Response to Influenza Vaccine During Pregnancy
Phase: PHASE1
Conditions: Influenza
Sponsor: Stanford University

 
 
 
 
Response to Influenza Vaccine During Pregnancy       
 
Study Protocol and Statistical Analysis Plan 
NCT03888989 
September 15, 2021 

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Response to Influenza Vaccine During Pregnancy 
 
 
 
 
 
 
 
 
 
 
 
 
Funding Mechanism: 5U19AI05722915 
 
IRB Protocol: 50163 
 
U19 CCHI Center Principal Investigator: Mark M. Davis, PhD 
 
Clinical Core Principal Investigator/Protocol Director:  Philip M. Grant, MD 
 
 
 
 
Version Number: V1.3 
 
 
15SEP2021 
 
 

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TABLE OF CONTENTS 
 
 
Page 
1 
Protocol Summary ................................................................................................................... 4 
2 
Endpoints ................................................................................................................................ 5 
3 
Background ............................................................................................................................. 6 
3.1 
Potential Risks and Benefits ........................................................................................ 6 
4 
Study Design ........................................................................................................................... 8 
5 
Study Enrollment and Withdrawal ........................................................................................... 9 
5.1 
Subject Inclusion Criteria ............................................................................................. 9 
5.2 
Subject Exclusion Criteria ............................................................................................ 9 
6 
Study Intervention/Investigational Product ............................................................................ 10 
6.1 
Study Product Description ......................................................................................... 10 
6.2 
Dosage, Preparation and Administration of Study Intervention/Investigational 
Product ................................................................................................................... 10 
6.3 
Accountability Procedures for the Study Intervention/Investigational Product(s) ...... 11 
6.4 
Concomitant Medications .......................................................................................... 11 
7 
Study Schedule ..................................................................................................................... 12 
7.1 
Schedule of Events .................................................................................................... 12 
7.2 
Year 1, Day 0 ............................................................................................................. 13 
7.3 
Year 2, Day 0 Evaluation ........................................................................................... 13 
7.4 
Post-vaccination Visits ............................................................................................... 13 
7.5 
Early Termination Visit ............................................................................................... 13 
7.6 
Definition of Evaluations ............................................................................................ 14 
8 
ADVERSE EVENTS AND TOXICITY MANAGEMENT ......................................................... 17 
8.1 
Definitions of AEs, Adverse Reactions, and Serious Adverse Events ....................... 17 
8.2 
Assessment of Adverse Events and Serious Adverse Event .................................... 18 
8.3 
Instructions for Reporting Adverse Events and Serious Adverse Events .................. 19 
8.4 
Reporting Procedures ................................................................................................ 19 
8.5 
Safety Oversight ........................................................................................................ 19 
9 
CRITERIA FOR STUDY DISCONTINUATION ...................................................................... 20 
9.1 
Criteria for Permanent Study Discontinuation ........................................................... 20 
10 
Statistical Considerations .................................................................................................... 21 
10.1 
Study Hypotheses ................................................................................................... 21 
10.2 
Sample Size Considerations ................................................................................... 21 
10.3 
Final Analysis Plan .................................................................................................. 21 
11 
Source Documents and Access to Source Data/Documents .............................................. 22 
12 
Ethics/Protection of Human Subjects .................................................................................. 23 
12.1 
Ethical Standard ...................................................................................................... 23 
12.2 
Institutional Review Board ....................................................................................... 23 
12.3 
Subject Confidentiality ............................................................................................. 23 
12.4 
Future Use of Stored Specimens ............................................................................ 24 
13 
Data Handling and Record Keeping .................................................................................... 25 
13.1 
Data Management Responsibilities ......................................................................... 25 

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13.2 
Data Capture Methods ............................................................................................ 25 
13.3 
Types of Data .......................................................................................................... 25 
13.4 
Timing/Reports ........................................................................................................ 25 
13.5 
Study Records Retention ......................................................................................... 26 
13.6 
Protocol Deviations .................................................................................................. 26 
14 
Publication Policy ................................................................................................................ 27 
15 
References .......................................................................................................................... 28 
16 
APPENDIX 1: Blood draw instructions for Response to Influenza Vaccine During Pregnancy 
(IRB-50163) ........................................................................................................................ 29 
 

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1 
PROTOCOL SUMMARY 
 
 
Response to Influenza Vaccine During Pregnancy 
 
Phase:  IV 
Population: Up to 50 healthy pregnant women ages 18-49 years 
 
Intervention: Women will be vaccinated with the Quadrivalent, Inactivated Influenza Vaccine 
(IIV4) in Year 1 at Screening/Entry with subsequent visits at Day 7 and Day 28. No more than 
60 mLs of blood will be collected from volunteers at each visit. In Year 2, participants will be 
vaccinated with IIV4 at Day 0. 60 mLs of blood will be collected at Day 0, Day 7, and Day 28 to 
compare immune response to influenza vaccination between the pregnant and non-pregnant 
states. 
Number of Sites: 1 
Study Duration: 60 months for enrollment, study completion, analysis 
Subject Participation Duration: Approximately 56 weeks 
Description of Agent or Intervention:   
Quadrivalent, Inactivated Influenza Vaccine (IIV4)  
Endpoint 
Primary: HAI titers 
Description of Study Design:  This is a Phase IV study of healthy pregnant women who will 
receive the current seasonal IIV4 during two consecutive influenza seasons (second year while 
non-pregnant). Immunization will be at Screening/Entry in Year 1 and Day 0 in Year 2. Blood 
samples for immunogenicity assays will be collected at the time of immunization and at Days 7 
(6-8) and 28 (21-35) in both Year 1 and Year 2.  
 
Study Participants: Up to 50 pregnant women will be given seasonal IIV4 in two consecutive 
influenza seasons. Each volunteer will complete a total of 6 visits:  Day 0, Day 7 and Day 28 in 
both Year 1 and Year 2.  
Estimated Time to Complete Enrollment: Participants will be enrolled Aug-Jan until 
enrollment is complete; anticipated time = 2 years 

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2 
ENDPOINTS 
 
Primary: HAI Titers at Week 4 after vaccination 
Secondary: Grade 2 or Higher Adverse Effects 

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3 
BACKGROUND 
 
Influenza virus infection represents a major cause of morbidity and mortality in the United 
States, resulting in 9.2-35.6 million illnesses, 140,000-710,000 hospitalizations, and 12,000-
56,000 deaths annually since 2010 (1). This results in life-years lost, quality of life reduced, 
and an economic and medical cost of between $71 billion and $167 billion per year. Along 
with the fact that influenza can trigger deadly pandemics such as the 1918 pandemic that 
resulted in the deaths of 50 million to 100 million people (3-5% of the global population), 
these data illustrate the high level of priority needed to curb the public health threat of 
influenza. Influenza continues to be a problem due to the problems with the current vaccine 
strategy. Now our vaccines incorporate only three or four of the large number of circulating 
strains, with no adjuvant except for the elderly, and provide only 10-60% protection from 
influenza infection (2). Annual modifications of the vaccine are required each year, based 
on predictions of the next season’s circulating strains. This strategy is often thwarted by the 
annual antigenic changes that occur in influenza virus composition. In addition to the issues 
with seasonal influenza, pandemic influenza typically starts with unpredicted strains, for 
which entirely new vaccines are required, significantly hindering our preparedness. These 
reasons and more highlight the necessity for a better understanding of the key components 
of an effective immune response and how this could lead to a universal vaccine. Pregnant 
women are known to have more severe influenza. In this study, we will investigate 
immunologic reasons to explain the increased morbidity/mortality associated with influenza 
in pregnant women 
 
3.1 
Potential Risks and Benefits 
 
3.1.1 Potential Risks 
 
This protocol will immunize adult participants with IIV4 (IM), which is recommended for use 
in the age groups and population studied. The discomforts of this study are those of 
receiving IM injection and blood drawn from an arm vein, and possible reactions to the 
vaccine. Drawing blood causes transient discomfort and may cause fainting. Infection at the 
site where blood will be drawn or where the vaccination is given is extremely unlikely but is 
a potential risk. Bruising at the site of blood drawing may occur, but can be prevented or 
lessened by applying pressure for several minutes immediately after the blood draw. 
Immediate allergic reactions to vaccine, including anaphylaxis, are extremely rare 
(approximately 1 person in 4,000,000), and might occur as a skin rash such as hives, 
difficulty breathing, fainting, drop in the blood pressure and death. Such reactions can 
usually be stopped by emergency medications administered by study personnel. Vaccine 
recipients may develop systemic reactions such as fever, headaches, body aches, and 
fatigue. These reactions are usually greatest within the first 24 to 72 hours after vaccination 
and last 1 to 2 days. Analgesics (e.g., aspirin or Tylenol) and rest will generally relieve or 
moderate these symptoms. Other hypersensitivity reactions, including Arthus reactions 
resulting in large local swelling reactions, are also possible. Although Guillain-Barré 
syndrome may have been associated with the 1976-77 inactivated swine influenza vaccine 
and TIV vaccines used in early 1990's, subsequent inactivated vaccines have not been 
associated with an increased risk of this condition. 
 

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Participation in this study may involve risks to the participant which are currently 
unforeseeable. 
 
3.1.1 Potential Benefits 
 
Participants given the seasonal influenza vaccine are likely to experience decreased 
frequency and severity of subsequent influenza infection. The beneficial role of influenza 
vaccination has been recognized increasingly over the past several years as more 
information has become available about the high rate of morbidity and mortality from this 
respiratory pathogen. 

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4 
STUDY DESIGN 
 
This is a phase IV study of 50 healthy 18-49 year old pregnant women who will be given licensed 
seasonal IIV4. There are no exclusions for ethnicity or race.  Following confirmation of written 
informed consent, baseline blood samples will be drawn from all study participants prior to 
immunization.  
 
Intervention Group: Up to 50 healthy pregnant volunteers, 18-49 year old, will be given seasonal 
quadrivalent inactivated influenza vaccine (IIV4). Each volunteer will complete a total of 3 visits in 
Year 1: Day 0 (Screening/Entry/Immunization visit), and Day 7 +/- 1 and Day 28+/- 7 and a total of 
3 visits in Year 2 (when not pregnant): Day 0 (Immunization visit), and Day 7 +/- 1 and Day 28 +/- 7 
(post-immunization). All visits will consist of drawing blood for study assays and monitoring for 
serious adverse events (SAEs) and adverse events (AEs). In Year 2, if participant is pregnant, they 
will not be entered into Year 2 of the protocol. 
 

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5 
STUDY ENROLLMENT AND WITHDRAWAL 
 
5.1 
Subject Inclusion Criteria 
 
1. 18-49 year old pregnant woman 
2. Willing and able to complete the informed consent process  
3. Availability for follow-up for the planned duration of the study with the expected delivery     
date more than 8 weeks after vaccination (i.e., before 32 weeks gestational age of 
pregnancy) 
4. Acceptable medical history by review of inclusion/exclusion criteria 
 
5.2 
Subject Exclusion Criteria 
1. Prior off-study vaccination with seasonal influenza vaccine within three months of study 
entry. 
2. Life-threatening reactions to previous influenza vaccinations. 
3. Allergy to egg or egg products or to vaccine components including gentamicin, gelatin, or 
arginine.  
4. Active systemic or serious concurrent illness, including febrile illness on the day of 
vaccination.  
5. Hemoglobin <9 g/dL within the past 8 weeks (those without a value within that timeframe 
will have a Hdb drawn at entry).  
 
6. History of immunodeficiency (including HIV infection).  
7. Known or suspected impairment of immunologic function; may include significant liver 
disease, diabetes mellitus treated with insulin or moderate to severe renal disease  
8. Chronic Hepatitis B or C.  
9. Recent or current use of immunosuppressive medication, including systemic 
glucocorticoids (corticosteroid nasal sprays, inhaled corticosteroids, and topical 
corticosteroids are permissible). Use of oral steroids (≤10mg prednisone-equivalent/day) 
may be acceptable after review by the Protocol Director.  
10. Malignancy (other than squamous cell or basal cell skin cancer) within the past 5 years.  
11. Autoimmune disease (such as Rheumatoid arthritis, lupus, etc.) treated with 
immunosuppressive medication such as Plaquenil, methotrexate, prednisone, Enbrel.  
12. Receipt of blood or blood products within the past 6 months or planned used during the 
study.  
13. Receipt of an inactivated vaccine 14 days prior to study enrollment, or planned 
vaccinations prior to completion of last annual study visit. 
14. Receipt of a live, attenuated vaccine within 28 days prior to enrollment or planned 
vaccination during post-vaccination follow-up. 
15. Need for allergy immunization (that cannot be postponed) until after the last study visit.  
16. History of Guillain–Barré syndrome.  
17. Use of investigational agents within 30 days prior to enrollment or planned use during 
the study.  
18. Donation of the equivalent of a unit of blood within 4 weeks prior to enrollment or 
donation of platelets within 2 weeks of enrollment or planned donation prior to completion 
of the last visit.  
19. Any condition which, in the opinion of the investigator, might interfere with volunteer 
safety, study objectives or the ability of the participant to understand or comply with the 
study protocol. 

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6 
STUDY INTERVENTION/INVESTIGATIONAL PRODUCT 
 
6.1 
Study Product Description 
 
6.1.1 Acquisition 
 
The study product will be shipped from the manufacturer to the investigational pharmacy 
at the study site. IIV4 will be supplied by Glaxosmithkline Biologicals as Fluarix® 
Quadrivalent.  
 
 
6.1.2 Formulation, Packaging, and Labeling 
 
FDA’s Vaccines and Related Biological Products Advisory Committee (VRBPAC) will 
make annual recommendations regarding the composition of the U.S. seasonal influenza 
vaccines based on global influenza virus surveillance data related to epidemiology and 
antigenic characteristics, serological responses to trivalent and quadrivalent seasonal 
vaccines, and the availability of candidate strains and reagents.   
 
The season-specific manufacturer package inserts for each study year will be attached in 
the IRB protocol submissions when available. 
 
Fluarix® Quadrivalent: Each 0.5 mL dose of Fluarix Quadrivalent (IIV4) will contain a 
total of 60 µg (15 μg of each strain) of influenza virus hemagglutinin of each of the 4 
strains selected for the seasonal formulation. The vaccine will be supplied in a prefilled, 
single dose syringe, 0.5 mL (no preservative), single dose vial 0.5 mL (no preservative) 
or multi-dose vial, 5 mL (with preservative). Each multi-dose vial contains ten 0.5 mL 
doses. 
 
6.1.3 Product Storage and Stability 
 
Fluarix® Quadrivalent vaccine presentations should be refrigerated at 2° to 8°C (35° to 
46°F). Vaccine that has been frozen will be discarded. Between uses, multi-dose vials 
will be returned to the recommended storage conditions at 2° to 8°C (35° to 46°F). 
Vaccine should not be used after the expiration date shown on the label.   
 
6.2 
Dosage, Preparation and Administration of Study 
Intervention/Investigational Product 
IIV4 vaccine will be administered as a 0.5 mL dose, with a sterile, disposable syringe and 
needle by IM injection into the deltoid muscle. The participant will choose whether the 
injection will be administered into the right or left deltoid. 
 
 

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6.3 
Accountability Procedures for the Study 
Intervention/Investigational Product(s) 
 
The study article will be shipped by the manufacturer to the study site. Use and disposition 
of each unit of vaccine will be appropriately documented by the Clinical Core staff in 
accordance with ICH GCP. Unused products will be given to researchers. 
 
6.4 
Concomitant Medications 
 
At entry and at each study visit, the participant will be questioned about medication use and 
the information will be recorded. Medication history will include vaccinations, allergy shots 
or PPD tests received and medications taken within 28 days prior to enrollment, as well as 
vaccinations, allergy shots or PPD tests received and current prescription and over-the-
counter medications used throughout the study period. The investigator should be 
consulted regarding eligibility if the participant is taking oral steroid medications or 
medications for treatment of autoimmune disease (such as Plaquenil, methotrexate, 
prednisone, Enbrel), or any other medications which might indicate a condition that 
precludes participant compliance with the protocol. 

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7 
STUDY SCHEDULE 
7.1 
Schedule of Events 
Evaluation 
Year 1 
Year 2 
Early Termination 
Visit 
D0 
D7 
D28 
D0 
D7 
D28 
Written Informed Consent 
X 
 
 
 
 
 
 
Eligibility Determination 
X 
 
 
 
 
 
 
Demographics/Medical 
History/Pregnancy 
History 
X 
 
 
 
 
 
 
Update Medical Hx/ 
Review Eligibility 
Requirements 
 
 
 
X 
 
 
 
Concomitant Medications 
X 
X 
X 
X 
X 
X 
X 
Signs/Symptoms/Adverse 
Events 
X 
X 
X 
X 
X 
X 
X 
Vital Signs/Weight 
X 
If clinically indicated 
X 
If clinically 
indicated 
 
Height 
X 
 
 
 
 
 
 
Hemoglobin* 
X 
 
 
 
 
 
 
Phlebotomy 
X 
X 
X 
X 
X 
X 
 
IIV4 Administration 
X† 
 
 
 
X 
 
 
 
* An adequate hemoglobin level (i.e., >9.0g/dL) from within 8 weeks of entry can substitute for the research 
hemoglobin draw); † - IIV in Year 1 may be administered by clinic staff at Stanford Ob/Gyn Flu Clinic as part 
of participant’s routine care (i.e., outside of research study) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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7.2 
Year 1, Day 0  
 
The following will be performed at screening (see Section 7.6 for a detailed explanation 
of each evaluation) 
 
• 
Written Informed Consent 
• 
Eligibility Determination 
• 
Demographics/Medical History/Pregnancy History 
• 
Concomitant Medications 
• 
Signs/Symptoms/Adverse Events 
• 
Vital Signs/Weight 
• 
Height 
• 
Hemoglobin 
• 
Phlebotomy 
• 
IIV4 Administration (may be administered by clinic staff at Stanford’s Ob/Gyn Clinic as 
part of participant’s recommended obstetrical clinical care) 
 
7.3 
Year 2, Day 0 Evaluation 
 
The following will be performed at the vaccination visit for Year 2: 
 
• 
Update Medical History/Review Eligibility Requirements 
• 
Concomitant medications 
• 
Signs/Symptoms/Adverse Events 
• 
Vital Signs/Weight 
• 
Phlebotomy 
• 
IIV4 Administration 
 
7.4 
Post-vaccination Visits 
 
Post-vaccination visits occur following the Year 1, Day 0 Visit and the Year 2, Day 0 
Visit. Week 1 visits (in both Year 1 and Year 2) occur at Day 7 (+/- 1 day) after IIV 
administration; Week 4 visits (in both Year 1 and Year 2) occur at Day 28 (+/- 7 days) 
after IIV administration. 
 
The following will occur at each Post-vaccination Visit: 
 
• 
Concomitant medications 
• 
Signs/Symptoms/Adverse Events 
• 
Vital Signs/Weight (only if clinically indicated) 
• 
Phlebotomy 

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7.5 
Early Termination Visit 
 
The Protocol Director should be notified within 48 hours if a participant terminates the 
study prior to completing all study visits.  
 
If a participant discontinues the study early for any reason then the following 
assessments for the Early Termination Visit should occur: 
 
• 
Concomitant medications 
• 
Signs/Symptoms/Adverse Effects 
 
However, if the participant discontinues the study between Year 1 and Year 2, the Day 
28 visit of Year 1 can serve also as the Early Termination Visit. 
 
7.6 
Definition of Evaluations 
 
7.6.1 Written Informed Consent 
 
Participants will be given the IRB-approved informed consent form at the 
Screening/Entry Visit. A discussion of risks and possible benefits of participation in 
this study will be provided to the participants.  Participants then will be asked for 
any questions and to read/sign the consent form. The consent form will be signed 
prior to the performance of any study procedures. A copy of the informed consent 
document will be given to the participant for her records.  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. 
 
7.6.2 Eligibility Determination 
 
At the completion of all protocol-defined screening procedures, the Eligibility 
Determination Form will be completed and signed by the Study Coordinator 
according to study criteria (see sections 4.1 and 4.2). Eligible participants giving 
informed consent will be enrolled in the study. 
 
7.6.3 Demographics/Medical History/Pregnancy History 
 
Participant demographics will include date of birth and race/ethnicity. A medical 
history will be obtained and must be recorded in the source documents. The 
medical history must include: 
 
• 
All past medical diagnoses, acute or chronic 
• 
Influenza Vaccination History within the past 5 years 
 
A pregnancy history will be obtained and must be recorded in source documents. 
The pregnancy history must include: 

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• 
Expected delivery date (in order to calculate gestational age) 
• 
Pre-pregnancy weight 
• 
Number of prior pregnancies 
• 
History of prior preterm births 
 
7.6.4 Update Medical History/Review Eligibility Requirements 
 
At the Day 0 visit of Year 2, the medical history from Year 1 will be updated. 
Additionally, eligibility criteria will be reviewed and only participants who still meet 
all Inclusion Criteria (other than the pregnancy criterion) and still meet no 
Exclusion Criteria will be entered into Year 2 of the study. Participants no longer 
eligible will be terminated from the study. 
 
7.6.5 Concomitant Medications 
 
At the Entry Visit record all current and past (within the last 28 days) prescription 
and non-prescription medications. At subsequent visits, record changes in 
medications since the last study visit. Additionally, record any vaccinations, allergy 
shots, or PPD tests received within the past 28 days.   
 
7.6.6 Signs/Symptoms/Adverse Events 
 
All Grade 2 or higher signs, symptoms, and toxicities and their relationship to 
study procedures must be documented in the participant’s record.  
 
Any sign or symptom that leads to discontinuation of study, regardless of grade, 
must be recorded on source documents. 
 
 
Refer to the Common Terminology for Adverse Effects, Version 5.0, November 
27, 2017, located at 
https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/CTCAE
_v5_Quick_Reference_8.5x11.pdf 
 
Report diagnoses for clinical events and other diseases and record whether they 
were related to study procedures.  
 
7.6.7 Vital Signs and Weight 
 
Assessment of vital signs will include measurement of resting blood pressure, 
pulse, respiratory rate, and temperature. Weight should be measured in kilograms.  
 
7.6.8 Height 
 
Height should be measured in centimeters. 
 

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7.6.9 Hemoglobin 
  
If no clinical value for hemoglobin is available from clinical care within 8 weeks 
prior to entry, a hemoglobin will be assessed at the Screening/entry visit. 
 
 
 
7.6.9 Phlebotomy 
 
Phlebotomy will be performed at each visit using antiseptic technique. See 
Appendix 1: Blood Draw Requirements for blood draw instructions for each visit. 
 
7.6.10 IIV4 Administration 
Participants will be administered the seasonal IIV4 vaccine in the left or right 
deltoid muscle using antiseptic technique. Volunteers will be observed in clinic for 
15 minutes after vaccination to monitor for any immediate serious reactions. The 
location of the injection, lot number and expiration date will be documented. 
In Year 1 for participant convenience, the IIV4 may be given as part of participant’s 
routine clinical care (i.e., outside of this research protocol) as part of participant’s 
recommended obstetrical clinical care. In this case, the administration of the 
vaccine will be done on the same day following the Day 0 evaluations described in 
Section 7.1 
In Year 2, all study related procedures, including the administration of the seasonal 
IIV4 vaccine will be completed by the Research Study Team as part of this study 
protocol. 
 

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8 
ADVERSE EVENTS AND TOXICITY MANAGEMENT  
8.1 
Definitions of AEs, Adverse Reactions, and Serious Adverse 
Events 
An adverse event (AE) is any untoward medical occurrence in a clinical study participant 
administered a pharmaceutical product, which does not necessarily have a causal 
relationship with the treatment. An AE can therefore be any unfavorable and/or 
unintended sign, symptom, or disease temporally associated with the use of a medicinal 
product, whether or not considered related to the medicinal product. AEs may also 
include pre-or post-treatment complications that occur as a result of protocol specified 
procedures, lack of efficacy, overdose, drug abuse/misuse reports, or occupational 
exposure. Preexisting events that increase in severity or change in nature during or as a 
consequence of participation in the clinical study will also be considered AEs. An AE 
does not include the following:  
 
• 
Medical or surgical procedures such as surgery, endoscopy, tooth extraction, and 
transfusion. The condition that led to the procedure may be an adverse event and must 
be reported   
• 
Pre-existing diseases, conditions, or laboratory abnormalities present or detected before 
the Screening Visit that do not worsen  
• 
Situations where an untoward medical occurrence has not occurred (e.g., hospitalization 
for elective surgery, social and/or convenience admissions) 
• 
Overdose without clinical sequelae 
• 
Any medical condition or clinically significant laboratory abnormality with an onset date 
before the consent form is signed and not related to a protocol-associated procedure is 
not an AE. It is considered to be pre-existing and should be documented as medical 
history. 
 
A serious adverse event (SAE) is defined as an event that results in the following:  
• 
Death  
• 
Life-threatening (note: The term “life-threatening” in the definition of “serious” refers to an 
event in which the participant was at risk of death at the time of the event; it does not 
refer to an event that hypothetically might have caused death if it were more severe.)  
• 
In-patient hospitalization or prolongation of existing hospitalization  
• 
Persistent or significant disability/incapacity 
• 
A congenital anomaly/birth defect  
• 
A medically important event or reaction; such events may not be immediately life-
threatening or result in death or hospitalization but may jeopardize the participant or may 
require intervention to prevent one of the other outcomes constituting SAEs. Medical and 
scientific judgment must be exercised to determine whether such an event is reportable 
under expedited reporting rules. Examples of medically important events include 
intensive treatment in an emergency room or at home for allergic bronchospasm; blood 
dyscrasias or convulsions that do not result in hospitalization; and development of drug 
dependency or drug abuse. For the avoidance of doubt, infections resulting from 
contaminated medicinal product will be considered a medically important event and be 
subject to expedited reporting requirements.  

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Clinical laboratory abnormalities and other abnormal assessments without clinical 
significance are not recorded as AEs or SAEs. However, laboratory abnormalities that 
require medical or surgical intervention or lead to study drug discontinuation must be 
recorded as an AE, as well as an SAE, if applicable. In addition, laboratory or other 
abnormal assessments (e.g., electrocardiogram, x-rays, vital signs) that are associated 
with signs and/or symptoms must be recorded as an AE or SAE if they meet the 
definition of an AE or SAE as described above. If the laboratory abnormality is part of a 
syndrome, record the syndrome or diagnosis (e.g., anemia), not the laboratory result 
(i.e., decreased hemoglobin).  
8.2 
Assessment of Adverse Events and Serious Adverse Event 
 
The Protocol Director is responsible for assessing AEs and SAEs for causality and 
severity, and for final review and confirmation of accuracy of event information and 
assessments.  
 
The Protocol Director is responsible for assessing the relationship to study drug 
treatment using clinical judgment and the following considerations:  
 
• 
No: Evidence exists that the adverse event has an etiology other than the study 
drug. For SAEs, an alternative causality must be provided (e.g., pre-existing 
condition, underlying disease, intercurrent illness, or concomitant medication).  
 
• 
Yes: There is reasonable possibility that the event may have been caused by the 
investigational medicinal product. 
 
Ineffective treatment should not be considered as causally related in the context of 
adverse event reporting. The relationship to study procedures (e.g., invasive procedures 
such as venipuncture or biopsy) should be assessed using the following considerations:  
 
• 
No: Evidence exists that the adverse event has an etiology other than the study 
procedure.  
 
• 
Yes: The adverse event occurred as a result of protocol procedures (e.g., 
venipuncture). 
 
The severity grading of AEs will be assessed as Grade 1, 2, 3, or 4 using the Common 
Terminology for Adverse Effects, Version 5.0, November 27, 2017, located at 
https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/CTCAE_v5_Q
uick_Reference_8.5x11.pdf and Grade 2 or higher AEs recorded. 
 
For AEs associated with laboratory abnormalities, the event should be graded on the 
basis of the clinical severity in the context of the underlying conditions; this may or may 
not be in agreement with the grading of the laboratory abnormality. 

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8.3 
Instructions for Reporting Adverse Events and Serious Adverse 
Events 
 
SAEs, regardless of cause or relationship, that occur after the participant first consents 
to participate in the study (i.e., signing the informed consent) and throughout the 
duration of the study, including the protocol-required post treatment follow-up period, 
must be reported on the CRF. This also includes any SAEs resulting from protocol-
associated procedures performed from screening onwards. All AEs, regardless of cause 
or relationship, that occur from initiation of study drug until 4 weeks after last 
administration of study drug must be reported on the CRF. Any SAEs and deaths that 
occur after the Post-Treatment follow-up visit OR within 30 days of the last dose of study 
drug (whichever is longer), regardless of causality, should also be reported. All AEs 
should be followed up until resolution or until the adverse event is stable, if possible. 
Investigators are not obligated to actively seek SAEs after the 30-day period.  
 
8.4 
Reporting Procedures 
 
8.4.1 Regulatory Reporting for Studies Not Conducted Under an IND 
 
For those events meeting the previously described definition of Serious Adverse Events, 
the completion of an SAE report form is required. For SAEs related to vaccine, a VAERS 
form will be filled out and submitted to the Vaccine Adverse Event Reporting System 
(VAERS) per federal regulations. The VAERS form will simultaneously be sent to the 
sponsor.  SAEs and events that meet the Prompt Reporting guidelines (events meeting 
the criteria for Unanticipated Problems) will also be reported to the Stanford IRB as 
required.  Unexpected deaths or life-threatening experiences related to the research will 
be reported to the sponsor and to the IRB within 5 working days from when the 
investigator learns of event.  SAEs not related to vaccine will be reported to the IRB on 
an annual basis. 
 
8.5 
Safety Oversight  
 
The Clinical Core Principal Investigator will oversee compliance with the protocol, the 
participant’s safety and any unanticipated problems involving risks to participants and 
will report these events as described above.  Unanticipated problems and serious 
adverse events will be reported to the Stanford IRB as required.  
 

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9 
CRITERIA FOR STUDY DISCONTINUATION 
9.1 
Criteria for Permanent Study Discontinuation 
 
• 
Requirement for prohibited concomitant medications (such as immunosuppressant 
medication) 
• 
Pregnancy during Year 2 of Study 
• 
Participant no longer meeting eligibility requirement at Day 0 visit of Year 2 (other than 
pregnancy requirement) 
• 
Clinical reasons such that continued participation in the study may be detrimental to 
the participant’s health as judged by the Protocol Director 
• 
Failure by the participant without reasonable cause to attend study visits 
• 
Request by the participant to withdraw. 
• 
Request of the primary care provider if s/he thinks the study is no longer in the best 
interest of the participant. 
• 
Participant judged by the investigator to be at significant risk of failing to comply with 
the provisions of the protocol as to cause harm to self or seriously interfere with the 
validity of the study results. 
• 
Participant died.   
• 
At the discretion of the IRB or Study Investigators. 
 

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10 
STATISTICAL CONSIDERATIONS 
 
10.1 Study Hypotheses 
 
We hypothesize that exposure to influenza vaccination will result in immunity to influenza 
in the majority of study participants and will be well-tolerated forming the basis of novel 
immunologic insights. 
 
10.2 Sample Size Considerations 
 
The sample size was selected based on feasibility. 
 
10.3 Final Analysis Plan 
 
We will report the percentage of participants having a 4 fold increase in HAI titers at 
Week 4 in Year 0 and Year 1 and the participants experiencing Grade 2 or higher AEs. 

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11 
SOURCE DOCUMENTS AND ACCESS TO SOURCE 
DATA/DOCUMENTS 
 
All participant information will be obtained by the investigators and their support staff and 
will remain confidential.  Specimens for research laboratory testing will be coded by a 
unique participant ID number and data for individual participants will be coded for data 
analysis.  A database containing a code key will be kept on a computer that is password 
secured or a locked cabinets and only available to clinical research staff.  Participants 
will not be identified in any reports or publications that may result from the study.  
Personal identifierswill be removed for analyses and publications.   
 
Participant confidentiality is held strictly in trust by the participating investigators, their 
staff, and their agents. This confidentiality extends to genetic and biological sample 
tests, in addition to the clinical information relating to participating volunteers.  The study 
protocol, documentation, data, and all other information generated will be held in strict 
confidence.   
 
The clinical study site will permit access to all documents and records that may require 
inspection by the sponsor or its authorized representatives. 
 
Quality Control and Quality Assurance 
 
Quality Control and Quality Assurance activities will generally be completed as outlined 
in the current version of the Stanford Quality Management Plan.  Chart audits for the trial 
will be conducted for research participant records utilizing the SLVP Chart Audit Tool.  
Audits will be conducted on a random sampling of participant charts in accordance with 
the low risk to volunteers participating in the trial. Charts will be randomly selected from 
among those not previously audited.  Results of these audits will be summarized using 
the SLVP QM_QA Summary Report tool, and shared with research staff at staff 
meetings, as necessary. 
 

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12 
ETHICS/PROTECTION OF HUMAN SUBJECTS 
12.1 Ethical Standard 
 
The Protocol Director will ensure that this study is conducted in full conformity with the 
principles set forth in The Belmont Report: Ethical Principles and Guidelines for the 
Protection of Human Subjects of Research of the US National Commission for the 
Protection of Human Subjects of Biomedical and Behavioral Research (April 18, 1979) 
and codified in 45 CFR Part 46 and/or the ICH E6; 62 Federal Regulations 25691 
(1997). 
   
12.2 Institutional Review Board 
 
Prior to enrollment of participants into this trial, the protocol and the informed consent 
form will be reviewed and approved by the appropriate IRB. The responsible official for 
the IRB will sign the IRB letter of approval of the protocol prior to the start of this trial and 
a copy will be provided to DAIT.  Notification of the IRB's composition and the institutions 
Federal Wide Assurance number will be provided to DAIT as needed. Should 
amendments to the protocol be required, the amendments will be reviewed by the 
sponsor and/or the investigators and submitted to the IRB. Volunteers will be 
compensated for their participation in this study. Compensation will be in accordance 
with the local IRB’s policies and procedures and requires IRB approval. 
 
12.3 Subject Confidentiality 
 
All participant information will be obtained by the investigators and their support staff and 
will remain confidential.  Specimens for laboratory testing will be coded by participant 
number and data for individual participants will be coded for data analysis.  A database 
containing a code key will be kept on a computer that is password secured and available 
only to study staff.  Participants will not be identified (except for age) in any reports or 
publications that may result from the study.  Personal identifiers, except for age, will be 
removed for publications. Upon completion of the study, data containing PHI will be 
retained for 50 years from the time of informed consent.  
 
Participant confidentiality is held strictly in trust by the participating investigators, their 
staff, and their agents. This confidentiality extends to genetic and biological sample 
tests, in addition to the clinical information relating to participating volunteers. 
The study protocol, documentation, data, and all other information generated will be held 
in strict confidence.   
 
The clinical study site will permit access to all documents and records that may require 
inspection by the sponsor or its authorized representatives, including but not limited to, 
medical records (office, clinic or hospital) and pharmacy records for the participants in 
this study.   
 
 
 
 

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12.4 Future Use of Stored Specimens 
 
After the study is complete, residual specimens will be stored for future research.  As 
new scientific discoveries identify technologies or mediators that might be useful in 
studying the immune response, stored samples may be used to explore new information 
that could be made available with these advanced methods.  Volunteer specimens will 
be stored under a unique identifier. The volunteer’s name or other personal identifiers 
will not be available in any data shared with outside investigators.  New studies using 
stored samples will be reviewed by the IRB as required. 
 
 

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13 
DATA HANDLING AND RECORD KEEPING 
 
The investigator is responsible to ensure the accuracy, completeness, legibility, and 
timeliness of the data reported. All source documents and data collection forms should 
be completed in a neat, legible manner to ensure accurate interpretation of data. Black 
or dark blue ink is required to ensure clarity of reproduced copies. When making 
changes or corrections, the original entry will be crossed out with a single line, and 
initialed and dated to indicate the change. DO NOT ERASE, OVERWRITE, OR USE 
CORRECTION FLUID OR TAPE ON THE ORIGINAL. 
 
Data entered into the data entry system that is derived from source documents or data 
collection forms should be consistent with the source documents and data collection 
forms or the discrepancies should be explained. 
 
13.1 Data Management Responsibilities 
 
All source documents will be reviewed by the clinical team and data entry staff, who will 
ensure that they are accurate and complete. Serious adverse events will be assessed 
for causality, and reviewed by the site PI or designee. 
 
Data collection is the responsibility of the clinical trial staff at the site under the 
supervision of the site PI. During the study, the investigator must maintain complete and 
accurate documentation for the study. 
 
The PI (or designee) will be responsible for data management, quality review, analysis, 
and reporting of the study data. 
 
13.2 Data Capture Methods 
 
Clinical data (including SAEs) will be entered into a 21 CFR Part 11-compliant data entry 
system. The data system includes password protection and internal quality checks, such 
as automatic range checks, to identify data that appear inconsistent, incomplete, or 
inaccurate. Clinical data will be entered directly from the source documents or data 
collection forms.  
 
13.3 Types of Data 
 
Data for this study will include clinical, safety and outcome measures. 
 
13.4 Timing/Reports 
 
 
Data will be reviewed on an ongoing basis according to the site Quality Management 
Plan.  Data analysis will begin once all clinical data have been collected and verified for 
accuracy. Preliminary analyses of outcome measures will begin as soon as laboratory 
data are available. Participants will receive a unique study ID at enrollment.  All data for 
study analysis will be coded by study ID number and will be password-protected.  Coded 

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protected health information will be provided only as needed for data analysis of study 
outcome measures.  Personal identifierswill be removed for publications. 
 
Protected health information may be disclosed as requested by The Office for Human 
Research Protections in the U.S. Department of Health and Human Services, the 
sponsor, or Stanford University Administrative Panel on Human Subjects in Medical 
Research and any other unit of Stanford University as necessary. 
 
13.5 Study Records Retention 
 
Records and documents pertaining to the conduct of this study, including CRFs, source 
documents, data collection forms, consent forms, and medication inventory records, 
must be retained by the investigator for at least 3 years and in accordance with Stanford 
University and Stanford IRB requirements and until the sponsor authorizes transfer or 
destruction of study records.   
 
13.6 Protocol Deviations 
 
A protocol deviation is any noncompliance with the clinical trial protocol or Good Clinical 
Practice (GCP).  The noncompliance may be either on the part of the participant, the 
investigator, or the study site staff.  As a result of deviations, corrective actions are to be 
developed by the site and implemented promptly.  
 
It is the responsibility of the site to use continuous vigilance to identify and report 
deviations. All deviations from the Protocol will be addressed in a study subject data 
collection form. Protocol deviations will be sent to the local IRB/IEC per their guidelines.  
The site PI/study staff is responsible for knowing and adhering to their IRB requirements.  

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14 
PUBLICATION POLICY 
 
Following completion of the study, the investigator may publish the results of this 
research in a scientific journal. The International Committee of Medical Journal Editors 
(ICMJE) member journals have adopted a trials-registration policy as a condition for 
publication. This policy requires that all clinical trials be registered in a public trials 
registry such as ClinicalTrials.gov, which is sponsored by the National Library of 
Medicine (NLM). Other biomedical journals are considering adopting similar policies. Any 
clinical trial starting enrollment after 27SEP2007 must be registered either on or before 
the onset of participant enrollment.  
 
The ICMJE defines a clinical trial as any research project that prospectively assigns 
human subjects to intervention or comparison groups to study the cause-and-effect 
relationship between a medical intervention and a health outcome. Studies designed for 
other purposes, such as to study pharmacokinetics or major toxicity (e.g., Phase 1 
trials), would be exempt from this policy.  
 

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15 
REFERENCES 
 
 
1. Osterholm MT, Kelley NS, Sommer A, Belongia EA: Efficacy and effectiveness of 
influenza vaccines: a systematic review and meta-analysis, Lancet Infect Dis 2012, 
12:36-44 
 
2. Goodwin K, Viboud C, Simonsen L: Antibody response to influenza vaccination in the 
elderly: a quantitative review. Vaccine. 2006 Feb 20;24(8):1159-69. 
 
 

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16 
APPENDIX 1: BLOOD DRAW INSTRUCTIONS FOR 
RESPONSE TO INFLUENZA VACCINE DURING 
PREGNANCY (IRB-50163) 
IRB approved 60 mL at all visits; all blood draws will occur at CTRU and all samples will be sent 
to the HIMC for processing 
Visit 
Samples 
CTRU Procession Instructions 
Volume 
Collected 
Year 1 Visit 1 
(Day 0) 
1 x 10 mL Serum Red Top 
1 x 2.5mL PAXgene Tube  
4 x 10mL Heparin Green 
Top  
1 x 4mL Heparin Green Top 
1 X 2 mL Lavender top (if 
required for a CBC)    
Sera Aliquot:  approximately 10 
aliquots of 0.5mL/vial of the serum 
from 10mL of blood. PAXgene 
saved for future testing; Plasma 
should be saved, and the PBMC 
processed and cryopreserved at 5-
10 million cells/vial; Lavender top 
should be sent to clinical lab for 
Hemoglobin  
56.5 mL – 
58.5 mL 
(depending if 
Hgb required 
at entry) 
All other visits 
(Year 1 visits 2 
and 3; Year 2 
visits 1, 2, and 
3) 
1 x 10 mL Serum Red Top 
5 x 10mL Heparin Green 
Top  
 
Sera Aliquot:  approximately 10 
aliquots of 0.5mL/vial of the serum 
from 10mL of blood. Plasma should 
be saved, and the PBMC processed 
and cryopreserved at 5-10 million 
cells/vial 
60 mL