)
2(2) – co2
1(1) – co3
Extreme Thirst
1(1)

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Thrombocytopenia
4(3)
Vomiting
1(1)
1(1)
1(1)
1(1) – co1
4(3) – co2
2(2) – co3
While blood cell 
count decreased
2(2)
3(3) – co2
2(2) – co3
5(4)
Total
26
88
12
170
37 – co1
140 – co2
119 – co3
296 - all
61
ALT: alanine transaminase; AST: aspartate transaminase; co: cohort; LDH: lactate dehydrogenase.
The number between brackets represent the number of subjects in which a given AE was observed. For study 
QP15C19, treatment was administered on Day 8 for cohort 1 and Day 10 for cohorts 2 and 3. For cohort 1, ibuprofen 
or paracetamol (acetaminophen) were administered for symptoms relief. For cohort 2, ibuprofen was administered 
preferably and for cohort 3, it was paracetamol.
2.3
RISK/BENEFIT ASSESSMENT
2.3.1
Known Potential Risks
2.3.1.1
Venipuncture and IV Placement
Risks occasionally associated with venipuncture and IV line placement include pain, bruising, 
bleeding, and infection at the site of venipuncture, lightheadedness, and rarely, syncope.
2.3.1.2
Challenge Agent Injection
In this study, HMPBS02-Pv challenge agent containing cryopreserved P. vivax isolate HMPBS02-
Pv will be used. Information regarding the HMPBS02-Pv challenge agent is available in the 
Investigator’s Brochure. The P. vivax MCB containing HMPBS02-Pv has been previously used to 
challenge 37 healthy study participants using the IBSM model. No SAEs related to the challenge 
agent have been reported in the participants exposed to date.
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 potentially being moderate or severe.
The challenge agent contains a small number of red blood cells (RBCs) from the original donor. 
The risk for development of RBC antibodies in this study is considered extremely low. The  donor 
of the malaria cell bank used in this study was confirmed to be blood group O, Rh (D) positive. 
People with blood group O are generally considered “universal donors” as recipients of their blood 
have minimal risk of developing RBC alloantibodies when given much larger volumes   of blood 
than is routinely used for IBSM. However, it is possible that participants could suffer a transfusion 

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reaction after they receive the inoculum or develop antibodies to the donor RBCs that may make 
blood transfusion more difficult in the future. Therefore, the participants will be monitored in the 
period immediately after the administration of the malaria parasite dose and screened at the end of 
the study for occurrence of RBC alloantibodies as part of the safety monitoring. In addition, 
eligible females of childbearing potential must not be Rh (D) negative.
The risk of bloodborne infection from the blood transfused in this study is expected to be very low 
for a number of reasons. First, the donor was screened and tested negative for the presence of acute 
bloodborne infections. Furthermore, the volume of blood used in IBSM challenge studies for 
transmitting malaria is significantly lower than in a transfused unit of blood. In addition, the white 
blood cells are removed from the MCB during the production process, which lowers the risk of 
any past/latent EBV and CMV infection due to transfusion. The bank has tested PCR negative for 
both CMV and EBV even though the donor of the bank was antibody positive for both CMV and 
EBV. As part of the safety monitoring, all study participants will have serum stored for testing of 
blood-borne virus infections before entry on and after the completion of the study.
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. Participants will be informed of any such risks 
should further data become available.
2.3.1.3
P. vivax IBSM
The number of blood-stage parasites in the challenge agent is much lower than what reaches the 
blood after the bite of a single malaria-infected mosquito, where approximately 30,000 parasites 
are released into the blood when they break out of a single infected liver cell. Following 
administration of the challenge agent, the growth of the parasites as well as any symptoms in the 
participants will be closely monitored. The threshold for commencement of treatment will be when 
the clinical symptom score is >6 (admission within 24 hours of notification that this threshold has 
been reached), or parasitemia is >20,000 parasites/mL, or at the investigator’s discretion. This 
treatment threshold has been selected because it is below the point at which advanced and severe 
clinical symptoms of malaria infection are likely to occur.
The parasites used in the challenge agent for this study are known to be sensitive to the standard 
antimalarial drugs artemether/lumefantrine and chloroquine. As such, there is no serious risk of 
inadequately treated clinical malaria provided that the inoculated participants comply with the 
curative antimalarial regimen as directed.
Symptoms related to malaria infection are expected to occur. The AEs include headache, fever, 
myalgia, arthralgia, presyncope, fatigue, and rigors. The majority of the recorded AEs reported 
have been transient in nature, mild in severity, and resolved either with antimalarial treatment or 
with acetaminophen or ibuprofen and overall last approximately 2-3 days.
Transient, asymptomatic LFT derangements have been reported in several participants in IBSM 
studies.[23, 24] These LFT derangements, which consisted of ALT/AST elevation with no change 
in bilirubin, did not require treatment and resolved by the end of each study. Similar elevations in 
LFTs have been reported following naturally acquired malaria infection. [25, 26] Following an 
independent review involving experts in drug-induced liver injury, it was concluded that these LFT 
elevations were most likely a consequence of the malaria infection. As a precaution, all participants 
in this study will undergo regular safety monitoring to assess for asymptomatic LFT abnormalities.

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Participants are required to limit their intake of possibly hepatotoxic substances during the course 
of the study, including alcohol and acetaminophen (acetaminophen can be used as second-line 
symptom control after ibuprofen and will not exceed 4 g/day in the study).
Other laboratory abnormalities observed in the studies in some volunteers were expected 
derangements of full blood count parameters consistent with malaria infection.  Such abnormalities 
include but are not limited to decreased counts of total white blood cells, neutrophils, and/or 
lymphocytes.  These aberrations may also  be expected to occur to similar degrees described in 
studies of natural Pv infections even if not previously reported in Pv IBSM trials.  For example, a 
study of Brazilian adults presenting with symptomatic Pv infections found that 85% of individuals 
had decreased lymphocytes, 16% had a decrease that would correspond to a Grade 3 adverse event 
based on the criteria in Appendix C, and 3% had a decrease that would correspond to a Grade 4 
adverse event [32].  These derangements in white blood count parameters (ANC, ALC, etc) are 
transient, expected, and self-limited once antimalarial treatment is completed and levels of 
parasitemia drop.
As with any clinical investigation, even with extensive precautions there is always a risk of serious 
or even life-threatening allergic reactions to administration of the investigational product. These 
risks are minimized by eligibility criteria that exclude participants with a potential for adverse 
reaction (AR) to the malaria challenge, infection, or study drugs. Likewise, participants will be 
closely monitored during the administration of challenge agent and/or drugs and in the immediate 
period following administration by clinical staff trained and equipped to respond immediately to 
acute systemic reactions including anaphylaxis and clinical malaria.
2.3.1.4
Artemether/lumefantrine (Coartem®)
Participants will be treated with Coartem, which is a registered, oral, proven, and highly 
efficacious antimalarial treatment.
Coartem has an acceptable safety profile. Individuals who may have any contraindication for the 
use of this drug (e.g., known prolonged corrected QT interval (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 Coartem 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.
Published data from clinical studies and pharmacovigilance data have not established an 
association with artemether/lumefantrine use during pregnancy and major birth defects, 
miscarriage, or adverse maternal or fetal outcomes. The estimated background risk of major birth 
defects and miscarriage for the indicated population is unknown. Results of animal studies suggest 
the possibility of increased risk of fetal loss with Coartem dosing, but the relevance of these 
findings from animal reproductive studies to human risk is unclear.
Thus, all female participants will undergo pregnancy testing prior to receipt of Coartem. Also, per 
the package insert, Coartem 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.
2.3.1.5
Chloroquine Phosphate
Participants may be treated with chloroquine phosphate, which is a registered, oral, proven, and 

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highly efficacious antimalarial treatment.
The most commonly reported side effects of chloroquine dosing include gastrointestinal 
disturbance, headache, dizziness, blurred vision, insomnia, tinnitus, and pruritus, but generally 
these effects do not require discontinuation of the drug. High doses of chloroquine, as used to treat 
rheumatic diseases (>3.5 mg/kg/day over 1 year or more), have been associated with retinopathy, 
although this generally requires a cumulative dose exceeding 100 g,[27] and thus is extremely 
unlikely at doses used for routine weekly malaria prophylaxis especially for the limited duration 
in this study. Chloroquine is reported to exacerbate psoriasis; therefore, subjects with a history of 
psoriasis are excluded.
2.3.1.6
IV Artesunate
Participants may be treated with IV artesunate, which is a registered, proven, and highly 
efficacious antimalarial treatment.
Artesunate is generally well tolerated. The most commonly reported side effects of artesunate use 
include rare reports of anemia, allergic reactions, anxiety, dizziness, headaches, metallic taste, 
erythema, pruritus, skin rash, anorexia, diarrhea, nausea, vomiting, hemolysis, neutropenia, 
increased serum ALT, increased blood urea nitrogen, and dyspnea.
2.3.1.7
Other Risks
Women of reproductive potential will be required to agree to use birth control as outlined in 
Section 5. Malaria can cause pregnancy complications and antimalarial medications have a low 
but possible risk of harming a fetus. Because this is a research study, women of reproductive 
potential will be asked to notify the site immediately upon learning of pregnancy during this study 
and will be tested for pregnancy prior to administration of the challenge agent and periodically 
throughout the course of the study as outlined in the Schedule of Activities (Section 1.3).
Medications including ibuprofen and acetaminophen may be used for symptom control during this 
study. These medications are considered safe, available over the counter, and will be used in 
accordance with the manufacturer’s instructions. The most common side effect of ibuprofen is 
dyspepsia. Rarely, mucosal bleeding has been reported related to excessive use. Acetaminophen, 
which may be used as a second-line agent, is typically well tolerated but may be associated with 
hepatotoxicity in excess.
Risks of a nasopharyngeal swab may include possible discomfort, bleeding or rarely infection at 
site of insertion.
2.3.1.8
Risk to the Community
Malaria is not contagious and cannot be spread by person-to-person contact but only via the bite 
of a female Anopheles mosquito. The window of time when participants can transmit to mosquitoes 
has been well documented in previous studies.[28] Based on these studies, there is negligible risk 
of volunteers transmitting to local mosquito vectors in the DC, Maryland, and Virginia area if they 
adhere to study procedures. The antimalarial treatment that study participants receive (Coartem, 
artemether/lumefantrine) is known to kill all parasite lifecycle stages, including gametocytes, and 
in contrast to P. falciparum, administration of primaquine as a gametocytocidal agent is not 
necessary. Additionally, field studies of P. vivax transmission have demonstrated that 
artemether/lumefantrine is an effective gametocytocidal agent.[29, 30]
There is a theoretical risk of bloodborne infection in study staff in the case of needlestick exposure 

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to blood product containing parasitized erythrocytes. This risk is considered extremely low for two 
reasons: the use of personal protective equipment and the small volume nature of a needlestick 
exposure.
2.3.2
Known Potential Benefits
Participants will not receive any direct benefit from participation in this study. It is hoped that 
information gained in this study will contribute to the development of a safe and effective malaria 
vaccine or other antimalarial interventions.

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2.3.3
Assessment of Potential Risks and Benefits
The anticipated benefit of this study is the development of a reliable tool to facilitate the 
development antimalarial interventions. The development of a reliable P. vivax blood stage 
parasite MCB will allow for further future IBSM studies for the efficient testing of investigational 
antimalarial interventions for safety and efficacy. These benefits justify the risks incurred by 
participants in this study. While IBSM does expose a healthy volunteer to risk that they would not 
otherwise be subject to, there have been many participants in previous trials utilizing IBSM 
without significant or lasting adverse effects observed. Participants in this study will be closely 
monitored for safety throughout their participation in the trial and will be fully treated for malaria 
prior to completing the study. In addition, very few participants (only 2 are envisioned) will 
undergo IBSM on this trial, limiting the risk to a small number of healthy volunteers. Part of the 
rationale for developing a P. vivax MCB is to reduce the risk of future P. vivax challenge studies 
by eliminating the possibility of hypnozoites and the risk of relapsing malaria infection in future 
participants.
3
OBJECTIVES AND ENDPOINTS
OBJECTIVES
ENDPOINTS
JUSTIFICATION 
FOR 
ENDPOINTS
Primary
The collection of blood from 
healthy participants 
experimentally infected with P. 
vivax isolate HMPBS02-Pv for 
the production of a P. vivax 
blood-stage parasite bank for use 
in future studies.
Collection of blood for the 
production of a P. vivax blood-
stage parasite bank from study 
participants following 
experimental infection with
P. vivax isolate HMPBS02-Pv.
The blood bank to be 
produced is intended 
for use in future 
studies of P. vivax 
vaccines, 
pathogenesis, or 
other antimalarial 
interventions.
Secondary
To assess the safety and 
tolerability of the P. vivax IBSM 
model following inoculation of 
healthy malaria-naïve 
participants with P. vivax.
Occurrence of solicited and 
unsolicited AEs following P. 
vivax inoculation prior to the 
initiation of antimalarial 
treatment.
Standard clinical 
safety endpoints.
Tertiary/Exploratory
To further characterize blood- 
and sexual-stage parasite 
growth profiles following 
inoculation with
P. vivax isolate and treatment 
with artemether/lumefantrine.
The rate of growth of blood- and 
sexual-stage P. vivax isolate 
following inoculation and 
treatment with 
artemether/lumefantrine as 
determined by blood smear 
and/or qPCR
Blood smear and 
qPCR are considered 
the gold standards for 
measuring malaria 
parasitemia and 
gametocytemia.

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4
STUDY DESIGN
4.1
OVERALL DESIGN
This is a single-center, open-label study to infect healthy volunteers using induced blood-stage 
malaria (IBSM) so that blood can be collected to enable production of a human malaria parasite 
(HMP) bank for use in future studies.
This study involves infecting healthy volunteers using IBSM so that blood can be collected to 
produce a HMP bank. This study will be conducted in up to 2 participants, who are healthy adults 
aged between 18 and 50 years old. Participants will be screened for eligibility up to 56 days before 
inoculation. Eligible participants will be inoculated intravenously on Day 0 with approximately 
564 viable P. vivax parasite-infected erythrocytes (HMPBS02-Pv challenge agent). A sample size 
of two participants has been selected to maximize the chances of at least one successful banking 
procedure and to minimize the volume of the HMPBS02-Pv cell bank, which is in limited supply.
Participants will be monitored daily via phone on Days 1 to 3 post-inoculation. Beginning on Day 4 
post-inoculation, the participants will be seen in the outpatient clinical unit daily for blood 
sampling to measure parasitemia via qPCR targeting the P. vivax 18S rRNA gene (referred to as 
malaria 18S qPCR), to monitor for symptoms and signs of malaria, and to record AEs.
The threshold for the commencement of blood collection for banking and subsequent antimalarial 
rescue treatment with artemether/lumefantrine will occur when the Malaria Clinical Score is >6, 
when parasitemia is >20,000 parasites/mL, or at the investigator’s discretion. Within 24 hours of 
notification that this threshold is reached, participants will be admitted to the clinical unit for initial 
safety assessments. The participant will then undergo the blood collection procedure with the 
Department of Transfusion Medicine as per the SOP. The participant will then receive the first 
dose of artemether/lumefantrine. The participant will remain inpatient within the clinical unit for 
a minimum of 48 hours, which may be extended to 72 hours or longer at the discretion of the 
investigator to monitor for safety and tolerability of rescue therapy and to ensure adequate clinical 
and parasitological response to treatment. For example, if qPCR results indicate unsatisfactory 
clearance of the parasitemia, defined as 2 consecutive qPCR time points showing less than 20% 
change from baseline (i.e., the parasitemia before drug treatment) by 72 hours, participants may 
be administered chloroquine.
In the unlikely event that artemether/lumefantrine fails to clear parasitemia, participants will be 
treated with chloroquine. If oral administration of either artemether/lumefantrine or chloroquine is 
not possible (e.g., the participant is vomiting), the participant will receive intravenous treatment 
with artesunate. After discharge from the inpatient unit, participants will be followed up on an 
outpatient basis for monitoring of safety and parasite clearance. Follow-up for safety assessments 
will be performed on Day 28 ±3, Day 56 ±7 (phone call only), and Day 90 ±7 (End of Study).
Participants may also be evaluated for the presence of sexual parasite stages (gametocytes) and 
other parasite lifecycle stages in the blood during the study using reverse transcriptase qPCR (qRT-
PCR). Study procedures and the planned timeline of events are outlined in the protocol below and 
summarized in the Schedule of Activities (Section 1.3).
4.2
SCIENTIFIC RATIONALE FOR STUDY DESIGN
This is a single-center, open-label study using IBSM infection to establish a HMP bank using 
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with blood-stage P. vivax. Participants will be allowed to develop patent infection, at which time 
an estimated target minimum 200-mL whole blood sample will be collected prior to receipt of 
effective antimalarial  therapy. This will allow for the local production of up to two P. vivax HMP 
banks for future IBSM model studies. The whole blood sample will undergo leukodepletion and 
aliquoting as per the standard operating procedure (SOP) to generate a bank (estimated 200 
aliquots) of P. vivax– parasitized erythrocytes. This study will also explore the safety, tolerability, 
and infectivity of this IBSM model at the NIH CC. Local generation of HMP banks will allow 
access to reliable blood- stage P. vivax human challenge studies with a consistent parasite dose and 
strain that permits efficient assessment of antimalarial drugs and vaccine candidates.
4.3
JUSTIFICATION FOR DOSE
The inoculum dose, containing an estimated 564 viable P. vivax-infected erythrocytes in a volume 
of 2 mL, has been established to be sufficient to provoke a reliable P. vivax infection in previous 
studies by QIMRB [28]. The inoculum will be administered intravenously to each participant on 
study Day 0. The actual number of parasites inoculated will take into account the loss of viability 
resulting from cryopreservation, storage, and thawing. The dose administered will be confirmed 
retrospectively based on in vivo parasite growth kinetics.
5
STUDY POPULATION
5.1
INCLUSION CRITERIA
All of the following criteria must be fulfilled for a participant to participate in this trial:
1. Age ≥18 and ≤50 years.
2. In good general health and without clinically significant medical history.
3. Does not live alone from study Day 0 until the end of the antimalarial drug treatment 
(investigator discretion).
4. Malaria comprehension exam completed, passed (a score of ≥80% or per 
investigator’s discretion) and reviewed prior to enrollment.
5. Reliable access to the NIH CC and availability to participate for duration of study.
6. Females of childbearing potential must be willing to use reliable contraception (as 
defined below) from 21 days prior to study Day 0 to 28 days following IBSM.

Subject to the judgment and discretion of the Principal Investigator (PI), 
female participants who meet ANY ONE of the criteria listed immediately below, 
may not be required to take any additional measures to avoid pregnancy. Such 
participants will be counseled on risks at the time of consent and at appropriate 
points (e.g., when pregnancy testing occurs) during the study:
o
Females who have had their uterus and/or BOTH ovaries removed.
o
Females who have undergone ligation or removal of BOTH fallopian tubes.
o
Females who are above the age of 45 and have spontaneously had no menses 
at any point during the past 12 or more consecutive months (i.e., have 
reached menopause).
o
Females who, in the conservative and reasonable judgment of the PI (e.g., 
due to sexual orientation, gender identity, or serious life choice [such as 
being celibate clergy]), during the entire trial will NOT participate in any 
potentially reproductive sexual contact.
o
Females who, in the conservative and reasonable judgment of the 
PI, are in a monogamous stable relationship with a male who has 

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undergone vasectomy at least 4 months prior or another 
procedure/medical condition that deems the male sterile.

Subject to the judgment and discretion of the PI, female participants who DO 
NOT meet ANY of the criteria listed above, will be appropriately counseled on 
reproductive risks and pregnancy avoidance, and will be required to adhere to the 
following measures and agree to 2 methods of pregnancy prevention as noted 
below:
CATEGORY 1:

a highly effective hormonal method to prevent pregnancy [e.g., CONSISTENT, 
CONTINUOUS use of contraceptive pill, patch, ring, implant or injection], and/or

Intrauterine device or equivalent.
IN ADDITION TO
CATEGORY 2:

a barrier method to be used at the time of potentially reproductive sexual activity 
(e.g. [male/female condom, ‘cap,’ or diaphragm] + spermicide).
7. Sign written informed consent prior to undertaking any study-related procedure.
5.2
EXCLUSION CRITERIA
A participant will be excluded from participating in this trial if any one of the following criteria is 
fulfilled:
1. Currently breastfeeding (if female).
2. Pregnant as determined by a positive urine or serum human choriogonadotropin (β-
hCG) test (if female).
3. Planned travel to a malaria-endemic area during the study period and up to 2 
weeks following the EOS visit (see www.cdc.gov/malaria/travelers/country_table).
4. History of recent travel to or residence in a P. vivax malaria–endemic region or prior 
participation in a malaria challenge study (investigator discretion).
5. Any history of confirmed malaria diagnosis on peripheral blood smear or by clinical 
history
6. Screening laboratory parameters outside of local lab normal range, to include  serum-
corrected calcium, creatinine, hepatic transaminase enzymes (ALT, AST), total bilirubin 
(unless the participant has documented Gilbert syndrome), and hemoglobin. Participants 
may be included at the investigator’s discretion for “not clinically significant” values 
outside of normal range.
7. Abnormal urinalysis as defined by positive urine glucose, protein, and hemoglobin. 
Participant can be included if investigator determine the abnormality is “not clinically 
significant.”
8. Duffy blood group negative (male or female).
9. ABO blood type other than O (male or female).
10. Rh blood group negative (females of childbearing potential).
11. Anticipated use during the study period, or use within the following periods prior to 
enrollment of any of the following (investigator discretion):
a.
Investigational malaria vaccine within the last 2 years.
b. Malaria chemoprophylaxis within the past 6 months.
c.
Chronic systemic immunosuppressive medications (>14 days) within 6 months 
(e.g., cytotoxic medications, adrenocorticotrophic hormone, or oral/parental 

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corticosteroids equivalent to >0.5 mg/kg/day of prednisone). Corticosteroid nasal 
spray for allergic rhinitis and topical corticosteroids for mild, uncomplicated 
dermatitis are allowed.
d. Blood products or immunoglobulins within the previous 6 months.
e.
Systemic antibiotics or medications with potential antimalarial effects within the 
past 6 weeks (e.g., clindamycin, chloroquine, piperaquine, benzodiazepines, 
fluoxetine, tetracycline, azithromycin, or doxycycline [if not used as an antimalarial 
prophylaxis agent]).
f.
Investigational or non-registered product or vaccine within 30 days.
g. Receipt of any vaccination within 28 days prior to P. vivax IBSM.
h. Medications known to interact with artemether/lumefantrine.
i.
Anticoagulants within the past 28 days.
12. History of:
a.
Sickle cell disease, sickle cell trait, or other hemoglobinopathies.
b. Splenectomy or functional asplenia.
c.
Systemic anaphylaxis.
d. Any allergic reactions to artemether/lumefantrine, chloroquine (or any 4-
aminoquinolines), artemether or other artemisinin derivatives, or their excipients.
e.
History of malignancy of any organ system (other than localized basal cell 
carcinoma of the skin or in situ cervical cancer), treated or untreated, within 5 years 
of screening, regardless of whether there is evidence of local recurrence or 
metastases.
f.
Blood transfusion.
13. Clinically significant medical condition, physical examination findings, other clinically 
significant abnormal laboratory results, or past medical history that may have clinically 
significant implications for current health status and participation in the study in the 
opinion of the investigator. A clinically significant condition or process includes but is not 
limited to:
a.
A process that would affect the immune response, or requires medication that 
affects the immune response.
b. Any contraindication to repeated phlebotomy.
c.
A condition or process in which signs or symptoms could be confused with 
reactions to malaria challenge and/or infection.
d. A chronic or subclinical condition which could be exacerbated by malaria infection.
e.
Frequent headaches and/or migraines, recurrent nausea, and/or vomiting (more 
than twice a month).
f.
A history of retinal abnormalities, disease of the retina or macula of the eye, 
visual field defects, or hearing disorders (e.g., reduced hearing, tinnitus).
g. History of coagulopathy or bleeding diatheses.
h. Any condition or disease that might affect drug absorption, distribution or excretion 
(e.g., gastrectomy, diarrhea).
i.
Presence of current or suspected serious chronic diseases such as cardiac or 
autoimmune disease, insulin-dependent and non-insulin–dependent diabetes, 
progressive neurological disease, severe malnutrition, acute or progressive hepatic 
disease, acute or progressive renal disease, porphyria, psoriasis, rheumatoid 
arthritis, asthma, epilepsy, or obsessive compulsive disorder.

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14. Vital signs taken after 5 minutes of resting in seated or supine position that fall outside the 
following ranges:
a.
Systolic blood pressure ≤90 mm Hg or ≥140 mm Hg.
b. Diastolic blood pressure ≤50 mm Hg or ≥90 mm Hg.
c.
Heart rate ≤40 bpm or ≥100 bpm.
15. Body mass index less than 17.0 or greater than 35.0 kg/m2 at the time of screening.
16. History of, or known active cardiac disease including: (1) prior myocardial infarction (heart 
attack); (2) angina pectoris; (3) congestive heart failure; (4) valvular heart disease; (5) 
cardiomyopathy; (6) pericarditis; (7) stroke or transient ischemic attack; (8) exertional 
chest pain or shortness of breath; (9) symptomatic cardiac arrhythmias; (10) clinically 
relevant bradycardia; or (11) other heart conditions under the care of a doctor.
17. Clinically significant electrocardiogram (ECG) findings as determined by the expert study 
cardiologist, or QTcF ≥450 ms, or presence of second- or third-degree atrioventricular 
block or abnormal T wave morphology.
18. Moderate or high risk for coronary heart disease based on National Health and Nutrition 
Examination Survey (NHANES) I cardiovascular risk assessment (Appendix A).
19. Family history of sudden death or of congenital prolongation of the QTc interval or known 
congenital prolongation of the QTc interval or any clinical condition known to prolong the 
QTc interval.
20. History of electrolyte disturbances, particularly hypokalemia, hypocalcemia, or 
hypomagnesemia.
21. Acute infectious disease or fever (e.g., temperature ≥38.5°C) within the 5 days prior to 
inoculation with malaria parasites.
22. Evidence of acute illness within the 4 weeks prior to screening that the investigator deems 
may compromise participant safety.
23. Positive result on any of the following tests: hepatitis B surface antigen (HBsAg), anti-
hepatitis C virus (anti-HCV) antibodies, and anti-human immunodeficiency virus 1 and 2 
antibodies (anti-HIV1 and anti HIV2 Ab).
24. Positive urine drug test for any drug listed in Section 8.2.2.1 (Drug Screening) unless there 
is an explanation acceptable to the investigator (e.g., the participant has stated in advance 
that they consumed a prescription or over-the-counter product that contained the detected 
drug) and/or the participant has a negative urine drug screen on retest by the pathology 
laboratory. Any participant testing positive for acetaminophen at screening may still be 
eligible for study participation, at the investigator’s discretion.
25. Elevated serum ethanol level.
26. Psychiatric condition that precludes compliance with the protocol including but not limited 
to:
a.
Psychosis within the past 3 years.
b. Ongoing risk for suicide, or history of suicide attempt or admission for danger to 
self or others.
c.
History of schizophrenia, bipolar disease, or other severe (disabling) chronic 
psychiatric diagnosis including depression or receiving psychiatric drugs or who 
has been hospitalized within the past 5 years prior to enrollment for psychiatric 
illness.
d. History of other serious psychiatric conditions that may affect participation in the 
study or preclude compliance with the protocol, including but not limited to past or 

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present psychoses, disorders requiring lithium, more than one previous episode of 
major depression, any previous single episode of major depression lasting for or 
requiring treatment for more than 6 months, or any episode of major depression 
during the 5 years preceding screening.
e.
The Patient Health Questionnaire-2 (PHQ-2) (Appendix F) will be used as an 
objective tool for the assessment of depression at screening. In addition to the 
conditions listed above, participants with a score of 3 or more on the PHQ-2 will 
not be eligible for participation. These participants will be referred to a general 
practitioner or medical specialist as appropriate. Participants with a score of 1 or 2 
may be enrolled at the discretion of the investigator if they do not have a history of 
the psychiatric conditions mentioned in this criterion and their mental state is not 
considered to pose additional risk to the health of the volunteer or to the execution 
of the study and interpretation of the data gathered.
27. Suspected or known current alcohol or drug abuse as defined by the American Psychiatric 
Association in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, at 
the discretion of the investigator.
28. Smoking more than 5 cigarettes or equivalent per day and unable to stop smoking for the 
duration of admission. Participants may smoke up to 5 cigarettes or equivalent per day for 
the rest of the study.
29. History or presence of alcohol abuse (alcohol consumption of more than 4 standard drinks 
per day), drug habituation, or any prior intravenous usage of an illicit substance.
30. Excessive consumption of beverages or food containing xanthine bases (such as Red Bull, 
chocolate, etc.), or more than 400 mg of caffeine per day (equivalent to more than 4 cups 
of coffee per day, investigator discretion).
31. Ingestion of any poppy seeds within the 24 hours prior to the screening blood test 
(participants will be advised by phone not to consume any poppy seeds in this time period, 
investigator discretion).
32. Use of prescription drugs or non-prescription drugs and herbal supplements (such as 
St John’s Wort) within 14 days or 5 half-lives (whichever is longer) prior to the inoculation 
administration. (Note: diazepam interferes with the analysis of blood levels of chloroquine 
and thus should not have been used for at least 8 weeks prior to administration of the study 
drug). If needed (i.e., an incidental and limited need), ibuprofen up to 1.2 g/day or 
acetaminophen up to 4 g/day is acceptable. The participant must inform the investigator of 
any ibuprofen or acetaminophen use at the next convenient time. Limited use of other non-
prescription medications or dietary supplements not believed to affect participant safety 
or the overall results of the study may be permitted on a case-by-case basis following 
approval by the sponsor in consultation with the investigator. Participants are requested to 
refrain from taking non-approved concomitant medications from recruitment until the 
conclusion of the study.
33. Clinical trial staff with direct involvement in the conduct of the trial are excluded from 
participation.
34. Participating in other clinical trials involving investigational interventions or off-label 
medication use during the study period or within the 12 weeks preceding study day 0 
(investigator discretion). Participation in other trials such as observational or imaging 
studies will be discussed with the investigators.
35. Blood donation of any volume within 4 weeks prior to study day 0, or participation in any 

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research study involving blood sampling (more than 450 mL/unit of blood), or blood 
donation to Red Cross (or other) blood bank within 8 weeks prior to study day 0.
36. Unwillingness to defer blood donations for at least 3 years.
37. Unwillingness to abstain from consumption of quinine-containing foods/beverages, such 
as tonic water or lemon bitter, from inoculation (study day 0) to the end of antimalarial 
treatment (investigator discretion).
38. Unwillingness to abstain from consumption of grapefruit or Seville oranges from 
inoculation (study day 0) to the end of antimalarial treatment (investigator discretion).
39. Any participant without a good peripheral venous access.
40. Participant who, in the judgment of the investigator, is likely to be noncompliant during 
the study, or is unable to cooperate because of a language or mental deficit.
41. Any other finding that, in the judgment of the investigator, would interfere with, or serve 
as a contraindication to, protocol adherence, assessment of safety or reactogenicity, or a 
participant’s ability to give informed consent, or increase the risk of having an adverse 
outcome from participating in the study.
5.3
INCLUSION OF VULNERABLE PARTICIPANTS
5.3.1
Justification for Exclusion of Pregnant Women
This study will not enroll pregnant and/or breastfeeding women since malaria infection can have 
adverse effects on both the pregnant mother and fetus. Additionally, though observational studies 
have shown initial safety data on the use of artemether/lumefantrine (Coartem) during the first 
trimester and has been approved for use in the second and third trimester in malaria-endemic 
regions, artemether/lumefantrine (Coartem) is currently not recommended in healthy pregnant 
women. Thus, women who are pregnant, nursing, or plan to become pregnant during the study are 
excluded from the study.
5.3.2
Justification for Exclusion of Children
Children are excluded from this study because there are insufficient data regarding dosing or AEs 
available in adults to judge the potential risk in children. In addition, given the nature of malaria 
challenge trials in US malaria-naïve participants, the risk being more than minimal, and no direct 
benefit to the child, evaluation of IBSM with P. vivax in infants and children under the age of 18 
would not be warranted when this can be completed successfully in healthy adults.
5.3.3
Justification for Exclusion of Adults Who Cannot Consent
Participants must be able to provide initial and ongoing informed consent to participate in this 
study. As with children, the risk of participation in this study is more than minimal, and this study 
offers no prospect of direct benefit to decisionally impaired adults. Therefore, participation by 
adults who cannot provide informed consent is not warranted when this study can be completed 
successfully in cognitively healthy adults.
5.3.4
Justification for Exclusion of Participants Older than 50
This study will not enroll participants aged over 50 years due the possibility of reduced 
erythrocyte survival following bank collection in older donors and the general lack of data and 
experience performing IBSM challenge studies in this age group. Thus, to optimize the 
production of a viable P. vivax cell bank from study participants, subjects aged over 50 will be 
excluded from this study.

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5.3.5
Participation of NIH Staff or Family Members of Study Team
NIH staff and family members of the study team may be enrolled in this study as this population 
meets the study entry criteria. Neither participation nor refusal to participate as a subject in the 
research will have an effect, either beneficial or adverse, on the participant’s employment or 
position at NIH.
Every effort will be made to protect participant information, but such information may be available 
in medical records and may be available to authorized users outside of the study team in both an 
identifiable an unidentifiable manner.
The NIH investigator will provide and request that the NIH staff member review the Frequently 
Asked Questions (FAQs) for Staff Who are Considering Participation in NIH Research and the 
Leave Policy for NIH Employees Participating in NIH Medical Research Studies (NIH Policy 
Manual 2300-630-3). Considerations for consent of staff is described in Section 10.1.3.
5.4
LIFESTYLE CONSIDERATIONS
During this study, participants are asked to abstain from alcohol for 24 hours prior to serum 
ethanol assay and from inoculation until the end of antimalarial treatment.
Participants should not consume more than 400 mg of caffeine per day, equivalent to more than 
4 cups of coffee, from inoculation until the end of the antimalarial treatment.
Participants should not consume tonic water, lemon bitter, or other drinks/foods containing quinine 
or grapefruit or Seville oranges, from inoculation until the end of antimalarial treatment.
Participants should not eat any poppy seeds in the 24 hours before the following time points: 
screening, inoculation day, and day of admission for antimalarial treatment.
5.5
SCREEN FAILURES
Screen failures are defined as participants who consent to participate in the clinical trial but are 
not subsequently assigned to the study intervention or entered in the study. A minimal set of screen 
failure information is required to ensure transparent reporting of screen failure participants, to meet 
the Consolidated Standards of Reporting Trials publishing requirements and to respond to queries 
from regulatory authorities. Minimal information includes demography, screen failure details, 
eligibility criteria, and any SAE.
5.6
STRATEGIES FOR RECRUITMENT AND RETENTION
Healthy adult male and non-pregnant, non-lactating female participants will be recruited from a 
variety of sources including those previously screened or enrolled in other vaccine trials at the NIH 
CC or by the use of an IRB-approved screening protocol and study-specific print or media 
advertising. After an initial phone screen (using an IRB-approved phone screen), a screening visit 
will be scheduled.
During the screening process, which may require more than one visit, the participant will read the 
consent form, be encouraged to ask questions, and then complete a written comprehension 
evaluation questionnaire (Malaria Comprehension Exam). The questionnaire is used to identify 
the areas of the study and consent that the participant may not fully understand. The person 
administering consent will review the answers with the participant. If the participant gets a 
question wrong, the person administering the consent will review the portion of the consent form 
that relates to that particular question with the participant. The participant may either sign the 

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consent form during the screening visit, or return after further consideration.
The accrual ceiling will be up to 50 individuals to recruit two subjects for the study.
5.6.1
Costs
Participants in this study will not be billed for any study procedures outlined in this protocol. 
Participants are required to have outside medical insurance in order to facilitate follow-up of any 
medical conditions or abnormalities uncovered as a result of this study that are not related to the 
study procedures.
5.6.2
Compensation
Participants will be compensated for their time while participating in this trial. Compensation is 
prorated based upon completion of specific visits and is not contingent upon completing the entire 
study. A compensation schedule is provided below (Table 2). Compensation for interim visits to 
follow up clinical or laboratory abnormalities will be provided at the investigator’s discretion, up 
to $80. If a participant withdraws from the trial, payment will be made based on the last completed 
visit. Information about compensation, including the amount and schedule of payment(s) and 
applicable reporting to the IRS, will also be described in the informed consent form. Participants 
will not be compensated for travel or lodging.
Table 2. Compensation Table
Study Activity
Number of 
Visits
Compensation 
Amount (USD)
Total 
(USD)
Screening Visit
1
$180
$180
DTM donor screening visit
1
$50
$50
Eligibility Confirmation Visit
1
$110
$110
Study Visits
Administration of Challenge Agent 
(IBSM inoculation)
1
$440
$440
3 (by phone)
$15
$45
Malaria Monitoring
~9 (outpatient)
$70
$630
Inpatient Stay Day 1 (including 
banking)
1
$550
$550
Inpatient Stay, beyond Day 1
1
$170
$170
Antimalarial treatment (whole course) 
1
$100
$100
Outpatient Monitoring
1
$80
$80
1 (Day 28)
$80
$80
1 (Day 56, by 
phone)
$15
$15
Safety Monitoring
1 (Day 90)
$80
$80
Approximate TOTAL for Study
$2530
The number of malaria monitoring visits and the duration of inpatient stay may vary depending on the 
progress of parasitemia. Estimates provided are based on previous experience at QIMR-B. If a 
participant is diagnosed with malaria early, compensation    may be less, or if more visits are needed 
before admission, compensation may be more, (diagnosis on Day 12 is presented here). An 
inpatient stay beyond the proposed two days will receive pro-rata reimbursement at the daily rate 

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for ‘Inpatient Stay, beyond day 1.’
6
STUDY INTERVENTION
6.1
STUDY INTERVENTIONS ADMINISTRATION
6.1.1
P. vivax Challenge Agent 
The P. vivax isolate HMPBS02-Pv was collected from blood group O Rhesus (Rh)-positive blood 
donated from a returned traveler from India who presented with clinical manifestations of malaria. 
The HMPBS02-Pv containing MCB was cryopreserved, aliquoted into cryovials, and stored under 
liquid nitrogen under controlled conditions. Refer to the HMPBS02-Pv Challenge Agent 
Investigator’s Brochure for more details. A MCB cryovial containing HMPBS02-Pv will be 
retrieved from storage, thawed, and used to aseptically prepare the challenge agent.
6.1.2
Dosing and Administration
A challenge agent dose, containing an estimated 564 viable P. vivax-infected erythrocytes in a 
volume of 2 mL, will be administered IV to each participant on the morning of study day 0. The 
actual number of parasites inoculated will take into account the loss of viability resulting from 
cryopreservation, storage, and thawing. On inoculation day, participants may have food until at 
least half an hour prior to inoculation. Participants will undergo intravenous cannulation with an 
appropriate gauge cannula. Placement and patency will be checked by flushing the vein with 
5-10 mL of clinical grade saline. The inoculum will be injected, and the cannula again flushed 
with 5- 10 mL of clinical grade saline. The cannula will then be removed, and hemostasis ensured 
by use of an appropriate dressing.
6.1.3
Antimalarial Treatment
Artemether/lumefantrine
Artemether/lumefantrine (Coartem) is a commercially available antimalarial drug. The package 
insert is provided. Artemether/lumefantrine (Coartem) will be purchased directly from a 
commercial source by the NIH CC pharmacy and will be held in appropriate locked storage 
conditions and labelled for study purposes in accordance with all applicable regulatory 
requirements. The standard treatment will be dispensed and accounted for in accordance with NIH 
CC pharmacy standard procedures. All used medications will be fully documented.
Chloroquine phosphate
Chloroquine phosphate is a commercially available antimalarial drug. The package insert is 
provided. Chloroquine phosphate will be purchased directly from a commercial source by the NIH 
CC pharmacy and will be held in appropriate locked storage conditions and labelled for study 
purposes in accordance with all applicable regulatory requirements. The standard treatment will 
be dispensed and accounted for in accordance with NIH CC pharmacy standard procedures. All 
used medications will be fully documented.
Intravenous artesunate
As of April 1, 2019, artesunate is the sole recommended parenteral treatment for malaria in the 
United States. Currently, it is not commercially available but can be obtained through an expanded 
access Investigational New Drug (IND) protocol administered by the US Centers for Disease 
Control (CDC). Please see the CDC’s website for further information on the process by which 
artesunate will be obtained, if needed: www.cdc.gov/malaria/diagnosis_treatment/artesunate.html.

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6.1.3.1
Dosing and Administration
Artemether/lumefantrine
All participants will receive treatment with artemether/lumefantrine. The threshold for treatment 
will occur when the Malaria Clinical Score is >6, parasitemia is >20,000 parasites/mL, or at the 
investigator’s discretion. Artemether/lumefantrine tablets containing 20 mg of artemether and 
120 mg of lumefantrine will be administered as 6 doses of 4 tablets (total course of 24 tablets) 
given over a period of 60 hours (total dose of 480 mg of artemether and 2.88 g of lumefantrine). 
Each dose of tablets administered orally should be taken with food or drinks rich in fat (e.g., milk). 
Participants will be reminded of the potential side effects of artemether/lumefantrine.
Chloroquine (only if required)
Participants will only be administered chloroquine if artemether/lumefantrine fails to clear the 
malaria parasites. For example, if qPCR results indicate unsatisfactory clearance of the 
parasitemia, defined as two consecutive qPCR time points showing less than a 20% decrease from 
baseline (i.e., the parasitemia before drug treatment) by 72 hours, participants may be administered 
chloroquine. Chloroquine tablets containing 250 mg of chloroquine phosphate (equivalent to 
155 mg of chloroquine base) will be administered as an initial oral dose of 4 tablets, followed by 
2 tablets at 6, 24, and 48 hours (total dose of 2.5 g of chloroquine phosphate [1550 g base]).
Artesunate (only if required)
Treatment of participants with IV artesunate will only occur in the event that participants are 
unable to complete oral treatment with either artemether/lumefantrine or chloroquine (e.g., the 
participant is vomiting). This would be done at the recommended dose regime of 2.4 mg/kg at 
approximately 0, 12, 24 hours and then daily for up to 7 days or until able to take oral drugs.
6.2
PREPARATION/HANDLING/STORAGE/ACCOUNTABILITY
6.2.1
Acquisition and Accountability
Transfer, receipt and maintenance of the P. vivax MCB from its storage site to the clinical trial site 
will follow SOP. During transport and at the study site, the liquid nitrogen vapor phase shipper 
will be monitored. Receipt of the malaria inocula will be documented on a tracking log by study 
staff. Final accountability will be performed at the conclusion of the Day 0 and at the end of the 
study. Final disposition of any remaining P. vivax vials will be determined and documented 
following SOP.
The investigator, clinical site pharmacist, or designee, as nominated by the investigator, is 
responsible for maintaining accurate study agent (inoculum and antimalarial drugs) accountability 
records throughout the study. Dispensing, accountability, and documentation will be in accordance 
with SOP. All products will be inventoried upon receipt by staff at the NIH CC. The condition 
of the products at the time of receipt will be documented, as will the time restrictions of use for 
the syringes containing the malaria challenge agent. The lot numbers and expiry dates of the 
inoculum  and antimalarial drugs will be documented. The investigator, pharmacist, or delegate 
will ensure that the received products are the specified formulation.
The storage, handling and the disposal of the challenge agents will be in accordance with approved 
procedures. All dosages prescribed and dispensed to the participants and all dose changes during 
the study must be documented. All drug supplies are to be used only in accordance with this 
protocol, and not for any other purpose. All used medications will be fully documented. Used and 

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unused drug containers must be destroyed at the site once drug accountability is final and has been 
checked by the sponsor or its delegate, and written permission for destruction has been obtained 
from the sponsor.
Study products and study accountability logs will be available to the sponsor or their representative 
as part of the study monitoring procedures. Upon completion of the study, copies of all study drug 
management records will be provided to the sponsor. Original records will be maintained at the 
clinical site with the rest of the study records.
6.2.2
Formulation, Appearance, Packaging, and Labeling
The P. vivax isolate HMPBS02-Pv is supplied by QIMRB. The NIH DTM prepares the challenge 
agent for dosing. It has been estimated that each challenge dose will contain approximately 1.5x109 
erythrocytes and approximately 564 viable intraerythrocytic wild type P. vivax, parasites in a 
volume of 2 mL of normal injectable saline. The challenge agent will be administered to each 
volunteer as an intravenous injection. The parasites injected in each volunteer will be quantified 
retrospectively using qPCR analysis of retained material.
6.2.3
Product Storage and Stability
Transfer, receipt, and maintenance of the P. vivax MCB from its storage site to the clinical trial 
site will follow SOP. During transport and at the study site, the liquid nitrogen vapor phase shipper 
will be monitored. Receipt of the MCB will be documented on a tracking log by study staff.
The inoculum will be prepared at the clinical trial site on inoculation day (Day 0). The time 
between preparation of the inoculum and administration to each participant will be a maximum of 
115 minutes, during which time the syringes will be kept at the required temperature as recorded 
on the label.
Artemether/lumefantrine tablets will be maintained in the manufacturer’s original packaging, 
stored below 30°C, and protected from moisture at the CC until prepared for dispensing.
Chloroquine phosphate tablets will be maintained in the manufacturer’s original packaging and 
stored below 30°C at the CC until prepared for dispensing.
IV artesunate is stored at pre-designated quarantine stations by the CDC in preparation for 
dispensing if needed.
6.2.4
Preparation
The P. vivax challenge agent will be prepared in the NIH DTM according to SOP. Briefly, the 
MCB vial will be thawed and washed, resuspended in normal saline, diluted, and dispensed into 
syringes. The inoculum will be kept on ice until injected. For preparation of each inoculum, a 
required volume of the thawed and diluted blood sample will be used, which has been estimated 
to contain approximately 564 (P. vivax) viable parasite-infected erythrocytes. This will be mixed 
with clinical grade normal saline. Each inoculum dose will contain parasitized and unparasitized 
RBCs, resuspended in 0.9% sodium chloride IV infusion, in a total volume of 2 mL in syringes. 
The time between preparation of the challenge agent and inoculation will be maximum 115 
minutes, during which time the challenge agent will be stored at 2-15C until administration (e.g. 
on ice).
6.3
MEASURES TO MINIMIZE BIAS: RANDOMIZATION AND BLINDING
Not Applicable

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6.4
STUDY INTERVENTION COMPLIANCE
Following administration of the challenge agent, adherence to the protocol will be assessed and 
verified at scheduled study visits, and unscheduled visits where required, including collection of 
blood samples for qPCR parasitemia monitoring and collection of malaria-related symptom data, 
including the malaria clinical score. These data will be used to determine the timing of collection 
for cell banking. The eCRF will be completed following study visits. Results of blood sample 
testing will be available as electronic reports from the laboratory responsible for testing and 
entered into the eCRF or printed and stored as hardcopy following review by the investigator.
6.5
CONCOMITANT THERAPY
For this protocol, a prescription medication is defined as a medication that can be prescribed only 
by a properly authorized/licensed clinician. Medications to be reported in the Clinical Research 
Information Management System of the NIAID (CRIMSON) are concomitant prescription 
medications, over-the-counter medications and supplements.
Concomitant medications, treatments, and procedures are those occurring from administration of 
the malaria inoculum until the end of the study (last visit). Those occurring prior to administration 
of the inoculum are classified as prior medications, treatments, and procedures. Medications taken 
within 28 days before the malaria inoculation will be recorded as prior medication. Prior and 
concomitant medications, treatments, and procedures permitted in this study are outlined in the 
inclusion/exclusion criteria (Sections 5 and 5.2).
On inoculation day, participants will be questioned in relation to relevant aspects of compliance 
with the study protocol, including drug intake since their screening clinic visit. Details of all other 
drugs taken (prescription and over-the-counter, systemic and topical administration) will be 
recorded at this time and appropriate action taken. The investigator may permit the use of ibuprofen 
up to 1.2 g/day or acetaminophen up to 4 g/day for treatment of headache or other pain if required. 
Any medication taken during the study for treatment of a medical condition or AE is to be recorded 
in the concomitant medication pages in CRIMSON (exact dose and timing of each dose to be 
specified).
All concomitant medications other than those routinely used for symptom relief in IBSM trials 
(i.e., acetaminophen, ibuprofen, ondansetron) or routine medications approved at screening (e.g., 
oral contraceptive) should be discussed with the investigator before being approved unless deemed 
medically urgent. If the medication has already been taken, then it should be reviewed by the 
investigator at the next opportunity and a decision should be made to continue, to stop, to switch 
to an alternative, or to withdraw the participant from the trial.
7
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL
7.1
DISCONTINUATION OF STUDY INTERVENTION
Discontinuation following challenge agent administration does not mean discontinuation from the 
study, and remaining study procedures should be completed as indicated by the study protocol. If 
a clinically significant finding is identified after enrollment (including, but not limited to changes 
from baseline), the investigator or qualified designee will determine if any change in participant 
management is needed. Any new clinically relevant finding will be reported as an adverse event 
(AE). Participants are free to withdraw from participation in the study at any time upon request.

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7.1.1
Withdrawal Criteria for an Individual Subject
An individual subject will be withdrawn from the study for any of the following:

An individual subject’s decision. The investigator should attempt to determine the 
reason for the subject’s decision.

Non-compliance with study procedures to the extent that it is potentially harmful to 
the subject or to the integrity of the study data.

The subject loses the capacity to provide ongoing informed consent.

Participants may be withdrawn for any AE that would cause continued participation in the 
study to not be in the best interest of the participant, as per the investigator’s judgment. 
Any participant who is withdrawn from the study because of an AE related to the 
investigational product 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.

A change in the subject’s condition as follows:
o
The participant acquires HIV or viral hepatitis infection during the course of the 
study.
o
The participant becomes pregnant during the course of the study.

The investigator determines that continued participation in the study would not be in the 
best interest of the subject.
7.1.1.1
Re-enrollment and Unplanned Procedure Repetition
Unless otherwise specified within this protocol, each person who is a subject in this study may be 
enrolled, and may pass through each step and process outlined in the protocol only ONCE 
(i.e., subjects may not “go back” and repeat a protocol step already completed). On a case-by-case 
basis, a request for re-enrollment, or for repetition of a protocol step or procedure already 
completed, may be submitted to, reviewed by, and approved by the SMM in writing. The SMM 
may also recommend or require consultation of the IRB.
7.1.1.2
Replacement of Withdrawn Subjects or Subjects Who Discontinue Study Agent
Participants who have received IBSM and who withdraw or are terminated from the study prior to 
completion will not be replaced. Participants withdrawn before the receipt of IBSM will be 
replaced.
All subjects exposed to study agent(s) MUST be included in the safety dataset.
7.2
LOST TO FOLLOW-UP
A participant will be considered lost to follow-up if they fail to return for two scheduled visits and 
are unable to be contacted by the study site staff.
The following actions must be taken if a participant fails to return to the clinic for a required 
study visit:

The site will attempt to contact the participant and reschedule the missed visit and counsel 
the participant on the importance of maintaining the assigned visit schedule and ascertain 
if the participant wishes to and/or should continue in the study.

Before a participant is deemed lost to follow-up, the investigator or designee will make 
every effort to regain contact with the participant (where possible, three telephone calls 

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and, if necessary, a certified letter to the participant’s last known mailing address or local 
equivalent methods). These contact attempts should be documented in the participant’s 
medical record or study file.

In the case of a participant failing to attend for visits after inoculation and prior to 
antimalarial treatment, next of kin and/or cohabitating individual may also be contacted.

In the case of a participant failing to attend for visits after inoculation and prior to 
antimalarial treatment, local Public Health services or the relevant Health Department may 
also be contacted.

Should the participant continue to be unreachable, they will be considered to have 
withdrawn from the study with a primary reason of lost to follow-up.
8
STUDY ASSESSMENTS AND PROCEDURES
8.1
SCREENING PROCEDURES
A screening visit will be scheduled after an initial telephone interview conducted by clinical unit 
staff has occurred to review background information. During this initial screening visit, the 
potential participant will read the informed consent form and be encouraged to ask questions. 
Individuals willing to be considered for inclusion may sign the informed consent form during the 
screening visit or return to the clinical unit later after further consideration. The participant will be 
given a copy of the Participant Information Sheet and signed consent form for their records. The 
signed and dated originals will be held on file. Participation consent must be obtained from all 
eligible participants prior to performing screening tests.
8.1.1
Screening activities performed prior to obtaining informed consent
Minimal risk activities that may be performed before the subject has signed a consent include the 
following:
An IRB approved telephone pre-screening. This screening will be conducted to determine if the 
subject appears to meet initial eligibility criteria. If the subject does not wish to complete the 
telephone prescreen, he/she may elect to complete the informed consent process and in-person 
screening process without first completing a telephone prescreen, as indicated below.
8.1.2
Screening activities performed after a consent for screening has been signed
After providing written consent to participate, the participant will undergo the screening 
procedures listed below. Some screening tests may be repeated during the Day -3 to Day -1 safety 
visit (as required) and/or on the day of malaria challenge inoculum administration to determine 
their continued eligibility. Participants must confirm that they will not be living alone from Day 0 
until completion of antimalarial treatment.
Screening will be conducted within 56 days prior to the Day 0 malaria challenge day and will 
include the following elements:
1. Provide the Participation Information Sheet and informed consent form and allow 
the participant sufficient time to review the contents of each document.
2. Explain the study via the main Participation Information Sheet and gain informed 
consent from the participant.
3. Ensure the participant has successfully completed the Malaria Comprehension 
Exam (scoring ≥80% correct and those questions answered in error reviewed).
4. Ensure the participant has signed the informed consent form and received a signed copy.

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5. A screening number will be assigned to each participant.
6. Elicit a complete medical history and use of medications.
7. Elicit a social history including alcohol and tobacco use.
8. Undertake a full physical examination.
9. Ask participant to complete the PHQ-2 questionnaire (Appendix F).
10. Assessment of the cardiovascular disease risk based on the NHANES I cardiovascular 
risk assessment (Appendix A).
11. Record vital signs.
12. Obtain a 12-lead ECG. The ECG should be reviewed, initialed and dated by study study 
staff and transmitted to the study cardiologist for the final review/read.
13. Collect urine for urinalysis and urine drug screen.
14. Ensure that HIV pre-test counseling has been performed and ensure that the participant has 
agreed to HIV testing (required by Maryland state law).
15. Collect blood samples for hematology, biochemistry, RBC alloantibodies, Duffy antigen, 
ethanol level, serum pregnancy testing (if applicable), and bloodborne infection testing.
16. Verify participant meets inclusion/exclusion criteria.
Participants who complete all screening procedures and satisfy all entry criteria will be considered 
eligible to participate in this study. To be eligible for study entry, laboratory values at screening 
must not be outside the range of the normal values at a level deemed to be clinically significant. 
For eligibility parameters, a repeat may be requested to exclude laboratory error.
If screening laboratory results are abnormal, e.g., HIV testing, the volunteer will be referred for 
appropriate counselling. If any clinically significant abnormalities are detected during screening, 
the participant will be referred for follow-up tests to a general practitioner or medical specialist as 
appropriate.
Note: Laboratory studies and ECG completed under a different NIH protocol (such as screening 
protocol 16-I-0039) can be used for screening purposes as long as they are 56 days prior to study 
enrollment.
To ensure the participant fully comprehends key concepts related to the study and to highlight 
areas that may need additional discussion or clarification, a Malaria Comprehension Exam will be 
administered to the participant before signing the informed consent form. All incorrect responses 
will be reviewed with the participant, and they must verbalize understanding of all incorrect 
responses. A score of ≥80% correct is required for enrollment. For participants scoring less than 
80%, study staff may choose to review study details again with participant and reassess 
comprehension with a repeat Malaria Comprehension Exam. At the discretion of the investigator, 
any participant whose comprehension is questionable, regardless of score, may be excluded from 
enrollment. Discussions of understanding will be documented in the participant’s source 
documentation.
Participants will also undergo routine DTM donor center screening prior to enrolment to ensure 
they are considered appropriate to donate blood products by NIH CC DTM service providers. This 
assessment will include routine screening outlined in Section 8.2.2.1. This visit may occur on the 
same day as the screening visit or at any time up to and including the Day -3 to Day -1 Eligibility 
Confirmation Visit. Any concerns regarding eligibility from NIH CC DTM service providers must 
be discussed with the investigator or delegate.
A maximum of 2 participants will undergo IBSM challenge in this trial. Each participant will be 

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actively monitored for approximately 3 months.
Definitions for the purpose of this study:

Screened – participants will receive a study identification (ID) number when the informed 
consent form is signed and will either be determined as “eligible” or “screen failures” 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 enrollment into the 
study.

If the screening visit is >56 days prior to enrollment, then an updated 
medical review and laboratory testing will be completed to determine 
eligibility for enrollment.

Enrolled – participant will be considered enrolled beginning with the receipt of the IBSM.

Screen Failures – participants are considered screen failures (Section 5.5) when they meet 
one of the following criteria after signing the consent form:
o
Screening results reveal that the participant is ineligible.
o
Participant withdraws consent before receiving IBSM.
o
Study completes enrollment prior to the participant being determined eligible for 
enrollment.

Discontinued – participants are considered discontinued when they meet 1 or more of the 
following criteria:
o
Participant withdraws consent after receiving IBSM.
o
Participant is withdrawn by the PI/sponsor.

Completed – participants are considered completed when they complete the final study 
visit.
8.2
STUDY EVALUATION & PROCEDURES
8.2.1
Clinical Evaluations
Medical history
Past medical/surgical history includes:

History of all known allergies

Current medications, including over-the-counter and herbal preparations

History of substance abuse and recreational drug use

History of depression, anxiety, mental illness, emotional problems, use of 
psychiatric medications, and previous psychotherapy

Surgical procedures and results 
Physical examination
Full physical examination includes:

Weight (screening only)

Height (screening only)

Review of systems excluding genitourinary examination and including the following:
o
Head, neck (including thyroid), ears, eyes, nose and throat
o
Heart/circulation

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o
Chest
o
Lungs
o
Abdomen
o
Skin
o
Neurological
Symptom-directed physical examination: physical examinations will be symptom-directed at 
specified time points (i.e., systems will be reviewed only if clinically indicated at the discretion of 
the investigator).
The Patient Health Questionnaire-2 (PHQ-2)
All participants will be required to complete the PHQ-2 questionnaire at screening. This is a 
validated questionnaire used as an objective tool for the assessment of depression (Appendix F).
Vital signs
Vital signs (temperature, heart rate, respiratory rate, and blood pressure) will be measured at 
screening. Tympanic temperature will be taken at the clinical unit, and sublingual temperature will 
be taken by participants at home for practical reasons.
Electrocardiograms
A 12-lead ECG will be recorded. Adverse event recording
AEs will be recorded as described in Section 8.3. 
Malaria Clinical Score
The following 14 signs/symptoms frequently associated with malaria will be graded using a
4-point scale (absent: 0; mild: 1; moderate: 2; severe: 3) and summed to generate a total Malaria 
Clinical Score (maximum score possible is 42). Individual scores for each symptom as well as the 
total score will be recorded (Appendix B):
Headache
Anorexia
Myalgia (muscle ache)
Nausea
Arthralgia (joint ache)
Vomiting
Fatigue/lethargy
Abdominal discomfort
Malaise (general discomfort/uneasiness)
Fever
Chills/shivering/rigors
Tachycardia
Sweating/hot spells
Hypotension
Photography of rash or injection site reactions
If a participant develops a rash or injection site reaction, photographs may be taken by the 
investigators. These photographs will not include the participant’s face or any identifying scars, 
marks, or tattoos.

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DTM NIH CC donor screening
A routine donor screening assessment by DTM NIH CC service providers to ensure the participant 
is appropriate for blood donation. At this visit clinical assessments including review of venous 
access and blood product donation eligibility will be conducted. 
8.2.2
Biospecimen Evaluations
Blood sampling
Blood will be collected for clinical laboratory evaluations including hematology, clinical 
chemistry, serology, and pregnancy testing. Blood samples will also be collected to monitor 
malaria parasitemia. The estimated blood volume required for these tests is listed in Appendix D. 
The total volume of whole blood drawn from each adult participant, including the red blood cells 
collected for the banking procedure, will not exceed 10.5 mL/kg or 550 mL, whichever is smaller, 
over any 8-week period. This volume includes allowance for unscheduled safety laboratory 
assessments that may be required at the discretion of the PI or the sponsor to ensure participant 
safety.
Urine sample collection
Urine will be collected for urinalysis, drug screening, and pregnancy testing.
8.2.2.1
Clinical Laboratory Testing
Using standard techniques, the NIH CC laboratory and Department of Transfusion Medicine will 
perform the following tests:
1. Hematology:

Complete blood count (CBC) plus white blood cell differential and platelet count

The following CBC parameters will be assessed for safety throughout the trial: WBC, 
absolute neutrophil count (ANC)/absolute granulocyte count, absolute lymphocyte count 
(ALC), hemoglobin, and platelet count

A manual blood smear should be reviewed if there are immature/abnormal cells detected 
on the automated differential or if an automated differential was not able to be performed

Reticulocyte count (days -3 to -1 eligibility confirmation visit or at screening if between 
days -3 to -1, and day 28±3 or early termination visit only)

Blood group and Rh(D) (screening visit only)

Duffy antigen (required for screening visit)
2. Biochemistry:

Acute panel (sodium, potassium, chloride, bicarbonate, creatinine, glucose, urea); 
hepatic panel (alkaline phosphatase, ALT, AST, total bilirubin, direct bilirubin); mineral 
panel (albumin, calcium, magnesium, phosphate); uric acid, lactate dehydrogenase 
(screening visit).

Acute panel and hepatic panel (other visits, additional testing at investigator discretion).
3. Bloodborne infection screening

DTM Viral Marker (Transplant Donor) Panel: HbsAg, HBV Ab, HCV Ab, HIV1/2 Ab, 
HTLV1/2 Ab, T.Cruzi Ab, West Nile Virus NAT, HIV/HBC/HCV NAT (screening 
visit).

CMV Ab, EBV Ab, Syphilis (algorithm-based Ab, RPR, TPPA), Babesia Ab, Parvovirus 
B19 NAT (screening visit). If CMV or EBV IgM positive, further testing may be 

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warranted.

CMV, EBV, HHV6 NAT (admission visit). Results not required for banking.
4. RBC alloantibodies (screening and days 28, 90, or early termination visit only)
5. Urine dipstick/urinalysis (screening, eligibility confirmation visit, admission, day 28 visit)
6. Urine and/or serum pregnancy testing (β-hCG)
7. Urine drug screen 
8. Serum ethanol level (screening visit only)
9. Serum storage (serum separating tube to hold; days 0 and 90 visit only)
10. Safety storage (EDTA tube hold; admission only)
11. SARS-COV-2 screen (days -3 to -1 eligibility confirmation visit or at screening if between 
days -3 to -1; as indicated by investigator’s discretion/NIH CC policy/Hospital 
Epidemiology Service recommendations)
Please note: if a participant tests positive for SARS-COV-2 prior to challenge they will be 
considered to meet exclusion criterion 13c.  A positive SARS-COV-2 test after inoculation 
will be discussed with hospital epidemiology and investigator discretion will be exercised 
to determine whether banking may proceed with reasonable safety to hospital staff.
Urinalysis
Urine may be tested by dipstick at the clinical unit. If there are any abnormalities considered 
clinically significant in blood, leucocytes, or protein, the urine will be sent for formal laboratory 
urinalysis.
Urine drug screens and serum ethanol tests
If the results of the urine drug screens or serum ethanol tests are positive, participants may be 
allowed to continue or may be delayed or withdrawn at the investigator’s discretion. All 
participants will be questioned about concomitant medications and use of recreational drugs. The 
urine drug screen may be repeated if the potential participant denies usage of any of these agents 
and the test result is believed to be a false positive.
Participants testing positive for acetaminophen at screening and/or inoculation day may still be 
eligible for study participation at the investigator’s discretion. Participants requiring 
acetaminophen on a daily basis will not be eligible to enroll in the study, as the use of over-the-
counter medication during the study is restricted and potential participants should not discontinue 
their usual medications in order to participate in the study.
Malaria monitoring
Blood will be collected to monitor malaria parasite numbers using qPCR targeting the 18S rRNA 
gene. Additional blood (up to approximately 2 mL per time point) may be collected for parasite 
lifecycle stage qRT-PCR at the investigator’s discretion. This is to evaluate for the presence of 
sexual parasite stages (gametocytes) and other parasite lifecycle stages in the blood for research 
purposes. This blood may also be used for research into various aspects of parasite biology, e.g., 
gametocytes, parasite lifecycle stages, recrudescence, commitment, etc. Targets for qRT-PCR 
may include the female gametocyte-specific transcript pvs25, the male gametocyte, and the ring- 
stage as appropriate. This testing will occur between inoculation and Day 28.

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Microscopic examination for evidence of parasitemia or gametocytemia may be conducted at the 
investigator’s discretion.
8.2.2.2
Blood Smears
The gold standard for malaria diagnosis and evaluation of efficacy endpoints is the detection of 
malaria parasites on Giemsa-stained thick blood films. When indicated, blood smears are prepared 
in duplicate according to standard challenge procedures and evaluated by trained study 
microscopists, and the results reported to the study investigator. At least 0.5 µL of blood is scanned 
for the presence of malaria parasites. This method allows for detection of a parasite density as low 
as 4 parasites/µL and early diagnosis, often before participants become symptomatic for malaria.
Per standard safety guidelines in place for P. falciparum and adopted for P. vivax challenge studies, 
symptomatic individuals may undergo more rigorous smear reading whereby 1.5 µL of blood is 
scanned for the presence of malaria parasites. Slides are considered positive if at least two 
unambiguous parasites per slide are identified and confirmed by a second microscopist.
8.2.2.3
Malaria PCRs
The Department of Laboratory Medicine at the NIH CC has developed a NIH malaria genus 
species (4-plex) qPCR with a sensitivity of 10,000 parasites/mL of whole blood (10 parasites/µL), 
detecting parasitemia approximately 1-2 days before clinical symptoms develop. This assay has 
been externally validated, is conducted under a CLIA-certified laboratory, and is currently the 
malaria molecular assay at the NIH CC.
NIH malaria genus species (4-plex) qPCR will be used for malaria diagnosis along with clinical 
scoring of symptoms per Appendix E.[31] Based on studies completed at QIMRB, timing of 
treatment typically occurs around day 10 post-inoculation. Once a diagnosis of induced malaria 
(by qPCR and/or symptoms) has been made, subsequent NIH CC qPCR will be conducted to 
document decrease in parasites numbers during treatment. Once this is documented, subsequent 
NIH CC qPCRs will not be done until the end of study visit, but research qPCRs will continue to 
be completed per the schedule of activities (Section 1.3) or at the investigator’s discretion.
Research LMIV qPCR (Section 8.2.3.1) will be completed solely for evaluation of research 
endpoints, specifically to characterize the presence and kinetics of subpatent parasitemia (sexual 
and asexual stages) following parasite exposure and following treatment.
8.2.2.4
NIH CC Malaria P. vivax PCR
Both assays must be performed to determine the final PCR result. The “Malaria Genus PCR” is a 
multiplexed PCR that consists of one set of primers and a TaqMan probe that will amplify and 
detect a 157-bp target region of the 18S rRNA present in the five species of malaria known to 
commonly infect humans (P. falciparum, P. vivax, P. ovale, P. malariae, and P. knowlesi). In 
addition, a separate set of primers and a TaqMan probe specific for the spiked internal control (IC) 
DNA is included in the reaction. If a signal is received from both the malaria and IC probes, the 
patient specimen is considered positive for malaria (unable to determine the specific species) and 
there is no indication of PCR inhibition present in the extracted DNA.
The malaria species PCR is performed to determine the Plasmodium species present in the patient 
specimen. This assay is a 4-plex PCR consisting of a combination of four different forward primers 
and one reverse primer and four different TaqMan probes—each labeled with a different 
fluorophore—that will amplify and detect varied 18S rRNA regions specific to a particular species 

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of Plasmodium. Detection of the appropriate fluorophore(s) will indicate the presence of 
P. falciparum (104-bp product), P. vivax (106-bp product), P. ovale (106-bp product), and 
P. malariae (112-bp product). A negative result on this qPCR assay from a specimen that was 
detected positive on the malaria genus PCR indicates, by default, that the infecting organism is 
P. knowlesi.
8.2.3
Correlative Studies for Research/Pharmacokinetic Studies
8.2.3.1
Research Pv (18s) Parasite and Pv Gametocyte (Pvs25) qPCR
While detection of parasites on thick blood smears has been the most common primary endpoint 
in human challenge trials, QIMRB has undertaken 23 clinical trials to date using a validated PCR 
assay to quantify parasitemia including gametocytemia with consistent results (Figure 2).
Figure 2. Asexual Parasitemia and Gametocytemia
Asexual parasitemia and gametocytemia following IBSM (HMPBS02-Pv). In a recent study, participants 
were treated on day 10 post-inoculation. By direct skin feeds (DSF) and direct membrane feeding assays 
(DMFA), participants were only able to transmit to mosquitoes on day 10 post-inoculation, prior to treatment. 
On days prior to and after treatment, no mosquitoes were infected by DSF or DMFA.
These molecular assays have significantly increased sensitivity for detection of blood-stage 
infection approaching 20 parasites/mL, typically 4 days earlier than by paired thick blood smears. 
Quantification of parasite density by these methods allows evaluation of parasite growth curves, 
e.g., for assessing the utility of partially effective vaccine candidates. LMIV plans to develop 
similar Pv qPCR assays to employ for this trial in partnership with QIMRB.
8.2.4
Samples for Genetic/Genomic Analysis
Whole genome transcriptional profiling will be performed to explore possible gene expression 
profiles or pathways following IBSM. Transcriptional analyses will be performed on whole blood 
collected as outlined in the schedule of activities.
Blood may be collected via venous puncture and placed in PaxGENE tubes (or equivalent) to 
preserve RNA integrity until the RNA is extracted. The molecular profiling encompasses the 

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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.
8.3
SAFETY AND OTHER ASSESSMENTS
See Sections 8 and 8.2.1 for descriptions of screening assessments.
8.3.1
Day -3 to Day -1 Eligibility Confirmation Visit
Participants (including reserve participants) will report to the NIH CC between Days -3 and -1 for 
the following baseline assessments, unless screening laboratory assessments were otherwise 
conducted within this period, in which case repeat sampling will not be required.
1. Collect blood samples for hematology and biochemistry analysis.
2. Collect urine for urinalysis.
3. Collect Sample for SARS-CoV-2 analysis
The timing of these assessments is to ensure that results are available for review by the investigator 
prior to inoculation on Day 0. Participants with clinically significant laboratory findings at this 
stage will not be eligible for malaria parasite inoculation.
8.3.2
Enrollment
Participants will be enrolled on a first-eligible-and-available basis. Enrollment may be staggered 
for safety and based on availability.
On the day of the administration of the challenge agent (IBSM Day 0), up to three previously- 
screened and eligible back-up participants may be asked to take the place of participants who do 
not continue to meet eligibility. These alternates will be compensated for their availability on that 
day even if not inoculated.
8.3.3
Administration of the Challenge Agent (IBSM Day 0)
Each participant (and up to 3 reserve participants) will report to the NIH CC on the morning of 
Day 0. The investigator will review the participants’ screening results prior to their enrollment into 
the study. The investigator will emphasize the requirement to return for malaria drug treatment 
after the administration of the challenge agent. Participants will be reviewed by the investigator to 
confirm their continued eligibility for the study, including confirmation that they will not be living 
alone from Day 0 until the end of antimalarial treatment by checking housemates’ contact details 
recorded at screening visit.
Participants will be required to repeat screening procedures to determine whether they remain 
eligible to be enrolled. Participants may have food until a half an hour prior to inoculation. A 
reserve participant may be asked to replace a participant who does not continue to meet eligibility. 
These reserves will be compensated for the study visit even if not inoculated.
The procedures that will be undertaken prior to inoculation include:
1. Verify that all applicable eligibility criteria have been met.
2. Elicit information regarding any new medical conditions or illnesses since screening.
3. Confirm three emergency contacts for the volunteer, including one who is 
aware of participant’s study participation and lives in the participant’s house.
4. Complete emergency medical release form.
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that the test is negative before IBSM; a positive test will exclude the 
participant from the trial.
6. For females, ensure agreement and compliance with pregnancy prevention before IBSM.
7. Perform urine drug screen.
8. Conduct symptom-directed physical examination.
9. Record vital signs.
10. Obtain a 12-lead ECG.
11. Cannulate participants with an indwelling intravenous cannula for the 
malaria inoculum, and record which arm is utilized.
12. Collect blood samples for malaria 18S qPCR (parasitemia baseline sample), 
parasite lifecycle stage qRT-PCR (parasite lifecycle stage baseline sample), 
and research labs – serum storage, transcriptional analyses.
Administration of the malaria inoculum:
1. IV administer the challenge agent of approximately 564 viable P. vivax–
infected human RBCs.
2. Observe for a minimum of 60 minutes after administration of the inoculum to 
evaluate for immediate ARs.
3. Educate participant on signs and symptoms of malaria (Appendix E).  
4. Emphasize to participant the importance of making all study visits per 
protocol or as advised by the clinical staff.
5. Provide participant with thermometers to take temperature readings during the 
study in the event of symptoms of fever.
6. Record AEs and concomitant medications.
7. Record vital signs prior to leaving the clinic (approximately 60 minutes after 
inoculation).
8. Record solicited symptoms for local and systemic IBSM reactogenicity. 
8.3.4
Malaria Monitoring
Malaria monitoring via phone (Day 1 to Day 3)
During this period, participants are expected to be asymptomatic. A daily phone call or text 
message will be made to the participants by clinic staff to monitor participant wellbeing and to 
solicit any AEs. The solicited symptoms for local and systemic IBSM reactogenicity will be 
reviewed remotely with participant, and continued pregnancy prevention compliance will be 
confirmed.
Daily clinic visits for malaria monitoring (Day 4 until admission for rescue treatment)
Daily follow-up will be done from Day 4 until the day of blood collection and rescue treatment 
initiation at the NIH CC. More frequent visits from Day 9 until treatment may be needed to allow 
frequent collection of blood samples for parasitemia determination. The study investigator may 
admit participants earlier than planned for symptom relief and observation prior to blood collection 
and treatment.
The following procedures will occur during these visits:
1. Perform symptom-directed physical examination when signs and symptoms of malaria are 
identified or at the investigator’s discretion.
2. Record vital signs.

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3. Collect blood samples for malaria 18S qPCR and parasite lifecycle stage qRT-PCR (if 
required). Sample may be collected up to 3 times per day from Day 9 until treatment day 
(at the discretion of the investigator and if maximum whole blood volume is not exceeded).
4. Review solicited malaria symptoms with participant.
5. Confirm continued pregnancy prevention compliance.
6. Record malaria clinical score.
7. Record AEs and use of concomitant medications.
8. Hematology and biochemistry will be performed on Day 9.
9. Research labs (transcriptional analysis) may be performed on Day 4.
10. SARs-CoV-2 screening may be collected based on investigator discretion, NIH CC 
policies, or NIH CC Hospital Epidemiology Service recommendations
Inpatient observation, blood collection, and antimalarial treatment phase (estimated Days 9, 
10, 11, 12)
Participants will be admitted to the clinical unit for a minimum of 48 hours (extendable at the 
discretion of the investigator) when the Malaria Clinical Score is >6 (within 24 hours of 
notification), or parasitemia is >20,000 parasites/mL, or at the investigator’s discretion. If a 
participant remains qPCR-negative through Day 14, they will start treatment on days 15, 16, and 
17 and will be considered an infection failure.
Participants will be allowed to leave the inpatient stay 48 hours after initiation of 
artemether/lumefantrine treatment at the investigator’s discretion if the participant is 
asymptomatic or has only mild (Grade 1) symptoms, has a normal examination, and no clinically 
significant laboratory abnormalities.
Admission
During the inpatient stay, participants will be seen at least twice daily by study staff and more 
often if needed.
The following procedures will occur at admission to the clinical unit (or just prior to blood 
collection):
1. Confirm continued pregnancy prevention compliance.
2. Perform symptom-directed physical examination.
3. Record vital signs.
4. Collect urine for urinalysis, drug screen and pregnancy testing (if applicable).
5. Collect blood samples for hematology, biochemistry, malaria 18S qPCR and parasite 
lifecycle stage qRT-PCR and malaria blood smear, bloodborne infection screening, 
research labs - safety storage, transcriptional analyses (optional). In the case where 
collection of blood for banking is not performed soon after admission but later in the day, 
blood sample collection can be postponed and performed just prior to the procedure.
6. Record Malaria Clinical Score.
7. Record AEs and use of concomitant medications.
8. Collect an estimated target minimum 200-mL blood sample for cell bank processing with 
the Department of Transfusion Medicine. The banking procedure should be performed as 
per the banking SOP. Increased volume may be collected at the discretion of the 
investigator based on the available maximum whole volume limit.
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The following procedures will occur during the rescue treatment and observation period:
1. Collect blood samples for hematology, biochemistry (if not collected in prior 24 hours), 
and malaria 18S qPCR (pre-treatment). A blood sample can also be collected for parasite 
lifecycle stage qRT-PCR (at the discretion of the investigator and if the maximum whole 
blood volume is not exceeded).
2. Obtain a 12-lead ECG.
3. Administer artemether/lumefantrine treatment under direct observation.
4. Perform symptom-directed physical examination when signs or symptoms of malaria 
are identified and it is clinically indicated.
5. Record vital signs 3 times a day while admitted.
6. Record Malaria Clinical Score 3 times a day while admitted.
7. Collect blood samples for malaria 18S qPCR at 12, 24, 36, and 48 hours following 
artemether/lumefantrine treatment initiation. A peripheral intravenous line may be 
inserted at any point during the admission to facilitate ease and comfort of frequent lab 
draws.  Additional blood samples can be collected at the discretion of the investigator if 
required to ensure the safety of the participant.
8. Record AEs and use of concomitant medications.
Prior to discharge from inpatient unit
Participants will be allowed to leave the unit 48 hours after initiation of artemether/lumefantrine 
treatment or at the investigator’s discretion. Participants may be requested to stay in the unit longer 
than 48 hours at the investigator’s discretion if deemed in their clinical interest.
The following procedures will occur prior to discharge from the clinical unit:
1. Perform symptom-directed physical examination.
2. Record vital signs.
3. Collect blood samples for hematology, biochemistry, and malaria 18S qPCR. A blood 
sample can also be collected for parasite lifecycle stage qRT-PCR (at the discretion of the 
investigator and if the maximum whole blood volume is not exceeded).
4. Record AEs and use of concomitant medications.
Chloroquine phosphate rescue treatment (if required)
It is predicted that artemether/lumefantrine treatment will be curative considering that it is a 
registered drug used for treatment of P. vivax malaria infection and all patients to date infected 
with the challenge agent derived from the HMPBS02-Pv MCB have been successfully treated with 
artemether/lumefantrine 
alone. 
However, 
there 
is 
a 
possibility 
that 
resistance 
to 
artemether/lumefantrine by the P. vivax challenge agent may occur. In case of treatment failure 
with artemether/lumefantrine, participants will receive a standard course of therapy with 
chloroquine phosphate within 72 hours of administration of the first dose of 
artemether/lumefantrine treatment, at the discretion of the investigator. Full details on the decision 
process to commence chloroquine treatment are presented in Section 6.1.2. If chloroquine dosing 
is required, safety labs (hematology and biochemistry) will be collected and assessed if not already 
scheduled prior to first dose and after last dose (or within 1 day of last dose). Monitoring of 
participants post-chloroquine treatment will occur as presented above for artemether/lumefantrine 
treatment.
Artesunate rescue treatment (if required)

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Treatment of participants with IV artesunate will only occur in the event that participants are 
unable to complete oral treatment with either artemether/lumefantrine or chloroquine (e.g., the 
participant is vomiting or otherwise unable to tolerate oral medications). Details on artesunate 
dosing are presented in Section 6.1.2. Participants will be administered IV artesunate on site and 
monitored as described above.
Outpatient monitoring post-artemether/lumefantrine treatment (post admission until Day 
28 safety visit)
If the participant is discharged before 72 hours post–artemether/lumefantrine treatment, a follow-
up visit will be undertaken at approximately 72 hours for clinical evaluation and blood sampling. 
If the 18S PCR result is positive, the participant will be followed up daily until a minimum of one 
negative qPCR is detected.
The following procedures will take place during this visit:
1. Confirm continued pregnancy prevention compliance.
2. Collect blood samples for malaria 18S qPCR monitoring. Blood sampling for malaria 
monitoring will occur at the investigator’s discretion if there is concern regarding the 
possible recrudescence of parasitemia.
3. Collect blood samples for parasite lifecycle stage qRT-PCR at the investigator’s discretion.
4. Collect blood samples for hematology and biochemistry.
5. Perform symptom-directed physical examination when signs and symptoms of malaria 
are identified and it is clinically indicated at the investigator’s discretion.
6. Record vital signs.
7. Record Malaria Clinical Score if vital signs are abnormal or at the investigator’s 
discretion.
8. Record AEs and use of concomitant medications.
Day 28±3 (safety visit)
The following procedures will occur on day 28±3:
1. Perform full physical examination.
2. Record vital signs.
3. Collect urine for urinalysis.
4. At the discretion of the investigator and if required for safety reasons, collect blood samples 
for hematology, biochemistry, malaria 18S qPCR and parasite lifecycle stage qRT-PCR (if 
required), RBC alloantibodies, research labs - transcriptional analyses (optional).
5. Record AEs and use of concomitant medications.
Follow-up phone call (Day 56±7)
A phone call will be made on day 56±7 to the participants by clinic staff to monitor participant 
well-being and to solicit any AEs.
End of Study Visit (Day 90±7)
The following procedures will occur at the end of study visit:
1. Perform symptom-directed physical examination.
2. Record vital signs.
3. If not already done on day 28±3, collect blood samples for hematology, biochemistry, 

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malaria 18S qPCR and parasite lifecycle stage qRT-PCR (if required), RBC alloantibodie s
4. Collect blood samples for and safety serum storage.
5. Record AEs and use of concomitant medications.
 Early Termination Visit
If withdrawal occurs at any stage of the study, the participant will be asked to complete an end-of-
study evaluation. In addition, participants are informed on the essential requirement to 
complete the antimalarial drug treatment for their safety.
Participation in an end-of-study evaluation by each participant is voluntary. Procedures during the 
early termination visit will include the following if withdrawal occurs prior to Day 28 visit:
1. Perform full physical examination.
2. Record vital signs.
3. Collect urine sample for urinalysis.
4. Obtain blood for hematology, biochemistry, malaria qPCR and parasite lifecycle 
stage qRT-PCR, RBC alloantibodies, and safety serum storage.
5. Record AEs and use of concomitant medications.
If withdrawal occurs after the Day 28 visit, the procedures outlined for the final study visit will be 
performed.
Unscheduled Visit
Unscheduled visits for malaria 18S qPCR or safety monitoring may be required at the 
investigator’s discretion based on parasitemia, clinical symptoms, or laboratory results. 
Participants will be contacted by phone to arrange these visits. Where possible, visits will be 
arranged at a time that is both convenient for the participant and meets any clinical urgency as 
determined by the investigator.
Schedule of Activities
The schedule of activities (Section 1.3) details all procedures to be conducted as per this protocol 
during recruitment and screening, enrollment, inpatient stay, and follow-up. During inpatient 
hospitalization, participants will be admitted to the NIH CC for observation and clinical 
management. During outpatient follow-up participants will be seen by study-trained nurses and 
study staff, including the PI, will be available 24 hours on call for questions and/or concerns.
8.4
ADVERSE EVENTS, AND SERIOUS ADVERSE EVENTS
8.4.1
Definition of an Adverse Event
Adverse Event: 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.
8.4.2
Definition of Serious Adverse Events (SAE) 
Serious Adverse Event: An SAE:

is an AE that results in death.

is an AE that is life threatening (places the subject at immediate risk of death from the 
event as it occurred).

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
is an AE that requires inpatient hospitalization or prolongs an existing hospitalization. 
NOTE:
o
Hospitalization is considered required if outpatient treatment would generally be 
considered inappropriate.
o
Same-day surgical procedures that are required to address an AE are considered 
hospitalizations, even if they do not involve an overnight admission.
o
Hospitalization due to a condition that has not worsened and that pre-dates study 
participation (e.g., elective correction of an unchanged baseline skin lesion), or due 
to social circumstance (e.g., prolonged stay to arrange aftercare), or that is 
planned/required “per protocol” AND that proceeds without prolongation or 
complication, is NOT considered an SAE by this criterion.

is, or results in a persistent or significant incapacity or substantial disruption of the ability 
to conduct normal life functions.

is a medically important event.
NOTE: Medical and scientific judgment should be exercised. Events that significantly 
jeopardize the subject and/or require intervention to prevent one of the SAE outcomes listed 
above are generally considered medically important, and are thus SAEs.
8.4.2.1
Other Definitions
Adverse Reaction (AR): An AR means any AE caused (see “Causality” below) by a study agent. 
ARs are a subset of all suspected adverse reactions (SARs; defined below) where there is reason to 
conclude that the study agent caused the event.
Suspected Adverse Reaction (SAR): SAR means any AE for which there is a reasonable 
possibility that the study agent caused the AE.
Per US FDA guidance:
For the purposes of IND safety reporting, “reasonable possibility” means there is evidence 
to suggest a causal (see “Causality” below) relationship between the study agent and the 
AE. An SAR implies a lesser degree of certainty about causality than an AR, which means 
any AE caused by a study agent.
SARs are the subset of all AEs for which there is a reasonable possibility that the study 
agent caused (see “Causality” below) the event. Inherent in this definition, and in the 
requirement to report SARs, is the need for the sponsor to evaluate the available evidence 
and make a judgment about the likelihood that the study agent actually caused the AE.
The sponsor is responsible for making the causality judgment.
Unexpected Adverse Event: An AE is unexpected if it is not listed in the investigator’s brochure 
or package insert (for marketed products) at the frequency, AND specificity, AND severity that 
has been observed.
NOTE:

Such events should also be evaluated for possible reporting as unanticipated problems 
(UPs).

Unexpected, as used in this definition, also refers to AEs or SARs that are mentioned in 
the investigator’s brochure as occurring with a class of drugs/biologics, or as anticipated 
from the pharmacological properties of the study agent but are not specifically mentioned 

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as occurring with the particular study agent under investigation.
Serious and Unexpected Suspected Adverse Reaction (SUSAR): A SUSAR is an SAR (defined 
above) that is both serious and unexpected.
Protocol Deviation: Any change, divergence, or departure from the IRB-approved research 
protocol.
1. 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.
2. 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.
1. 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 affects 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.
2. 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).
8.4.3
Classification of an Adverse Event
All AEs, including all solicited and those that may appear to have a non-study cause (see 
“Causality” below), will be documented (e.g., on the clinical chart/progress notes/clinical 
laboratory record), recorded (e.g., in the study-specified case report form [CRF]/research 
database), and reported (e.g., cumulatively from the research database, or according to protocol-
specified expedited reporting mechanism) to the sponsor from the time informed consent is 
obtained through the timeframe specified below. At each contact with the subject, information 
regarding AEs will be elicited by open-ended questioning and examinations.
AEs and SAEs, including all solicited AEs will generally be recorded, assessed, and reported 
according to the timeframes outlined below.

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Table 3. Standard Event Recording, Assessment, and Reporting Timeframes
Event type
Record, assess, and report
Related SAEs
End of subject participation in study, or if 
study personnel become aware thereafter
Unrelated SAEs
End of subject participation in study
Related non-serious AEs of grade 1 to 3
End of subject participation in study
All other related non-serious AEs
End of subject participation in study
Unrelated non-serious AEs
End of subject participation in study
The Investigator will assess all AEs with respect to seriousness (according to SAE definition 
above), severity (intensity or grade, see below), and causality (relationship to study agent and 
relationship to participation in the research, see below).
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.
The type of AE information (solicited symptoms: direct question of known possible side effects 
of the product; unsolicited: open-ended questioning such as “do you have any other symptoms”), 
duration of collected information, and format of information to be captured are summarized below:
IBSM (local reactogenicity related to the injection – solicited questions includes pain/tenderness, 
redness, swelling/induration, pruritus at the injection site):

Collected from Day 0 to Day 3.

Collected from the participant via solicited questions at each phone call/study visit (clinic 
follow up)
IBSM (systemic reactogenicity related to the injection – solicited questions includes rash, urticaria, 
pruritus, edema, headache, fever, chills, malaise, myalgia, arthralgia):

Collected from Day 0 to start of Day 3.

Collected from the participant via solicited questions at each phone call/study 
visit (clinic follow up)
IBSM and Clinical Assessment (systemic symptoms related to parasitemia/malaria infection):

Malaria clinical score collected from Day 4 to confirmation of successful antimalarial 
treatment (any open or ongoing symptoms will continue to be followed until conclusion)
Unsolicited AEs will be assessed throughout the study at each study visit (telephone and in-person 
follow-up) until the final study visit.
All AEs will be graded for severity and assessed for relationship to the study product. Reactions 
will be graded as described in this protocol.
All local and systemic reactions will be captured on the appropriate source documents and 
CRIMSON. AEs judged to be possibly, probably, or definitely related to the study product will be 
followed to adequate resolution. All concomitant medications will be collected through day 28 
post-IBSM.

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Solicited AEs will be captured by direct questioning during the study. Solicited AEs to be recorded 
as endpoints for this study are provided below.
Table 4. Solicited Adverse Events
IBSM (local)
Injection pain/tenderness
Injection swelling/edema
Injection pruritus
Injection erythema/redness
Injection induration
IBSM (systemic)
Rash
Headache
Myalgia
Urticaria
Fever
Arthralgias
Generalized pruritus
Chills
Malaise
Generalized edema
IBSM (malaria)
Headache
Malaise (general 
discomfort/uneasiness)
Vomiting
Myalgia (muscle ache)
Chills/shivering/rigors
Abdominal discomfort
Arthralgia (joint ache)
Anorexia
Fever
Fatigue/lethargy
Nausea
Tachycardia
Laboratory Results (specified intervals)
AST/ALT (increased ALT/AST) Hgb (decreased Hgb)
WBC (leukopenia, 
leukocytosis)
Cr (increased Cr)
Platelet 
(thrombocytopenia, 
thrombocytosis)
ANC (decreased neutrophil 
count)
ALC (decreased 
lymphocyte count)
If a clinical diagnosis is associated with an abnormal laboratory finding, the relevant AE should 
be recorded as the diagnosis rather than the incidental laboratory finding (e.g., “viral hepatitis” 
should be recorded rather than “elevated transaminases”).
Surgical procedures themselves are not AEs; they are therapeutic measures for conditions which 
may, or may not, be AEs.
All events, both expected/unexpected and related/unrelated will be recorded on a source document. 
Source documents will include progress notes, laboratory reports, consult notes, and phone call 
summaries. Source documents will be reviewed in a timely manner by the research team.
AEs that occur following enrollment of the participant 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 final outcome 
is known. If it is not possible to obtain a final outcome for an SAE (e.g., the participant is lost to 
follow-up), the reason a final outcome could not be obtained will be recorded by the investigator 
on the AE electronic record.
8.4.3.1
Severity of Event
The investigator will grade the severity of each AE (solicited and unsolicited), including laboratory 
and testing abnormalities and results, according to a modified version of the “Guidance for Industry: 

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Toxicity Grading Scale for Healthy Adult and Adolescent Volunteers Enrolled in Preventive 
Vaccine Clinical Trials” which can be found in Appendix C.
Events that are NOT gradable using the above specified table will be graded as described below.
Table 5. Definitions for Severity of AE Grading
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 (Potentially Life-Threatening)
Extreme limitation in activity, significant 
assistance required; immediate medical 
intervention or therapy required to prevent 
death
Grade 5
Death
8.4.3.1.1 Laboratory Value Assessment and Clinical Significance Criteria
Except as specified below, ALL abnormal lab values of grade 1 or above are REPORTABLE.
Grade 1 and 2 abnormal laboratory values are considered CLINICALLY SIGNIFICANT, and are 
to be recorded in the research database, and reported, if they meet ONE or more of the following 
criteria:

result in a study agent dosage adjustment, interruption, or discontinuation

are accompanied by clinically abnormal signs or symptoms that are likely related to 
the laboratory abnormality (e.g., clinical jaundice)

indicate a possible organ toxicity (e.g., elevated serum creatinine)

result in additional/repeat testing or medical intervention (procedures/treatments) (e.g., 
ECG to evaluate arrhythmia potential with a high serum potassium; one or more ECGs to 
assess an elevated troponin level; potassium supplementation for hypokalemia)

indicates possible over-dosage

are considered clinically significant by the investigator or sponsor medical monitor (SMM)
8.4.3.2
Relationship to Study Intervention
Causality (likelihood that the event is caused by the study agent[s]) will be assessed by the PI 
considering the factors listed under the following categories:

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Definitely Related

reasonable temporal relationship

follows a known response pattern

clear evidence to suggest a causal relationship

there is no alternative etiology
Probably Related

reasonable temporal relationship

follows a suspected response pattern (based on similar agents)

no evidence of a more likely alternative etiology
Possibly Related

reasonable temporal relationship

little evidence for a more likely alternative etiology
Unlikely Related

does not have a reasonable temporal relationship 
AND/OR

there is good evidence for a more likely alternative etiology
Not Related

does not have a temporal relationship AND/OR

definitely due to an alternative etiology
Note: Other factors (e.g., dechallenge, rechallenge, if applicable) should 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.
Causality assessment will be reviewed by the sponsor. The sponsor may make a separate and final 
determination on the “reasonable possibility” that the event was “related” (comprising definitely, 
probably, and possibly related) or “unrelated” (comprising unlikely and not related) to the study 
agent, in keeping with applicable (US FDA) guidance on sponsor IND safety reporting.
8.4.3.3
Expectedness
The investigator or delegate will be responsible for determining whether an adverse event (AE) is 
expected or unexpected. An AE will be considered unexpected if the nature, severity, or frequency 
of the event is not consistent with the risk information previously described for the study 
intervention.
8.4.4
Time Period and Frequency for Event Assessment and Follow-Up
The occurrence of an adverse event (AE) or serious adverse event (SAE) may come to the attention 
of study personnel during study visits and interviews of a study participant presenting for medical 
care, or upon review by a study monitor.
All AEs including local and systemic reactions not meeting the criteria for SAEs will be captured 
on the appropriate case report form (CRF). Information to be collected includes event description, 

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time of onset, clinician’s assessment of severity, relationship to study product (assessed only by 
those with the training and authority to make a diagnosis), and time of resolution/stabilization of 
the event. All AEs occurring while on study must be documented appropriately regardless of 
relationship. All AEs will be followed to adequate resolution.
Any medical condition that is present at the time that the participant is screened will be considered 
as baseline and not reported as an AE. However, if the study participant’s condition deteriorates 
at any time during the study, it will be recorded as an AE.
8.4.5
Adverse Event Reporting
8.4.5.1
Recording of Events
AEs will be promptly recorded in the research database, regardless of possible relationship to study 
interventions. 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. The 
investigator will review events regularly to ensure they have been captured correctly, and to 
perform assessment of events individually and cumulatively to assess possible safety trends.
8.4.5.2
Investigator Reporting Responsibilities
The PI and/or equally qualified designee will check daily for events that may require expedited 
reporting.
The PI and/or equally qualified designee will also monitor all accumulating data no less than 
weekly, or according to superseding NIH or NIAID policy, whichever is more frequent.
Data will be reviewed by the PI/designee on a regular basis for accuracy and completeness.
Data will be submitted to the sponsor in keeping with all applicable agreements and when requested, 
such as for periodic safety assessments, review of IND annual reports, review of IND safety 
reports, and preparation of final study reports.
The PI and/or other study designee will ensure prompt reporting to safety oversight bodies, 
regulatory entities, and stakeholders as specified below, and per any additional requirements or 
agreements.
8.4.5.2.1 Adverse Events
Unless otherwise specified above, AE data will be entered into the research database no less than 
every other week and will include all data through one week prior to database entry.
8.4.6
Serious Adverse Event Reporting
Unless otherwise specified above, all SAEs (regardless of relationship and whether or not they are 
also UPs) must be reported to the CSO as specified by the CSO (e.g., Research Electronic Data 
Capture [REDCap] system; use the safety expedited report form [SERF]/email if REDCap is not 
available). If the preferred/indicated mechanism for reporting is not available, the CSO/SMM 
should be contacted by telephone, fax, or other reasonable mechanism to avoid delays in reporting.

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CSO CONTACT INFORMATION:
Clinical Safety Office 5705 Industry Lane
Frederick, MD 21704
Phone 301-846-5301
Fax: 301-846-6224
Email: rchspsafety@mail.nih.gov 
https://crimsonredcap.cc.nih.gov/redcap/index.php
Unless otherwise specified above, deaths and immediately life-threatening SAEs must be reported 
to the CSO promptly, and no later than the first business day following the day of study personnel 
awareness.
All other SAEs must be reported to the CSO no later than the third business day following the 
day of study personnel awareness.
If an individual subject experiences multiple SAEs in a closely timed/overlapping “cause-and- 
effect” (cascade) sequence, the PI, after careful evaluation, will report ONLY 
primary/precipitating event(s) individually. SAEs that are determined to be definitely secondary 
to other SAEs will be detailed in the narrative portion of the report of the relevant 
primary/precipitating SAE. A clinical rationale and findings to support such reporting should be 
part of the narrative.
For each SAE report, the research database entry MUST match the corresponding entries on the 
SAE report (e.g., start and stop dates, event type, relationship, and grade), and must be updated 
if necessary (e.g., if the SAE report was generated after the corresponding AE was entered in the 
research database).
Unless otherwise specified above, SAEs that have not resolved by the end of the per-protocol 
follow-up period for the subject are to be followed until final outcome is known (to the degree 
permitted by the IRB-approved informed consent form). If it is not possible to obtain a final 
outcome for an SAE (e.g., the subject is lost to follow-up), and to update the CSO, the last known 
status and the reason a final outcome could not be obtained will be recorded by the investigator on 
an SAE report update and the CRF.
8.4.6.1
Sponsor’s Reporting Responsibilities
Events reported to the sponsor will be promptly evaluated and will be reported as required 
according to FDA IND safety reporting guidance and regulations. IND safety reports will be sent 
to other investigators conducting research under the same IND and will be shared with other 
stakeholders according to applicable agreements (e.g., Cooperative and Development Research 
Agreements [CRADAs] and Clinical Trial Agreements [CTAs]).
The sponsor will also submit an IND annual report of the progress of the investigation to the FDA 
as defined in 21 CFR 312.33.
All UPs will be evaluated by the sponsor, and a summary of the event, and any necessary 
(corrective/preventative) actions, will be distributed to investigators conducting research under the 
same IND as may be relevant and appropriate.
8.4.7
NIH Intramural IRB Reporting of IND Safety Reports
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information that might affect the willingness of subjects on the NIH study to enroll or remain in 
the study will need to be reported to the NIH Intramural IRB.
8.4.8
Events of Special Interest
Not applicable.
8.4.9
Reporting of Pregnancy
Unless otherwise specified above, all pregnancies will be reported (by REDCap, or by email and 
SERF if REDCap is not available) to the CSO no later than the first business day following the 
day of study personnel awareness.
Pregnancy outcome data (e.g., delivery outcome, spontaneous or elective termination of the 
pregnancy) will be reported to the CSO no later than the third business day following the day of 
study personnel awareness (by REDCap, or by email and SERF if REDCap is not available).
Pregnancy itself is not an AE. Events that meet AE or SAE criteria in relation to pregnancy, 
delivery, or the conceptus/neonate (see Section 8.4.2) are reportable (by REDCap, or by email and 
SERF if REDCap is not available).
In the event of pregnancy in a study subject exposed to study agent, the following actions will be 
taken, with the goal of ensuring maternal and fetal well-being:

Withdraw from the study but continue in follow-up for safety.

Report to NIH IRB and SMM as an informational item no later than 1 business day after 
study site awareness.

Advise research participant to notify the obstetrician of study exposure and provide contact 
information for the obstetrician to contact the study PI, should this be required, and with 
the participant’s consent.

Administration of chloroquine daily for 3 days if pregnancy occurs after IBSM.

Continue to follow for safety for the duration of the pregnancy, and for a period of up to 
3 months following delivery for assessment of the neonate.
8.5
UNANTICIPATED PROBLEMS
8.5.1
Definition of Unanticipated Problems (UP)
Unanticipated Problem (UP): A 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 (including but not limited to risks) as described in the IRB-approved 
research protocol and informed consent document, investigator’s brochure, or other 
study documents; and
b. the characteristics of the subject population being studied; and is
2. possibly, probably, or definitely related (see “Causality” below) to participation in the 
research; and
3. suggests the research places subjects or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or 
recognized, per the documents currently approved by the IRB.
NOTE:

Per the sponsor, an SAE always meets this “greater risk” criterion.

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
An incident, experience, or outcome that meets the definition of a UP generally will 
warrant consideration of changes to the protocol or informed consent form, or to study 
procedures (e.g., the manual of procedures for the study), in order to protect the safety, 
welfare, or rights of participants or others. Some UPs may warrant a corrective and 
preventive action plan at the discretion of the sponsor or other oversight entities.
Unanticipated Problem that is not an Adverse Event (UPnonAE): A UPnonAE belongs to a 
subset of UPs that:

meets the definition of a UP, AND

does NOT fit the definition of an AE or an SAE
NOTE: Examples of UPnonAEs include, but are not limited to:
o
a breach of confidentiality
o
prolonged shedding of a vaccine virus beyond the anticipated timeline
o
unexpectedly large number of pregnancies on a study
o
subject departure from an isolation unit prior to meeting all discharge criteria
o
accidental destruction of study records
o
unaccounted-for study agent
o
overdosage, underdosage, or other significant error in administration or use of study 
agent or intervention, even if there is no AE/SAE
o
development of an actual or possible concern for study agent purity, sterility, 
potency, dosage, etc.
NOTE: A decision to temporarily quarantine, or to permanently not use all or part 
of study agent supply due to an unexpected finding or event (e.g., particulate, 
cloudiness, temperature excursion), even if there is no known or proven issue (i.e., 
out of an “abundance of caution”), is considered a UPnonAE.
8.5.2
Unanticipated Problem Reporting
The investigator will report UPs to the NIH IRB as per Policy 801.
Unless otherwise specified above, UPs (as defined in this protocol, or as defined by the IRB of 
record, whichever definition is more conservative) that are also AEs or SAEs, must be reported to 
the CSO (by REDCap, or by email and SERF if REDCap is not available) no later than when they 
are due to be reported to the IRB.
UPnonAEs are NOT reported to the CSO but must be reported to the Clinical Trials Management 
(CTM) group and the IRB according to their requirements and preferred methods. If the UPnonAE 
raises a significant potential subject safety concern, the SMM should be consulted by email or 
phone no later than when reports are made to the IRB and/or CTM
8.6
ADDITIONAL REPORTING REQUIREMENTS
8.6.1
Safety Oversight and Reporting
A safety review and communication plan (SRCP) is required for this protocol. The SRCP is an 
internal communications document between the PI and the CSO, as sponsor representative, which 
delineates key safety oversight responsibilities of the PI, the CSO, and other stakeholders. The 
SRCP includes a plan for conducting periodic safety surveillance assessments by the CSO.
A SMM, representing the sponsor, has been appointed for oversight of safety in this clinical study. 
The SMM will be responsible for performing safety assessments as outlined in the SRCP.

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As this study has a limited sample size of two participants and all interventions have been 
previously well characterized, safety oversight will be limited to the CSO and SMM.
8.6.2
Reporting to the NIH IRB
Non-compliance and other reportable events will be reported to the NIH IRB according to Human 
Research Protections Program (HRPP) Policy 801.
8.6.3
Reporting to the NIAIAD Clinical Director
The PI will report UPs, major protocol deviations, and deaths to the NIAID clinical director 
according to institutional timelines.
8.7
HALTING RULES FOR THE PROTOCOL
“Halting” is discontinuation of study intervention/treatment/dosing (agent/placebo/procedure, etc.) 
for all subjects in a study and suspension of enrollment until a decision is made to either resume 
or permanently discontinue such activity. Subjects continue to be followed for safety during a halt.
The halting rules are:

One or more participants experience an SAE that is determined to be possibly, probably or 
definitely related to IBSM or

One or more participants experience a hypersensitivity reaction that is probably or 
definitely related to IBSM or

Any severe clinical illness occurs that is not explained by a diagnosis that is unrelated or 
unlikely related to study product or

Two participants experience a solicited or unsolicited Grade 3 event (excluding laboratory 
abnormalities) or a Grade 4 event that is determined to be possibly, probably or definitely 
related to the study product or

Any safety issue that the PI or the CSO determines should halt the study.
In addition, the FDA or any regulatory body having oversight authority may halt the study at any 
time.
8.7.1
Reporting a study halt
If a halting criterion is met, a description of the AE(s) or safety issue must be reported by the PI, 
within 1 business day to the CSO and the IRB according to their requirements.
8.7.2
Resumption of a halted study
The CSO, in collaboration with the PI, will determine if study activities, including enrollment, 
study agent administration, and/or other study interventions, may be resumed and any additional 
modifications or requirements that may apply.
The CSO or sponsor designee will notify the PI of the decision. The PI will notify the IRB of the 
decision according to the IRB’s process.
8.7.3
Discontinuation of study agent/intervention
Subjects who do not resume study agent/study intervention will continue to be followed for 
protocol-specified safety assessments or as clinically indicated, whichever is more conservative.

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9
STATISTICAL CONSIDERATIONS
This study involves collecting blood from donors experimentally infected with malaria to generate 
blood stage parasite banks. As such, no formal statistical analysis plan will be generated.
The safety analysis dataset will include all participants who receive the malaria inoculum. This 
population will be used to analyze all safety data as well as demographic and baseline data.
All measured variables and derived values will be listed. As the sample size for this study is two 
participants, with an accrual ceiling of 50 participants, individual data will be presented in lieu of 
descriptive statistics. Categorical data will be presented using N and % (using the number of 
participants without missing data in the calculation).
9.1
SAFETY ANALYSES
The overall number and percentage of participants with at least one AE (and SAE) will be tabulated 
over the entire study period. All AE data will be summarized by Medical Dictionary for Regulatory 
Activities (MedDRA) system organ class and preferred term, and maximum severity. Vital signs, 
routine safety laboratory data, and ECG parameters will be summarized descriptively by time 
point. Both absolute values and change from baseline (inoculation) will be presented.
9.2
BASELINE DESCRIPTIVE STATISTICS
Demographic data, including the total number of observations, will be presented. The participant 
disposition will be summarized. Study completion, study withdrawals, exclusions, and violations 
will be summarized and the reasons for withdrawal, exclusions, and violations will be listed. 
Medical history, current medical conditions, previous and concomitant medications, results of 
laboratory screening tests, drug tests and any other relevant baseline information will be listed by 
participant.
10 REGULATORY AND OPERATIONAL CONSIDERATIONS
10.1 INFORMED CONSENT PROCESS
10.1.1 Consent/Assent Procedures and Documentation
Informed consent is a process where information is presented to enable persons to voluntarily 
decide whether or not to participate as a research participant. It is an ongoing conversation between 
the human research participant and the researchers, which begins before consent is given and 
continues until the end of the participant’s involvement in the research. Discussions about the 
research will provide essential information about the study and include purpose, duration, 
experimental procedures, alternatives, risks, and benefits. Coercion and undue influence will be 
minimized by informing participants that their decision to join the study will not affect any medical 
care they are currently receiving at the NIH, or their eligibility to participate in other research 
studies at the NIH. Participants will be given as much time as they need to read the consent form 
and ask questions of the investigators. Participants will also be given time to discuss their 
participation with family members, friends, and other healthcare providers. Informed consent will 
be obtained in person in a private setting by a study team member authorized to obtain consent.
An IRB approved telephone pre-screening will first be conducted to determine if the subject 
appears to meet initial eligibility criteria. A waiver of consent is not required for telephone pre- 
screening per 45CFR46.116(g) §46.116. In this telephone pre-screening, general demographic 
information is requested as well as a series of yes/no medical questions and a list of current 

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medications; this information will be used to determine the general health and potential eligibility 
of the subject. If the subject does not wish to complete the telephone prescreen, he/she may elect 
to complete the informed consent process and in-person screening process without first completing 
a telephone prescreen, as indicated below.
If the volunteer meets initial eligibility criteria or opts out of the telephone prescreen, then they 
will be scheduled to appear in person at the National Institutes of Health (NIH) Clinical Center 
(CC) for evaluation by a healthcare provider.
Participants will be fully informed of the nature of the study, the properties and adverse effects of 
the inoculum and potential rescue treatments and all relevant aspects of study procedures in the 
‘Participant Information Sheet’. The Participant Information Sheet and informed consent form 
describe in detail the study agents, study procedures, and risks.
The participants will sign the informed consent document prior to undergoing any research 
procedures. The participants may withdraw consent at any time throughout the course of the trial. 
A copy of the informed consent document will be given to the participants for their records. The 
researcher will document the signing of the consent form in the participant’s medical record. The 
rights and welfare of the participants 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.
10.1.2 Participation of Subjects Who Are/Become Decisionally Impaired
Participants who become decisionally impaired during their participation in this study, and can 
therefore no longer provide their ongoing informed consent, will be withdrawn from the study.
10.1.3 Considerations for Consent of NIH Staff
Even though NIH staff members are not targeted, if they are incidentally enrolled, informed 
consent will be obtained as detailed above with following additional protections:
Consent from staff members will be obtained by an individual independent of the individual’s 
team whenever possible. Otherwise, the consent procedure will be independently monitored as 
described in Policy 404 to minimize the risk of undue pressure on the staff member.
10.2 STUDY DISCONTINUATION AND CLOSURE
This study may be temporarily suspended or prematurely terminated if there is sufficient 
reasonable cause. If the study is prematurely terminated or suspended, the PI will promptly inform 
study participants, the IRB, the IND sponsor, and regulatory authorities, and will provide the 
reason(s) for the termination or suspension. Study participants will be informed of changes to study 
visit schedule.
Circumstances that may warrant termination or suspension include, but are not limited to:

Determination of unexpected, significant, or unacceptable risk to participants

Insufficient compliance to protocol requirements

Data that are not sufficiently complete and/or evaluable

Determination that the primary endpoint has been met

Determination of futility
The study may resume once concerns about safety, protocol compliance, and data quality are 
addressed, and satisfy the IND sponsor, IRB, and/or FDA.

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10.3 CONFIDENTIALITY AND PRIVACY
Participant confidentiality and privacy is strictly held in trust by the participating investigators, 
their staff, and the sponsor(s) and their interventions. This confidentiality is extended to cover 
testing of biological samples and genetic tests in addition to the clinical information relating to 
participants. Therefore, the study protocol, documentation, data, and all other information 
generated will be held in strict confidence. No information concerning the study or the data will 
be released to any unauthorized third party without prior written approval of the sponsor.
All research activities will be conducted in as private a setting as possible.
The study monitor, other authorized representatives of the sponsor, representatives of the IRB, 
and/or regulatory agencies may inspect all documents and records required to be maintained by 
the investigator, including but not limited to, medical records (office, clinic, or hospital) and 
pharmacy records for the participants in this study. The clinical study site will permit access to 
such records.
The study participant’s contact information will be securely stored at each clinical site for internal 
use during the study. At the end of the study, all records will continue to be kept in a secure location 
for as long a period as dictated by the reviewing IRB, institutional policies, or sponsor 
requirements.
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, including but not limited to, medical records. 
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 
participant, except as necessary for monitoring by IRB, the FDA, the NIH, the Office of Human 
Research Protections (OHRP), or the sponsor’s designee.
To further protect the privacy of study participants, a Certificate of Confidentiality has been issued 
by the National Institutes of Health (NIH). This certificate protects identifiable research 
information from forced disclosure. It allows the investigator and others who have access to 
research records to refuse to disclose identifying information on research participation in any civil, 
criminal, administrative, legislative, or other proceeding, whether at the federal, state, or local 
level. By protecting researchers and institutions from being compelled to disclose information that 
would identify research participants, Certificates of Confidentiality help achieve the research 
objectives and promote participation in studies by helping assure confidentiality and privacy to 
participants.
10.4 FUTURE USE OF STORED SPECIMENS AND DATA
Intended Use: Samples and data collected under this protocol will be used to study malaria and 
related diseases and possible ARs to IBSM. Genetic testing will not be performed.
Storage: Access to stored research samples will be limited using either a locked room or a locked 
freezer. Samples will be stored at the LMIV in Bethesda, MD or at LMIV’s designated repository, 
Thermo Scientific, Rockville, MD. 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.

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Disposition: In the future, other investigators (both at the NIH and outside) may wish to study 
these samples and/or data. If the planned research falls within the category of “human subjects 
research” on the part of the NIH researchers, IRB review and approval will be obtained. This 
includes the NIH researchers sending out coded and linked specimens or data and getting results 
that they can link back to their participants.
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 a reportable 
event will be reported to the NIH IRB according to Policy 801.
Consent to allow long-term storage of study samples is a part of the inclusion criteria for this study. 
However, if a participant decides following enrollment not to have their samples stored, then the 
PI or designee will destroy all known remaining samples and report this destruction to the 
participant and the NIH IRB. This decision will not affect the participant’s continued participation 
in this protocol, or any other protocols supported by the NIH.
10.5 SAFETY OVERSIGHT
Safety oversight for this study is described in Section 8.6.1: Safety Oversight and reporting.
10.6 CLINICAL MONITORING
According to the ICH E6(R2) GCP guidelines, section 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 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 (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 data abstracts or clinical records readily available for inspection by the IRB, FDA, the site 
monitors, and the NIAID staff for confirmation of the study data.
A specific protocol monitoring plan will be discussed with the site and study principal investigators 
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.
10.7 QUALITY ASSURANCE AND QUALITY CONTROL
During the study, the PI and study team will be responsible for implementing a quality 
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a summary report on the quality plan to the NIAID clinical director or designee at least annually 
as detailed in the quality management plan. A courtesy copy will also be sent to CTM.
10.8 DATA HANDLING AND RECORD KEEPING
10.8.1 Data Collection and Management Responsibilities
Study data will be maintained in CRIMSON and/or REDCap and collected directly from 
participants during study visits and telephone calls or will be abstracted from participants’ medical 
records. 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. Data entry into 
CRIMSON will be performed by authorized individuals. The investigator is responsible for 
assuring that the data collected are complete, accurate, and recorded in a timely manner. Study 
data, including cumulative subject accrual numbers, should be generated via the chosen data 
capture method and submitted to the IRB as needed.
10.8.2 Study Records Retention
The investigator is responsible for retaining all essential documents listed in the ICH GCP 
guidelines. Study records will be maintained by the PI according to the timelines specified in 21 
CFR 312.62 or a minimum of 7 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 with the name of the person who will accept responsibility for the transferred 
records and/or their new location. NIAID will be notified in writing and written OCRPRO/NIAID 
permission shall be obtained by the site prior to destruction or relocation of research records.
10.9 PROTOCOL DEVIATIONS
It is the responsibility of the investigator to use continuous vigilance to identify and report 
deviations to the NIH IRB as per Policy 801. All deviations must be addressed in study source 
documents and reported to CTM. The investigator is responsible for knowing and adhering to the 
reviewing IRB requirements.
10.9.1 NIH Definition of Protocol Deviation
The definition of a protocol deviation is provided in Section 8.4.2.1.
10.10 PUBLICATION AND DATA SHARING POLICY
10.10.1.1
Human Data Sharing Plan
We will comply with NIH policies on data access, sharing, and dissemination, and clinical trials 
registration, as applicable. Human data generated in this study will be shared for future research 
as follows:

De-identified data in an NIH-funded or approved public repository.

De-identified data in another public repository.

Identified data in the Biomedical Translational Research Information System (automatic 
for activities in the CC).

De-identified or identified data with approved outside collaborators under appropriate 
agreements.

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
De-identified data in publications and/or public presentations. 
Data will be shared at the time of or shortly after publication.
10.10.1.2
Genomic Data Sharing Plan
Not applicable.
10.11 COLLABORATIVE AGREEMENTS
Amendment #1 to the Research Collaboration Agreement (RCA) dated 20 December 2017 
between QIMRB and LMIV specifies the transfer of up to 6 vials of blood stage P. vivax cell bank 
(HMPBS02-Pv) isolates from QIMRB to LMIV.
10.12 CONFLICT OF INTEREST POLICY
The independence of this study from any actual or perceived influence, such as by the 
pharmaceutical industry, is critical. Therefore, any actual conflict of interest of persons who have 
a role in the design, conduct, analysis, publication, or any aspect of this trial will be disclosed and 
managed. Furthermore, persons who have a perceived conflict of interest will be required to have 
such conflicts managed in a way that is appropriate to their participation in the design and conduct 
of this trial. The study leadership in conjunction with NIAID has established policies and 
procedures for all study group members to disclose all conflicts of interest and will establish a 
mechanism for the management of all reported dualities of interest.

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11 ABBREVIATIONS
AE
adverse event
ALC
absolute lymphocyte count
ALT
alanine transaminase
ANC
absolute neutrophil count
AR
adverse reaction
AST
aspartate transaminase
β-hCG
human choriogonadotropin
CBC
complete blood count
CC
Clinical Center
CDC
Centers for Disease Control and Prevention
CFR
Code of Federal Regulations
CHMI
controlled human malaria infection
CK
creatine kinase
CMV
cytomegalovirus
CRF
case report form
CRIMSON
Clinical Research Information Management System of the NIAID
CSO
Clinical Safety Office
CTM
Clinical Trials Management
CYP
cytochrome p450 isozyme
DMFA
direct membrane feeding assay
DSF
direct skin feed
DTM
Department of Transfusion Medicine
EBV
Epstein-Barr Virus
ECG
electrocardiogram
ELISA
enzyme-linked immunosorbent assay 
EOS
End of Study
FDA
Food and Drug Administration
GCP
Good Clinical Practice
HBsAg
hepatitis B surface antigen
HCV
hepatitis C virus
HHV
human herpes virus
HIV
human immunodeficiency virus
HMP
human malaria parasite
HMPBS-Pv
human malaria parasite blood stage Plasmodium vivax
IBSM
induced blood stage malaria
ICH
International Council for Harmonisation of Technical Requirements for 
Pharmaceuticals for Human Use
ID
identification
IND
Investigational New Drug application
IRB
institutional review board

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IV
intravenous(ly)
LDH
lactate dehydrogenase
LFT
liver function test
LLN
lower limit of normal
LMIV
Laboratory of Immunology and Vaccinology 
MCB
master cell bank
MedDRA
Medical Dictionary for Regulatory Activities 
NAT
nucleic acid test
NHANES
National Health and Nutrition Examination Survey 
NIAID
National Institute of Allergy and Infectious Diseases 
NIH
National Institutes of Health
OCRPRO
Office of Clinical Research Policy and Regulatory Operations
OHRP
Office of Human Research Protections 
PHQ-2
Patient Health Questionnaire-2
PI
Principal Investigator
QIMRB
Queensland Institute of Medical Research, Berghofer 
qPCR
quantitative polymerase chain reaction
qRT-PCR
quantitative reverse transcriptase polymerase chain reaction 
QTc
corrected QT interval
RBC
red blood cell
REDCap
Research Electronic Data Capture 
Rh
Rhesus
SAE
serious adverse event
SAR
suspected adverse reaction
SERF
safety expedited report form
SMM
sponsor medical monitor
SOP
standard operating procedure
SRCP
safety review and communications plan 
SUSAR
suspected unexpected serious adverse reaction 
ULN
upper limit of normal
UP
unanticipated problem
UPnonAE
unanticipated problem that is not an adverse event 
US
United States
WHO
World Health Organization

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12 REFERENCES
1.
WHO: World Malaria Report 2018. In.: World Health Organization; 2018: 210.
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Arévalo-Herrera M, Forero-Peña DA, Rubiano K, Gómez-Hincapie J, Martínez NL, 
Lopez-Perez M, Castellanos A, Céspedes N, Palacios R, Oñate JM et al: Plasmodium 
vivax Sporozoite Challenge in Malaria-Naïve and Semi-Immune Colombian 
Volunteers. PloS one 2014, 9(6):e99754-99712.
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Davenport M, Sattabongkot J et al: Safety and Reproducibility of a Clinical Trial 
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American Journal of Tropical Medicine and Hygiene 2009, 81(5):740-746.
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Recommendations. Am J Trop Med Hyg 2020, 103(1):378-393.
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Grigg MJ, Lalloo DG et al: Liver function test abnormalities in experimental and 
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dihydroartemisinin-piperaquine versus current first-line therapies for repeated 
treatment of uncomplicated malaria: a randomised, multicentre, open-label, 
longitudinal, controlled, phase 3b/4 trial. Lancet 2018, 391(10128):1378-1390.
26.
Woodford J, Shanks GD, Griffin P, Chalon S, McCarthy JS: The Dynamics of Liver 
Function Test Abnormalities after Malaria Infection: A Retrospective 
Observational Study. Am J Trop Med Hyg 2018, 98(4):1113-1119.
27.
Salako LA: Toxicity and side-effects of antimalarials in Africa: a critical review. Bull 
World Health Organ 1984, 62 Suppl:63-68.
28.
Collins KA, Wang CY, Adams M, Mitchell H, Robinson GJ, Rampton M, Elliott S, 
Odedra A, Khoury D, Ballard E et al: A Plasmodium vivax experimental human 
infection model for evaluating efficacy of interventions. J Clin Invest 2020, 
130(6):2920-2927.
29.
Pukrittayakamee S, Imwong M, Singhasivanon P, Stepniewska K, Day NJ, White NJ: 
Effects of different antimalarial drugs on gametocyte carriage in P. vivax malaria. 
Am J Trop Med Hyg 2008, 79(3):378-384.
30.
Douglas NM, Simpson JA, Phyo AP, Siswantoro H, Hasugian AR, Kenangalem E, 
Poespoprodjo JR, Singhasivanon P, Anstey NM, White NJ et al: Gametocyte dynamics 
and the role of drugs in reducing the transmission potential of Plasmodium vivax. J 
Infect Dis 2013, 208(5):801-812.
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Karunaweera ND, Carter R, of GGTAj, 1998: Demonstration of anti-disease immunity 
to Plasmodium vivax malaria in Sri Lanka using a quantitative method to assess 
clinical disease. ASTMH 1998, 58(2):204-210.
32.
Silva-Filho JL, Dos-Santos JC, Judice C, Beraldi D, Venugopal K, Lima D, Nakaya HI, 
De Paula EV, Lopes SC, Lacerda MV, Marti M, Costa FT. Total parasite biomass but 
not peripheral parasitaemia is associated with endothelial and haematological 
perturbations in Plasmodium vivax patients. Elife. 2021 Sep 29;10:e71351.

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Appendix A: Cardiovascular Risk Assessment
As part of the eligibility determination, participants will be screened for cardiac risk based on the 
NHANES I study criteria (Gaziano, Young et al. 2008), and screening electrocardiogram.
Results will be documented in the participant source documentation and Cardiac Risk 
Assessment CRF.
NHANES cardiovascular risk assessment includes the following assessments:

Evaluation of risk factors: Calculated BMI [weight (kg)/height (m2)], measured 
Systolic

Blood Pressure, smoking status and known diabetes status as reported by the participant 
on review of medical history

Evaluation of 5-year cardiovascular risk using: Low, Moderate, High
Note: participants under the age of 35 are considered low risk by the NHANES I risk assessment
Only participants classified as low risk by the NHANES I criteria (green and blue 
categories below) who have a non-significant ECG, as determined by the study cardiologist, 
are eligible for the study.
NHANES I Classification for Women

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NHANES I Classification for Men

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Appendix B: Clinical Score for Malaria
[31]
Participant ID:
Study Day:
Date:
Clinical Score
Symptoms
Absent (0) Mild (1)
Moderate (2) Severe (3)
Headache
Myalgia (muscle aches)
Arthralgia (joint aches)
Fatigue/lethargy
Malaise (general 
discomfort/uneasiness)
Chills/Shivering/Rigors
Sweating/hot spells
Anorexia
Nausea
Vomiting
Abdominal discomfort
Fever
Tachycardia
Hypotension
Total Score:
Maximum Score = 42
Threshold for treatment > 6

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Appendix C: Toxicity Grading Scales
These tables are modified versions of the FDA Toxicity Grading Scale for healthy adult and 
adolescent participants enrolled in Preventive Vaccine Clinical Trials to be used to grade adverse 
events.
Local Reaction to 
Injectable Product
Mild (Grade 1)
Moderate (Grade 2)
Severe (Grade 3)
Potentially Life 
Threatening
Pain
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 *
2.5 – 5 cm
5.1 – 10 cm
> 10 cm
Necrosis or 
exfoliative
Induration/Swelling
**
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
Tenderness
Mild discomfort to 
touch
Discomfort with 
movement
Significant 
discomfort at 
rest
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
* In addition to grading the measured local reaction at the greatest single diameter, the measurement should be 
recorded as a continuous variable.
** Induration/Swelling should be evaluated and graded using the functional scale as well as the actual 
measurement

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Vital Signs *
/Systemic adverse
Mild (Grade 1)
Moderate(Grade 2)
Severe (Grade 3)
Potentially Life 
Threatening
Fever (°C) **
38.0 – 38.4
38.5 – 38.9
39.0 – 40
> 40
Tachycardia – 
beats per minute
101 – 115
116 – 130
> 130
ER visit or hospitalization 
for arrhythmia
Bradycardia – 
beats per minute***
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
Rash
Localized rash with no 
medical intervention 
indicated
Localized rash with 
medical intervention 
indicated
Generalized rash with 
medical intervention 
indicated
ER visit or 
hospitalization
Abdominal Pain
No or minimal interference
with usual activities
Greater than minimal 
interference with usual 
activities
Inability to perform 
usual activities
ER visit or 
hospitalization
Anorexia
Transient (< 24 hours) or 
intermittent anorexia with 
no or minimal interference 
with oral intake
Persistent anorexia 
resulting in decreased 
oral intake for 24 – 48 
hours
Persistent anorexia 
resulting in minimal 
oral intake for > 48 
hours OR Aggressive 
rehydration indicated 
(e.g., IV fluids)
Life-threatening 
consequences 
(e.g., 
hypotensive 
shock)
Back Pain
No or minimal interference
with usual activities
Greater than minimal 
interference with usual 
activities
Inability to perform 
usual activities
ER visit or 
hospitalization
Chills/Sweats
No or minimal interference
with usual activities
Greater than minimal 
interference with usual 
activities
Inability to perform 
usual activities
ER visit or 
hospitalization
Generalized Pruritus
Itching causing no or 
minimal interference with 
usual activities
Greater than minimal 
interference with usual 
activities
Inability to perform 
usual activities
ER visit or 
hospitalization

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Generalized Edema
Localized edema causing 
no or minimal interference 
with usual activities
Greater than minimal 
interference with usual 
activities
Inability to perform 
usual activities
ER visit or 
hospitalization
Vital Signs *
/Systemic adverse 
events
Mild (Grade 1)
Moderate (Grade 2)
Severe (Grade 3)
Potentially Life 
Threatening (Grade 4)
Dizziness
Dizziness causing minimal 
interference and above 
baseline
Dizziness causing 
greater than minimal 
interference with usual 
social & functional 
activities
Dizziness causing 
inability to perform 
usual social & 
functional activities
Disabling dizziness 
causing inability to 
perform basic self-care 
functions
Change in Vision
Change in vision causing 
minimal interference and 
above baseline
Difficulty seeing 
causing greater than 
minimal interference 
with usual social & 
functional activities
Difficulty seeing 
(diplopia, blurriness) 
causing inability to 
perform usual social & 
functional activities
Disabling change in 
vision (visual field loss, 
blindness) causing 
inability to perform 
basic self-care functions
Insomnia or 
Difficulty Sleeping
Difficulty sleeping causing
minimal interference and 
above baseline
Difficulty sleeping 
causing greater than 
minimal interference 
with usual social & 
functional activities
Difficulty sleeping 
causing inability to 
perform usual social & 
functional activities
Disabling insomnia 
causing inability to 
perform basic self-care 
functions
Photosensitivity
Sensitivity to light causing 
no or minimal interference 
with usual activities
Greater than minimal 
interference with usual 
activities secondary to 
sensitivity to light
Inability to perform 
usual activities 
secondary to sensitivity 
of light
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
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

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Vital Signs *
/Systemic
Mild (Grade 1)
Moderate (Grade 2)
Severe (Grade 3)
Potentially Life 
Threatening
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
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
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
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
Urticaria
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
Tinnitus
Ringing in your ears 
causing no or minimal 
interference with usual 
activities
Greater than minimal 
interference with usual 
activities secondary to 
ringing in your ears
Inability to perform 
usual activities 
secondary to ringing in 
your ears.
ER visit or 
hospitalization
Peripheral 
Neuropathy
Tingling in your hands 
or feet causing no or 
minimal interference 
with usual activities
Tingling in your hands 
or feet causing greater 
than minimal 
interference with usual 
activities
Inability to perform 
usual activities due to 
tingling or pain in your 
hands or feet
ER visit or 
hospitalization

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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
* Participant should be at rest for all vital sign measurements.
** Oral temperature; no recent hot or cold beverages or smoking.
*** When resting heart rate is between 60 – 100 beats per minute. Use clinical judgment when 
characterizing bradycardia among some healthy participant populations, for example, conditioned 
athletes.
Serum*
Mild 
(Grade 1)
Moderate 
(Grade 2)
Severe 
(Grade 3)
Potentially Life 
Threatening
(Grade 4)**
Creatinine – mg/dL
1.5 – 1.7
1.8 – 2.0
2.1 – 2.5
> 2.5 or requires
Liver Function Tests – 
ALT, AST
1.1 – 2.5 x ULN
2.6 – 5.0 x ULN
5.1 – 10 x ULN
> 10 x ULN
Hematology *
Mild (Grade 1)
Moderate (Grade 2)
Severe (Grade 3)
Potentially Life 
Threatening 
(Grade 4)
Hemoglobin
10.0 -11.0
8.5 - 9.9
7.5 – 8.4
< 7.5
Hemoglobin (Male)
12.0 – 13.0
10.0 - 11.9
8.0 - 9.9
< 8.0
WBC Increase -
cell/mm3
10,800 – 15,000
15,001 – 20,000
20,001 – 25, 000
> 25,000
WBC Decrease -
cell/mm3
2,500-3500
1,500 – 2499
1,000 – 1,499
< 1,000
Lymphocytes
750 – 1,000
500 – 749
250 – 499
< 250
Neutrophils
1000-1499
750-999
500 – 749
< 500
Platelets Decreased - 
cell/mm3
125000-140000
100000-124000
25,000 – 99000
< 25,000
* The 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.
** The 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 
(125-127 mE/L) should be recorded as a grade 4 hyponatremia event if the participant had a new seizure 
associated with the low sodium value.
***ULN is the upper limit of the normal range.
⌃Values adjusted according to the NIH clinical laboratory normal values

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Urine*
Mild (Grade 1)
Moderate (Grade 2)
Severe (Grade 3)
Potentially Life 
Threatening (Grade 4)
Protein
Trace
1
+
2+
Hospitalization or Dialysis
Glucose
Trace
1
+
2+
Hospitalization for 
Hyperglycemia
Blood (microscopic)
–
red blood cells per 
microliter (rbc/μL)
17 – 30
31– 60
> 60 and/or gross
blood
Hospitalization or packed red 
blood cells (PRBC) 
transfusion
*The 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.
⌃Values adjusted according to the NIH clinical laboratory normal values

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Appendix D: Total Whole Blood Volume for Collection During Study
Procedure
Sample
Volume 
per 
sample 
(mL)
No. samples per 
participant for 
the first 30 days
Total volume per 
participant (mL) 
for the first 30 
days
2
4
8
Hematology
4
1
4
Biochemistry 
(including LFT)
5
5
25
Laboratory 
Safety 
Assessment
Safety Serum 
storage
5
1
5
Cannulation
Discard
2
8 (+2 if required)
16 (+4 if
required)
Malaria qPCR (18S)
2
15 (+5 if required)
30 (+10 if
required)
Microscopy
2
0 (as needed)
0
Malaria 
Monitoring
Parasite life-cycle 
stage qRT-PCR
2
5 (+3 if required)
10 (+6 if
required)
HMP bank 
blood borne 
infection 
testing
55
Up to 1
55
Study volume (mL) not including banking volume
153 (+20 if
required)
Blood 
Collection for 
Banking
200
1
200 (+ 
discretionary 
volume)
Total study volume (mL)
353 (+ 
discretionary 
volume)

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Appendix E: Symptoms and Signs of Malaria
Following administration of the intravenous malaria challenge agent and during the post- 
challenge period, the following signs and symptoms of malaria will be monitored:
Signs of Malaria

Fever (≥38°C)

Chills/Shivering/Rigors

Tachycardia

Hypotension
Symptoms of Malaria

Headache

Myalgia (muscle ache)

Arthralgia (joint ache)

Fatigue/lethargy

Malaise (general discomfort/uneasiness)

Sweating/hot spells

Anorexia

Nausea

Vomiting

Abdominal discomfort

87
Abbreviated Title: Blood-stage Plasmodium vivax cell bank
Version Date:  17 May 2022
Appendix F: The Patient Health Questionnaire-2 (PHQ-2)
The PHQ-2 inquires about the frequency of depressed mood and anhedonia over the past two 
weeks. The PHQ-2 includes the first two items of the PHQ-9. The purpose of the PHQ-2 is not to 
establish a final diagnosis or to monitor depression severity, but rather to screen for depression in 
a “first step” approach.
Scoring
A PHQ-2 score ranges from 0-6. A PHQ-2 score of 3 or higher will be the cut off point for 
exclusion for screening purposes.