Safety and Immunogenicity of a Tetravalent Dengue Vaccine in HIV-Positive Adults Aged 18 to 50 Years in Brazil
Phase: PHASE2
Conditions: Dengue Fever, Dengue Hemorrhagic Fever, Human Immunodeficiency Virus
Sponsor: Sanofi Pasteur, a Sanofi Company



 
 
 
  
 
 
 
 
 
 
  
 
 
Global Safety Officer: 
 
 
 
 
  
Regional Clinical Trial Manager: 
 
 
 
 
 
 
Version and Date of the Protocol: 
Version 3.0 dated 10 December 2019 
This protocol version 3.0 is the third version of the initial trial protocol version 1.0 dated 08 March 2016.  
 
Information contained in this publication is the property of Sanofi Pasteur and is confidential. This information may not be 
disclosed to third parties without written authorization from Sanofi Pasteur. This document may not be reproduced, stored in a 
retrieval system, or transmitted in any form or by any means–electronic, mechanical recording or otherwise–without prior 
authorization from Sanofi Pasteur. This document must be returned to Sanofi Pasteur upon request. 
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History of Protocol Versions 
 
Version* 
Date 
Comments 
1.0 
08 March 2016 
IEC/IRB-approved version not used in the study 
2.0 
06 December 2018 
IEC/IRB-approved version used in the study 
3.0 
10 December 2019 
Amendment 1 
 
* Versions in bold font have been approved by the Independent Ethics Committee(s) (IEC[s]) / Institutional Review 
Board(s) (IRB[s]) and used in the study. 
 
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Table of Contents 
History of Protocol Versions ........................................................................................................... 3 
List of Tables .................................................................................................................................... 9 
Synopsis .......................................................................................................................................... 10 
Table of Study Procedures ............................................................................................................ 19 
List of Abbreviations ..................................................................................................................... 22 
1 
Introduction ..................................................................................................................... 25 
1.1 
Background ..................................................................................................................... 25 
1.2 
Background of the Investigational Product ..................................................................... 27 
1.3 
Potential Benefits and Risks ........................................................................................... 29 
1.3.1 
Potential Benefits to Subjects ....................................................................................... 29 
1.3.2 
Potential Risks to Subjects ........................................................................................... 30 
1.4 
Rationale for the Study ................................................................................................... 32 
2 
Study Objectives .............................................................................................................. 34 
2.1 
Primary Objective ........................................................................................................... 34 
2.2 
Secondary Objectives ...................................................................................................... 34 
2.3 
Observational Objective(s) ............................................................................................. 34 
3 
Investigators and Study Organization ........................................................................... 35 
4 
Independent Ethics Committee / Institutional Review Board..................................... 35 
5 
Investigational Plan ......................................................................................................... 36 
5.1 
Description of the Overall Study Design and Plan ......................................................... 36 
5.1.1 
Study Design ................................................................................................................. 36 
5.1.2 
Justification of the Study Design .................................................................................. 37 
5.1.3 
Study Plan ..................................................................................................................... 39 
5.1.4 
Visit Procedures ............................................................................................................ 41 
5.1.5 
Planned Study Calendar ................................................................................................ 48 
5.1.6 
Early Safety Data Review ............................................................................................. 48 
5.2 
Enrollment and Retention of Study Population .............................................................. 48 
5.2.1 
Recruitment Procedures ................................................................................................ 48 
5.2.2 
Informed Consent Procedures ...................................................................................... 49 
5.2.3 
Screening Criteria ......................................................................................................... 49 
5.2.4 
Inclusion Criteria .......................................................................................................... 50 
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5.2.5 
Exclusion Criteria ......................................................................................................... 50 
5.2.6 
Medical History ............................................................................................................ 52 
5.2.7 
Contraindications for Subsequent Vaccinations ........................................................... 52 
5.2.7.1 
Temporary Contraindications ..................................................................................... 52 
5.2.7.2 
Definitive Contraindications ...................................................................................... 53 
5.2.8 
Conditions for Withdrawal ........................................................................................... 53 
5.2.9 
Lost to Follow-up Procedures ....................................................................................... 54 
5.2.10 
Classification of Subjects Who Discontinue the Study ................................................ 54 
5.2.11 
Follow-up of Discontinuations ..................................................................................... 55 
5.2.12 
Follow-up and Reporting of Pregnancies ..................................................................... 55 
5.3 
Safety Emergency Call ................................................................................................... 56 
5.4 
Modification of the Study and Protocol .......................................................................... 56 
5.5 
Interruption of the Study ................................................................................................. 56 
6 
Vaccines Administered ................................................................................................... 57 
6.1 
Identity of the Investigational Products .......................................................................... 57 
6.1.1 
Identity of Study Products ............................................................................................ 58 
6.1.1.1 
Composition ............................................................................................................... 58 
6.1.1.2 
Preparation and Administration ................................................................................. 58 
6.1.1.3 
Dose Selection and Timing ........................................................................................ 59 
6.1.2 
Identity of Control Product ........................................................................................... 59 
6.1.2.1 
Composition ............................................................................................................... 59 
6.1.2.2 
Preparation and Administration ................................................................................. 59 
6.1.2.3 
Dose Selection and Timing ........................................................................................ 59 
6.2 
Identity of Other Product ................................................................................................ 59 
6.3 
Product Logistics ............................................................................................................ 59 
6.3.1 
Labeling and Packaging ................................................................................................ 59 
6.3.2 
Product Shipment, Storage, and Accountability ........................................................... 60 
6.3.2.1 
Product Shipment ....................................................................................................... 60 
6.3.2.2 
Product Storage .......................................................................................................... 60 
6.3.2.3 
Product Accountability ............................................................................................... 60 
6.3.3 
Replacement Doses ....................................................................................................... 61 
6.3.4 
Disposal of Unused Products ........................................................................................ 61 
6.3.5 
Recall of Products ......................................................................................................... 61 
6.4 
Blinding and Code-breaking Procedures ........................................................................ 61 
6.5 
Randomization and Allocation Procedures ..................................................................... 62 
6.6 
Treatment Compliance .................................................................................................... 63 
6.7 
Concomitant Medications and Other Therapies ............................................................. 63 
7 
Management of Samples ................................................................................................. 64 
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7.1 
Sample Collection ........................................................................................................... 64 
7.1.1 
Blood Samples .............................................................................................................. 64 
7.1.1.1 
Blood Sample for Screening Characteristics Assessment .......................................... 64 
7.1.1.2 
Blood Sample for Dengue, YF, and Zika Serostatus, Dengue Neutralizing 
Antibodies, CD4 Count, and HIV Viral Load Assessments ...................................... 65 
7.1.1.3 
Blood Sample for Dengue Vaccinal Viremia ............................................................. 65 
7.1.2 
Blood Sample for Virological Confirmation of Suspected Hospitalized Dengue 
Disease and Assessment of Disease Severity ............................................................... 65 
7.1.3 
Urine Samples for Pregnancy Test ............................................................................... 66 
7.2 
Sample Preparation ......................................................................................................... 66 
7.2.1 
Blood Sample Preparation ............................................................................................ 66 
7.2.1.1 
Screening Characteristics Assessment ....................................................................... 66 
7.2.1.2 
CD4 Count and and HIV-1 Viral Load ...................................................................... 67 
7.2.1.3 
Dengue, YF, and Zika Serostatus at Baseline; Dengue Neutralizing Abs, 
Vaccinal Viremia, and Wild-Type Dengue Viremia .................................................. 67 
7.2.2 
Urine Samples ............................................................................................................... 67 
7.3 
Sample Storage and Shipment ........................................................................................ 67 
7.4 
Future Use of Stored Biological Samples for Research .................................................. 67 
8 
Clinical Supplies .............................................................................................................. 68 
9 
Endpoints and Assessment Methods ............................................................................. 69 
9.1 
Primary Endpoints and Assessment Methods ................................................................. 69 
9.1.1 
Safety ............................................................................................................................ 69 
9.1.1.1 
Safety Definitions ....................................................................................................... 69 
9.1.1.2 
Safety Endpoints ........................................................................................................ 71 
9.1.1.3 
Safety Assessment Methods ....................................................................................... 72 
9.1.1.3.1 
Immediate Post-vaccination Observation Period ..................................................... 72 
9.1.1.3.2 
Reactogenicity (Solicited Reactions From Day 0 to Day 7/D14 After Each 
Vaccination) ............................................................................................................. 72 
9.1.1.3.3 
Unsolicited Adverse Events ..................................................................................... 76 
9.1.1.3.4 
Adverse Events of Special Interest .......................................................................... 77 
9.1.1.3.5 
Assessment of Causality .......................................................................................... 78 
9.1.1.4 
Methods for Virological Confirmation of Suspected Dengue Disease and 
Assessment of Disease Severity ................................................................................. 78 
9.1.2 
Immunogenicity ............................................................................................................ 79 
9.1.3 
Efficacy ......................................................................................................................... 80 
9.2 
Secondary Endpoints and Assessment Methods ............................................................. 80 
9.2.1 
Safety ............................................................................................................................ 80 
9.2.1.1 
Safety Definitions ....................................................................................................... 80 
9.2.1.2 
Safety Endpoints ........................................................................................................ 80 
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9.2.1.3 
Safety Assessment Methods ....................................................................................... 80 
9.2.2 
Immunogenicity ............................................................................................................ 81 
9.2.2.1 
Immunogenicity Endpoints ........................................................................................ 81 
9.2.2.2 
Immunogenicity Assessment Methods ....................................................................... 81 
9.2.3 
Efficacy ......................................................................................................................... 81 
9.3 
Observational Endpoints and Assessment Methods ....................................................... 82 
9.3.1 
Immunogenicity ............................................................................................................ 82 
9.3.1.1 
Immunogenicity Endpoints ........................................................................................ 82 
9.3.1.2 
Immunogenicity Assessment Methods ....................................................................... 82 
10 
Reporting of Serious Adverse Events ............................................................................ 83 
10.1 
Initial Reporting by the Investigator ............................................................................... 83 
10.2 
Follow-up Reporting by the Investigator ........................................................................ 84 
10.3 
Reporting of SAEs Occurring After a Subject Has Completed the Study ...................... 84 
10.4 
Assessment of Causality ................................................................................................. 84 
10.5 
Reporting SAEs to Health Authorities and IECs / IRBs ................................................. 84 
10.6 
Using a Verbal Autopsy Questionnaire to Aid in Determining the Cause of Death ...... 85 
10.7 
Special Considerations on CD4 Count- and HIV-1 Viral Load Safety Signals ............. 85 
11 
Data Collection and Management ................................................................................. 85 
11.1 
Data Collection and CRB Completion ............................................................................ 85 
11.2 
Data Management ........................................................................................................... 86 
11.3 
Data Review .................................................................................................................... 87 
12 
Statistical Methods and Determination of Sample Size ............................................... 87 
12.1 
Statistical Methods .......................................................................................................... 87 
12.1.1 
Hypotheses and Statistical Methods for Primary Objective ......................................... 88 
12.1.1.1 
Hypotheses ................................................................................................................. 88 
12.1.1.2 
Statistical Methods ..................................................................................................... 88 
12.1.2 
Hypotheses and Statistical Methods for Secondary Objective(s) ................................. 88 
12.1.2.1 
Hypotheses ................................................................................................................. 88 
12.1.2.2 
Statistical Methods ..................................................................................................... 88 
12.2 
Analysis Sets ................................................................................................................... 89 
12.2.1 
Full Analysis Set ........................................................................................................... 89 
12.2.2 
Safety Analysis Set ....................................................................................................... 89 
12.2.3 
Per-Protocol Analysis Set ............................................................................................. 89 
12.2.4 
Other Analysis Set ........................................................................................................ 89 
12.2.5 
Populations Used in Analyses ...................................................................................... 90 
12.2.6 
Populations Used in Analyses ...................................................................................... 90 
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12.3 
Handling of Missing Data and Outliers .......................................................................... 90 
12.3.1 
Safety ............................................................................................................................ 90 
12.3.2 
Immunogenicity ............................................................................................................ 90 
12.3.3 
Efficacy ......................................................................................................................... 90 
12.4 
Interim / Preliminary Analysis ........................................................................................ 90 
12.5 
Determination of Sample Size and Power Calculation ................................................... 90 
13 
Ethical and Legal Issues and Investigator / Sponsor Responsibilities ........................ 90 
13.1 
Ethical Conduct of the Study / Good Clinical Practice ................................................... 90 
13.2 
Source Data and Source Documents ............................................................................... 91 
13.3 
Confidentiality of Data, Data Protection, and Access to Subject Records ..................... 91 
13.4 
Monitoring, Auditing, and Archiving ............................................................................. 92 
13.4.1 
Monitoring .................................................................................................................... 92 
13.4.2 
Audits and Inspections .................................................................................................. 93 
13.4.3 
Archiving ...................................................................................................................... 93 
13.5 
Financial Contract and Insurance Coverage ................................................................... 93 
13.6 
Stipends for Participation ................................................................................................ 93 
13.7 
Publication Policy ........................................................................................................... 93 
14 
Reference List .................................................................................................................. 95 
15 
Signature Page ............................................................................................................... 100 
 
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List of Tables 
Table 1.1: Number of Dengue cases (total and confirmed), incidence rate, and number of deaths 
reported in Brazil during the 2014-2019 period .............................................................................. 32 
Table 5.1: Blood Sampling Volume (mL) per Visit for all Assessments ........................................ 40 
Table 7.1: Blood Sampling Volume (mL) for Suspected Hospitalized Dengue Case .................... 66 
Table 9.1: Solicited injection site reactions: terminology, definitions, and intensity scales ........... 73 
Table 9.2: Solicited systemic reactions: terminology, definitions, and intensity scales ................. 74 
 
 
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(SAEs) (including serious adverse events of special interest [AESIs]), based upon the 
Investigator’s judgment and as per local regulation. 
History of dengue infection/vaccination, YF infection/vaccination, and Zika infection 
will be collected. 
Collection of Safety data 
Immediate adverse events (AEs) observed to occur within 30 minutes post-vaccination 
will be collected. Solicited injection site reactions will be collected for Days 0–7 after 
each injection. Solicited systemic reactions will be collected for Days 0–14 after each 
injection. Unsolicited events will be collected for Days 0-28 after each injection. SAEs 
will be reported throughout the study (ie, from the Screening Visit to the 6 months 
safety follow-up phone call) and serious and non-serious AESIs will be collected in 
defined time windows according to the type of AESI. In addition, hospitalized 
suspected dengue cases occurring at any time in the study will be collected and 
documented. 
IDMC 
An IDMC will be involved in the regular review of hospitalized virologically-
confirmed dengue cases (VCD), including assessment of severity. Related SAEs or 
deaths will be promptly reviewed by the IDMC. 
The IDMC will be involved in review of safety data of the first 20 subjects and will 
provide a recommendation on whether to continue enrollment and administration of the 
second dose of vaccine to the 20 already enrolled subjects, if no increased safety risk is 
concluded. 
Additionally, the IDMC will also be promptly notified of any significant confirmed 
modification of a subject’s HIV infection status, as well as if any of the criteria for 
interruption of the study for safety reason are met (see next section for details). 
Early Safety Data 
Review: 
The safety of the CYD dengue vaccine will be continuously monitored by the Sponsor. 
In the context of this study (ie, HIV-positive adults), a blinded early safety data review 
(ESDR) will be performed, the goal of which is to allow for a cautious, stepwise 
approach to vaccine administration. An initial safety review for this study is planned 
when the first 20 subjects have received the first injection (Inj 1) and have provided 
safety data for Days 0-14 post-first injection. During the ESDR, study recruitment (and 
second injection for first 20 subjects, in case the safety review has not been completed 
at the time of second injection) will be paused.  
The safety data collected will be entered into the electronic case report book (CRB), 
and will be summarized and reviewed by the Sponsor. The safety evaluation team 
(SET) will conduct a blind review of the safety data. It is understood that this review 
will be based on preliminary data that have not been subject to validation and database 
lock. The SET will prepare a recommendation that will be reviewed by the IDMC. The 
IDMC will also review the safety data and then provide recommendation as to whether 
vaccination of the first enrollees and the enrollment of remaining subjects should 
resume or not. The ESDR will be assessing the following safety parameters: 
• 
Immediate (within 30 minutes) AEs 
• 
Solicited injection site and systemic reactions 
• 
Unsolicited AEs reported as related by the Investigator within 14 days after the 
first injection 
• 
SAEs and AESIs (including serious and non-serious AESIs) 
Case unblinding may be performed if required. Some unblinded analyses may be 
provided by an independent Sanofi Pasteur statistician (ie, not involved either in the 
study or in the Dengue project) upon IDMC request. 
The decision regarding the continuation of vaccination of the 20 first enrollees and of 
the remaining 130 subjects will be communicated to the Investigators and will be sent 
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to the Independent Ethics Committees (IECs)/Institutional Review Boards (IRBs) and 
the IDMC for information. 
Interruption of the 
Study for Safety 
Reason: 
The detection/fulfillment of the following safety signals will put the study on a 
temporary hold: 
• 
With regard to investigational products: 
• 
15% of the total subjects included in the study experience a Grade 3 
solicited systemic reaction occurring within 14 days after any study injection 
and persisting for at least 48 hours and judged as related to the vaccination by 
the Investigator and not explained by any other possible etiology. 
and/or 
• 
3 SAEs (including serious AESI) considered as related to the vaccination by the 
Investigator or the Sponsor, except for the SAEs corresponding to the HIV 
condition included below. 
• 
With regard to HIV condition: 
• 
In 20% of the total subjects included in the study: Confirmed plasma HIV-1 
ribonucleic acid (RNA) > 1000 copies/mL 28 days post-injection after having 
been undetectable (< 50 copies/mL) pre-injection, not explained by non-
adherence to ART and not explained by any other possible etiology. 
or 
• 
In 10% of the total subjects included in the study: Confirmed decrease in 
CD4+ T-cell (CD4) count greater than 30% assessed 28 days post-injection 
compared to the pre-injection value, not explained by non-adherence to ART 
and not explained by any other possible etiology. 
It is to be noted that any case of an increase in HIV-1 RNA >1000 copies/mL or 
decrease in CD4 count greater than 30% observed 28 days post-injection, not explained 
by non-adherence to ART and not explained by any other possible etiology, will be 
considered as an SAE. This increase in HIV viral load or decrease in CD4 count will 
be considered as “confirmed” if a second test taken 4 weeks after the first (ie, 
approximately 2 months post-injection) shows the same value/trend. The IDMC will be 
immediately notified if either or both criteria occur in any of the subjects enrolled in 
the study. 
The IDMC will also be immediately notified if the percentage of subjects defined in 
one of the 4 safety signals described above has been reached. The IDMC will then 
assess and recommend in an expedited way whether study enrollment and injections 
can continue, and/or whether other actions should be completed. In this scenario, 
additional biological tests may be required to assess the evolution of the subjects and to 
decide on the study continuation. 
Apart from the temporary hold following the enrollment of the first 20 subjects, and 
apart from a possible temporary hold following the detection of a safety signal, the 
study may be discontinued if new data about the investigational product resulting from 
this or any other studies become available; or for administrative reasons; or on advice 
of the Sponsor, the Investigators, the regulatory authorities in Brazil, and/or the 
IECs/IRBs. 
If the study is prematurely terminated or suspended, the Sponsor will promptly inform 
the Investigators, the IECs/IRBs, and the regulatory authorities of the reason for 
termination or suspension. If the study is prematurely terminated for any reason, the 
Investigator will promptly inform the study subjects and assure appropriate therapy and 
follow-up. 
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Primary Objective: 
Safety 
• 
To describe the safety of each injection of CYD dengue vaccine in HIV-positive 
adults previously exposed to dengue  
Primary Endpoints: 
Safety 
• 
Occurrence of any unsolicited systemic AE reported within 30 minutes after each 
injection 
• 
Occurrence of solicited (ie, pre-listed in the subject's diary card [DC] and in the 
CRB) injection site reactions (pain, erythema, and swelling) occurring up to 7 days 
after each injection 
• 
Occurrence of solicited systemic reactions (fever, headache, malaise, myalgia, and 
asthenia) occurring up to 14 days after each injection 
• 
Occurrence of unsolicited AEs occurring up to 28 days after each injection 
• 
Occurrence of serious and non-serious AESIs in defined time windows according 
to the type of AESI 
• 
Occurrence of SAEs throughout the study (ie, from D0 through the end of the 
study) 
• 
Occurrence of hospitalized VCD cases throughout the study (ie, from D0 through 
the end of the study) 
Other endpoints will be recorded or derived as described in the Statistical Analysis 
Plan. Depending on the item, these could include: nature (Medical Dictionary for 
Regulatory Activities [MedDRA] preferred term), time of onset, duration, number of 
days of occurrence, intensity, relationship to vaccine, action taken, whether the 
event/reaction led to early termination from the study, seriousness, or outcome. 
Hospitalized suspected dengue disease is defined as an acute febrile illness with 
diagnosis of dengue requiring hospitalization (inpatient care). In such cases, 
1 unplanned acute blood sample (within the first 5 days after fever onset) will be 
collected for virological confirmation of dengue disease. A suspected case will be 
considered VCD if there is a detection of wild-type (WT) dengue virus by dengue non-
structural protein (NS) 1 antigen (Ag) enzyme-linked immunosorbent assay (ELISA) 
and/or dengue reverse transcriptase-polymerase chain reactions (RT-PCRs) (at the 
Global Clinical Immunology [GCI] or GCI designated laboratory). 
Note: Acute blood sample for all suspected hospitalized dengue cases should be 
collected within the pre-specified timeframe as described above. If this cannot be 
accomplished, this sample should still be obtained as soon as possible thereafter, for 
IDMC severity assessment 
Secondary Objectives: 
Immunogenicity: 
• 
To describe the humoral immune response to each dengue serotype at baseline and 
after each injection of CYD dengue vaccine in HIV-positive adults previously 
exposed to dengue 
 
Safety: 
• 
To detect the CYD dengue vaccinal viremia post-injection 1 (post-Inj 1) in HIV-
positive adults previously exposed to dengue 
• 
To describe changes in CD4 count and HIV RNA viral load after each injection of 
CYD dengue vaccine in HIV-positive adults previously exposed to dengue 
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Secondary Endpoints: 
Immunogenicity 
• 
Neutralizing antibody (Ab) levels (measured by dengue plaque reduction 
neutralization test [PRNT]) against each of the 4 parental dengue virus strains of 
CYD dengue vaccine construct at baseline and 28 days after each injection 
Safety 
• 
CYD dengue vaccinal viremia at 7 and 14 days post-Injection 1 
• 
CD4 count and HIV RNA viral load 28 days after each injection of CYD dengue 
vaccine 
Observational 
Objective: 
Immunogenicity 
• 
To describe the flavivirus (dengue, YF, and Zika) serological status in the study 
population at baseline 
Observational 
Endpoints: 
Immunogenicity 
• 
Anti-NS1 IgG at baseline 
• 
Neutralizing Ab levels against YF at baseline 
• 
Neutralizing Ab levels against Zika at baseline 
Planned Sample Size: 
A total of 150 subjects are planned to be enrolled, in a 2:1 randomization ratio: 
• 
Group 1 – CYD Dengue Vaccine Group: 100 subjects 
• 
Group 2 – Placebo Group: 50 subjects 
Schedule of Study 
Procedures: 
Visits/phone calls 
During this study there will be 8 visits (V) and 5 phone contacts. 
 
Vaccinations: 
3 injections at D0, M6, and M12 with either the CYD dengue vaccine or a Placebo 
 
Blood sampling 
All subjects will provide blood samples: 
• 
for screening tests (13 mL) (if results not already available from routine periodical 
tests; see Screening Criteria below) within 4 weeks before the first vaccination  
• 
for assessment of previous dengue exposure (1 mL) at screening 
• 
for dengue, YF, and Zika serostatus (5 mL) before the first injection at D0 
• 
for vaccine immunogenicity assessments by PRNT (dengue neutralizing Abs) 
(4 mL) at baseline (prior to Inj 1) and 28 days after each injection at, respectively, 
Inj 1+28D, Inj 2+28D, and Inj 3+28D 
• 
for CD4 count (2x5mL) and HIV viral load (2x5 mL) prior to each injection in 
subjects for whom the tests have not been performed within 2 months before 
vaccination visit 
• 
for CD4 count (2x5 mL) and HIV viral load (2x5 mL) 28 days after each injection 
at, respectively, Inj 1+28D, Inj 2+28D, and Inj 3+28D 
• 
for dengue vaccinal viremia (4 mL) 7 and 14 days post-Inj 1 in all subjects 
• 
Unplanned blood samples (approximately 3 mL) will be collected in case of acute 
febrile illness with diagnosis of dengue requiring hospitalization (inpatient care) 
within the first 5 days after fever onset, for virological confirmation of dengue 
disease by NS1 antigen test (ELISA), and/or WT dengue RT-PCRs  
 
Urine sampling 
All female subjects will provide urine samples for urine pregnancy test before each 
injection 
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Safety data: 
Staff will record information about immediate (within 30 minutes) AEs after each 
injection. 
Subjects will record in a DC information about solicited injection site reactions 
occurring up to 7 days after each injection, solicited systemic reactions occurring up to 
14 days after each injection, and unsolicited AEs occurring up to 28 days after each 
injection. Information on SAEs will be reported throughout the study and serious and 
non-serious AESIs will be collected in defined time windows according to the type of 
AESI. 
DCs will also be provided to the subjects to collect information on SAEs in-between 
injections (from 28 days post-injection until the next injection). Finally, a memory aid 
(MA) will be provided to collect information on SAEs during the safety follow-up 
(from 28 days after the last injection until 6 months after the last injection). 
Staff will review the safety data with the subjects during post-vaccination visits. 
Duration of 
Participation in the 
Study: 
The expected duration of each subject’s participation in the study is approximately 
18 months, including a safety follow-up period of 6 months post last vaccination. 
Subjects who are dengue-positive by rapid diagnostic test (RDT) or dengue IgG ELISA 
at Screening Visit and negative by PRNT (sample collected before the first injection [at 
Visit 1] and assayed before second injection) will be considered as not previously 
exposed. Therefore, they will not receive any further injections and will be followed 
for safety until 6 months after the last dose. In addition, if they received the vaccine, 
provisions for timely access to medical care will be offered for 10 years after the last 
dose, according to IDMC prior recommendations. 
Investigational Products 
 
Study Product: 
CYD Dengue Vaccine 
 Form: 
Powder and solvent for suspension for injection 
 Composition: 
Each individual 0.5 mL dose of reconstituted tetravalent vaccine contains: 
• 
4.5-6.0 log10 cell-culture infectious dose 50% (CCID50) of each live, attenuated, 
dengue serotype 1, 2, 3, 4 virus 
• 
Excipients: essential amino acids, non-essential amino acids, L-arginine 
chlorhydrate, saccharose, D-trehalose dihydrate, D-sorbitol, Tris (hydroxymethyl) 
aminomethane, and urea 
• 
Solvent: NaCl 0.4% 
 Route: 
Subcutaneous (SC) 
 Batch Number: 
To be determined 
Control Product: 
Placebo 
 Form: 
Solution 
 Composition: 
NaCl 0.9% 
 Route: 
SC 
 Batch Number: 
To be determined 
Screening Criteria: 
The Screening Visit will take place within 4 weeks before the first injection. After a 
potential participant has signed an IEC/IRB-approved informed consent form (ICF), 
she/he will have a blood sample drawn in order to be screened for hepatitis B virus 
antigen (HBsAg)*, hepatitis C virus (HCV) antibodies*, assessment of previous 
dengue exposure, and for any hematological (hemoglobin, hematocrit, platelet count, 
white blood cells count) or biochemical (aspartate aminotransferase, alanine 
aminotransferase, urea, and creatinine) abnormalities. If serology, hematology, and 
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biochemistry results are available and were obtained within 4 weeks before first 
injection, tests do not need to be performed again. 
Pre-injection HIV viral load and CD4 count will come from routine periodical tests of 
subjects as per local guidelines. For subjects for whom HIV viral load and CD4 count 
have not been assessed within 2 months before the Screening Visit, the Investigator 
will perform tests to ensure that results are available at the time of Visit 1. 
Subjects’ previous exposure to dengue will be identified using a RDT (OnSite™ 
Dengue IgG/IgM3.0 Combo Rapid Test commercialized by CTK Biotech, Inc.) or an 
ELISA (Anti-Dengue IgG ELISA commercialized by Euroimmun) if the RDT result is 
negative. Only subjects identified as dengue seropositive will be eligible to participate 
in the study.  
Note: Subjects who previously tested negative by RDT can be re-screened using IgG 
ELISA. 
During the Screening Visit, applicable inclusion and exclusion criteria will be checked 
and a physical / clinical examination will be performed. 
* Unless documented information on previous infections is already available at the 
time of screening. 
Inclusion Criteria: 
Consent will be provided once at the Screening Visit. Inclusion criteria will be checked 
at Screening Visit and at the first vaccination Visit (V01 at D0). 
An individual must fulfill all of the following criteria in order to be eligible for study 
enrollment: 
1) Aged 18 to 50 years on the day of first study vaccination (study product 
administration) (“18 to 50” means from the day of the 18th birthday to the day 
before the 51th birthday) 
2) ICF has been signed and dated 
3) Able to attend all scheduled visits and to comply with all study procedures 
4) Documented seropositivity for HIV-1 infection based on the Brazilian HIV 
Guidelines’ laboratory criteria (ie, 2 positive results obtained from different and 
independent determination methods) or detectable HIV-1 viral load results in the 
past 
5) Stable HIV condition according to Brazilian HIV Guidelines (ie, with both CD4 
count > 350 cells/mm3 and sustainable and undetectable HIV viral load 
[< 50 copies/mL]) for at least 1 year before consent 
6) Stable antiretroviral (ART) regimen based on local HIV protocol for at least 1 
year before consent 
7) Previous exposure to dengue confirmed by RDT or dengue IgG ELISA 
Exclusion Criteria: 
Exclusion criteria will be checked at Screening Visit and at the first vaccination Visit 
(V01 at D0). 
An individual fulfilling any of the following criteria is to be excluded from study 
enrollment: 
1) Subject is pregnant, or lactating, or of childbearing potential (to be considered of 
non-childbearing potential, a female must be pre-menarche or post-menopausal 
for at least 1 year, surgically sterile, or using an effective method of contraception 
or abstinence from at least 4 weeks prior to the first vaccination until at least 4 
weeks after the last vaccination) 
2) Participation at the time of study enrollment (or in the 4 weeks preceding the first 
study vaccination) or planned participation during the present trial period in 
another clinical study investigating a vaccine, drug, medical device, or medical 
procedure 
3) Receipt of any vaccine in the 4 weeks preceding the first study vaccination or 
planned receipt of any vaccine in the 4 weeks following any study vaccination 
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4) Previous vaccination against dengue disease with either the study vaccine or 
another vaccine 
5) Receipt of immune globulins, blood or blood-derived products in the past 
3 months 
6) Self-reported or suspected congenital or acquired immunodeficiency, except 
HIV; or receipt of immunosuppressive therapy such as anti-cancer chemotherapy 
or radiation therapy within the preceding 6 months; or long-term systemic 
corticosteroid therapy (prednisone or equivalent for more than 2 consecutive 
weeks within the past 3 months) 
7) Previous acquired immunodeficiency syndrome (AIDS), defined as the 
occurrence of opportunistic infection in the last 2 years before consent 
8) Known systemic hypersensitivity to any of the vaccine components, or history of 
a life-threatening reaction to the vaccines used in the study or to a vaccine 
containing any of the same substances 
9) Deprived of freedom by an administrative or court order, or in an emergency 
setting, or hospitalized involuntarily 
10) Current alcohol abuse or drug addiction 
11) Chronic illness that, in the opinion of the Investigator, is at a stage where it might 
interfere with study conduct or completion 
12) Moderate or severe acute illness/infection (according to Investigator judgment) or 
febrile illness (temperature ≥ 38.0°C) on the day of vaccination. A prospective 
subject should not be included in the study until the condition has resolved or the 
febrile event has subsided 
13) Identified as an Investigator or employee of the Investigator or study center with 
direct involvement in the proposed study, or identified as an immediate family 
member (ie, parent, spouse, natural or adopted child) of the Investigator or 
employee with direct involvement in the proposed study 
14) Previous CD4 count < 200 cells/mm3 (nadir) since diagnosis of HIV 
15) History of chronic and active hepatitis B infection or HBsAg-positive 
16) History of chronic and active hepatitis C infection or HCV Ab-positive 
17) Aspartate aminotransferase (AST), alanine aminotransferase (ALT), urea, and 
creatinine > 3 times the upper limit of normal range (ULN) 
18) Hemoglobin (Hb) < 10 g/dL 
19) White blood cell count (WBC) < 1500 cells/mm3 
20) Platelets < 100 000 cells/mm3 
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Statistical Methods: 
All main analyses will be descriptive. For the main parameters, 95% confidence 
intervals (CIs) of point estimate will be calculated using normal approximation for 
quantitative data and exact binomial distribution (Clopper-Pearson method) for 
proportions. 
Two statistical analyses will be performed on unblinded data 28 days after the last 
injection (for safety and immunogenicity), and 6 months after the last injection of the 
last subject enrolled (for safety). 
Sample Size 
The objective of the study is to provide descriptive safety and immunogenicity results 
and therefore the sample size is arbitrarily set to 100 subjects for the CYD dengue 
vaccine Group and 50 subjects for the Placebo Group. There is a 95% probability of 
observing an event that has a true incidence of 3% for the CYD dengue vaccine Group. 
 
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Table of Study Procedures 
Phase II Trial: a Screening Visit (Scr.), 8 Visits (V), and 5 Phone Calls (PC); 3 Injections; 7 to 9 Blood Samples; 18-month duration per subject 
Visit (V) and Phone Call (PC) Number 
Scr. *  
V01* 
V02 
V03 
V04 
V05 
PC1 
PC2 
V06 
V07 
PC3 
PC4 
V08 
6-month 
Follow-up† 
Trial Timelines 
Injection (Inj); Day (D); Month (M) 
-D28 to –
D0 
Inj 1 (D0) 
Inj 1 
+7D 
Inj 1 
+14D 
Inj 1 
+28D 
Inj 2 
(M6) 
Inj 2 
+7D 
Inj 2 
+14D 
Inj 2 
+28D 
Inj 3 
(M12) 
Inj 3 
+7D 
Inj 3 
+14D 
Inj 3 
+28D 
Last Inj 
+6 months 
Time Windows (Days) 
 
 
+3 
+3 
+14 
±20 
+3 
+3 
+14 
±20 
+3 
+3 
+14 
+30 
Phone calls 
 
 
 
 
 
 
X† 
X† 
 
 
X† 
X† 
 
X† 
Informed Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion/Exclusion Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Demography/Body Stature 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Significant Medical History 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
History of dengue infection/vaccination, 
YF infection/vaccination, or Zika infection 
X 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Physical/Clinical Examinations ‡ 
X 
X 
 
 
 
X 
† 
† 
 
X 
† 
† 
 
† 
Temperature § 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
 
IRT Contact 
X 
X 
 
 
 
X 
 
 
 
X 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Concomitant Therapy ** 
 
X 
X 
X 
X 
X 
 
 
X 
X 
 
 
X 
 
Urine Pregnancy Test †† 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
 
Contraindications 
 
 
 
 
 
X 
 
 
 
X 
 
 
 
 
Blood Sampling 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Screening tests ‡‡ 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Previous exposure to dengue using RDT 
or dengue IgG ELISA §§ 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
FV status (dengue, YF, and Zika) *** 
 
BL1 
 
 
 
 
 
 
 
 
 
 
 
 
Dengue neutralizing Abs*** 
 
BL1 
 
 
BL4 
 
 
 
BL5 
 
 
 
BL6 
 
Dengue vaccinal viremia 
 
 
BL2 
BL3 
 
 
 
 
 
 
 
 
 
 
CD4 count and HIV Viral Load ††† 
 
††† 
 
 
BL4‡‡‡ 
††† 
 
 
BL5‡‡‡ 
††† 
 
 
BL6‡‡‡ 
 
Virological confirmation of dengue by NS1 
Ag ELISA and/or WT dengue RT-PCR 
 
All acute febrile illness with diagnosis of dengue requiring hospitalization within the first 5 days after fever onset,  
occurring after the first visit (V01) and until the end of the 6-month safety follow-up 
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Visit (V) and Phone Call (PC) Number 
Scr. *  
V01* 
V02 
V03 
V04 
V05 
PC1 
PC2 
V06 
V07 
PC3 
PC4 
V08 
6-month 
Follow-up† 
Trial Timelines 
Injection (Inj); Day (D); Month (M) 
-D28 to –
D0 
Inj 1 (D0) 
Inj 1 
+7D 
Inj 1 
+14D 
Inj 1 
+28D 
Inj 2 
(M6) 
Inj 2 
+7D 
Inj 2 
+14D 
Inj 2 
+28D 
Inj 3 
(M12) 
Inj 3 
+7D 
Inj 3 
+14D 
Inj 3 
+28D 
Last Inj 
+6 months 
Time Windows (Days) 
 
 
+3 
+3 
+14 
±20 
+3 
+3 
+14 
±20 
+3 
+3 
+14 
+30 
Injection 
 
Inj. 1 
 
 
 
Inj 2 
 
 
 
Inj 3 
 
 
 
 
30-Min. Observation Period – Collection of 
immediate events 
 
X 
 
 
 
X 
 
 
 
X 
 
 
 
 
Injection Site Reactions & Systemic Events 
Assessment 
 
Solicited injection site reactions will be collected for Days 0–7 after each injection. Solicited systemic reactions will be collected for Days 0–14 
after each injection. Unsolicited events will be collected for Days 0-28 after each injection.  
 
Diary Card (DC) §§§ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Provided 
 
DC1 
 
 
DC2 
DC3 
 
 
DC4 
DC5 
 
 
 
 
Checked 
 
 
DC1 
DC1 
DC1 
DC2 
 
 
DC3 
DC4 
 
 
DC5 
 
Collected 
 
 
 
 
DC1 
DC2 
 
 
DC3 
DC4 
 
 
DC5 
 
Memory Aid (MA)§§§ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Provided 
 
 
 
 
 
 
 
 
 
 
 
 
MA 
 
Termination Record**** 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 
SAEs and Serious AESIs †††† 
‡‡‡‡ 
SAEs from the first visit (V01) and until the end of the 6-month safety follow-up; AESIs in defined time windows according to the type of AESI  
*  
Serology, hematology and biochemistry results, as well as all other information collected as part of the screening of potential subjects will be captured in the source document. Inclusion/exclusion 
criteria, significant medical history, history of dengue infection/vaccination, of YF infection/vaccination, and of Zika infection, physical/clinical examinations, CD4 count and HIV viral load results 
will be captured in the CRF at V01 for eligible subjects. The Screening Visit and Visit 1 can be simultaneous for subjects tested positive by RDT and whose tests have been performed in 
appropriate time windows (within 4 weeks before injection for hepatitis serology, hematology, and biochemistry; within 2 months for CD4 count and HIV viral load) as part of the subject’s routine 
follow-up. 
†  
A follow-up visit can be arranged depending on the information provided during the phone call, at the Investigator’s discretion. In the case of the 6-month follow-up phone call, this can be 
anticipated to perform the 6 months follow up after the last vaccination in case of early termination. 
‡  
A full physical/clinical examination will be conducted on each vaccination visit (before vaccine injection), and at the Investigator’s discretion at the time of other visits, based on the health status of 
the subject. 
§  
Subject’s temperature is to be measured before each injection, and at the Investigator’s discretion at the time of other visits, based on the health status of the subject. Temperatures will be recorded 
in source document only. 
**  
Concomitant therapy will be collected for Days 7, 14 and 28 days post-Injection 1 as well as before and 28 days after Injection 2 and Injection 3. 
††  
In all female subjects, result of urine pregnancy test should be confirmed as negative before each vaccine injection. 
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‡‡  
Screening tests will be performed at local laboratory within 4 weeks before the first vaccination. These tests will include: serology (HBsAg, HCV Ab), hematology (hemoglobin, hematocrit, platelet 
count, white blood cells count), and biochemistry (AST, ALT, urea and creatinine). HBsAg and HCV tests will not be performed in case the information is already available in subject's medical 
history. If serology, hematology, and biochemistry results are available and were obtained within 4 weeks before first injection, tests do not need to be performed again. 
§§  
Tests will be performed sequentially. RDT will be performed first, and IgG ELISA will only be performed on subjects who tested negative for RDT. Subjects who previously tested negative by 
RDT can be re-screened using dengue IgG ELISA. 
*** Blood sample to be collected before vaccine injection. 
†††  Pre-injection CD4 count and HIV viral load will come from routine periodical tests of subjects as per local guidelines. For subjects for whom HIV viral load and CD4 count have not been assessed 
within 2 months before the Screening Visit, the Investigator will perform tests to ensure that results are available at the time of Visit 1. Likewise, if HIV viral load and CD4 count have not been 
tested within 2 months before Inj 2 or Inj 3 (for checking contraindication) the Investigator will perform tests to ensure that results are available before the corresponding vaccination visit. 
‡‡‡  If an increase in HIV viral load (plasma HIV-1 RNA increase > 1000 copies/mL 28 days post-injection after having been undetectable [< 50 copies/mL] pre-injection) or a decrease in CD4 count 
(decrease in CD4 count greater than 30% assessed 28 days post-injection compared to pre-injection value), another blood sample is to be taken 4 weeks later for confirmation. 
§§§  DCs are used for the collection of solicited and unsolicited AEs and concomitant medication. DC2 and DC4 are used for the collection of medical events and/or hospitalization and medications at 
the time of the event in the period between V04 and V05 and V06 and V07, respectively. Each DC is to be reviewed and collected by the site at the following visit. The MA is used for the 
collection of medical events and/or hospitalization and medications at the time of the event for 6 months after the third injection. The caller will ascertain whether any SAEs occurred since the last 
contact. During the follow-up period, subjects will be instructed to contact the clinical site if they are hospitalized or experience an AE that might be considered serious. 
****  Termination record will be checked either during a planned study visit or a phone call. 
††††  Serious AESIs will be reported after each injection in defined time windows as follows: serious hypersensitivity/allergic reactions occurring within 7 days, serious viscerotropic disease occurring 
within 30 days, serious neurotropic disease occurring within 30 days; hospitalized suspected dengue disease will be reported during the entire study. Non-serious AESIs (ie, hypersensitivity / 
allergic reactions) will be reported within 7 days after each injection. 
‡‡‡‡  SAEs related to study procedures (from Screening Visit to V01) will be reported on paper form; at V01, all SAE information for eligible subjects reported on paper SAE form should be transcribed 
into the EDC system. From V01 until the end of the safety follow-up, all SAEs and AESIs in defined time windows according to the type of AESI will be documented in the EDC. 
 
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List of Abbreviations 
Ab 
antibody 
Ag 
antigen 
AE 
adverse event 
AESI 
adverse event of special interest 
AIDS 
acquired immune deficiency syndrome 
AR 
adverse reaction 
ART 
antiretroviral therapy 
CCID50 
cell-culture infectious dose 50% 
CD4 
CD4+ T-cell 
CDM 
Clinical Data Management 
CI 
confidence interval 
C&MQO 
Clinical and Medical Quality Operations 
CRA 
Clinical Research Associate 
CRB 
case report book 
CRF 
case report form 
CTA 
clinical trial agreement 
CTL  
Clinical Team Leader  
DC 
diary card 
DENV 
dengue virus 
DF 
dengue fever 
DHF 
dengue hemorrhagic fever 
EDC 
electronic data capture 
ELISA 
enzyme-linked immunosorbent assay  
ESDR 
early safety data review 
FAS 
full analysis set 
FDA 
Food and Drug Administration 
FV 
flavivirus 
FVFS 
first visit, first subject 
FVLS 
first visit, last subject 
GCI 
Global Clinical Immunology 
GCP 
Good Clinical Practice 
GMT 
geometric mean titer 
GPV 
Global PharmacoVigilance  
HBsAg 
Hepatitis B surface antigen 
HCV 
Hepatitis C virus 
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HIV 
Human Immunodeficiency Virus  
IATA 
International Air Transport Association 
ICF 
informed consent form 
ICH 
International Conference on Harmonisation 
IDMC 
independent data monitoring committee 
IEC 
Independent Ethics Committee 
Ig 
immune-globuline 
IND 
investigational new drug (application) 
IRB 
Institutional Review Board 
IRT 
interactive response technology 
IVRS 
interactive voice response system 
IWRS 
interactive web response system 
JE 
Japanese encephalitis 
LCLS 
last contact, last subject 
LLT 
lowest level term 
LLOQ 
lower limit of quantification 
MA 
memory aid 
MedDRA 
Medical Dictionary for Regulatory Activities 
mL 
milliliter 
N/A 
not applicable 
NR 
not reportable 
NS 
non-structural 
post-Inj 
post-Injection 
PPAS 
per-protocol analysis set 
PRNT 
plaque reduction neutralization test  
PSO 
Product Safety Officer 
RTM 
Regional Trial Manager 
RDCS 
Regional Director of Clinical Sciences 
RDT 
rapid diagnostic test 
RMO 
Responsible Medical Officer 
RNA 
ribonucleic acid 
RT-PCR 
reverse transcription-polymerase chain reaction 
SAE 
serious adverse event 
SafAS 
safety analysis set 
SC 
subcutaneous 
SET 
safety evaluation team 
TMF 
trial master file 
UAR 
unexpected adverse reaction 
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ULOQ 
upper limit of quantification 
VCD 
virollogically-confirmed dengue case  
WHO 
World Health Organization 
WT 
wild-type 
YF 
yellow fever 
 
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1 
Introduction 
1.1 
Background 
This is a Phase II study assessing the safety and immunogenicity of the CYD dengue vaccine 
when administered in Human Immunodeficiency Virus (HIV)-positive adults, previously exposed 
to dengue, with clinically-stable condition under regular antiretroviral therapy (ART). 
Dengue 
Dengue disease is caused by 4 closely related, but antigenically distinct, dengue virus serotypes 
(1, 2, 3, and 4) of the genus flavivirus (FV). Infection with a dengue virus is usually asymptomatic 
but can produce a spectrum of clinical illnesses ranging from a non-specific viral syndrome to 
severe, fatal hemorrhagic disease (1-4). Dengue fever (DF) is characterized by biphasic fever, 
headache, and myalgia in various parts of the body, prostration, rash, and lymphadenopathy. 
Recovery from DF is usually complete in 7 to 10 days, but prolonged asthenia is common. 
Decreases in leukocytes and platelets count are frequent. The incubation period of DF after the 
mosquito bite averages 4 days (range from 3 to 14 days) (2). 
Dengue hemorrhagic fever (DHF) is characterized by abnormalities of homeostasis and increased 
vascular permeability that can lead to hypovolemia and hypotension (dengue shock syndrome), 
often complicated by severe internal bleeding. The case fatality rate of severe dengue can be as 
high as 20% without medical care, but is below 1% in most centers with modern intensive 
supportive therapy (2). 
Human infection occurs by injection of the virus into the extravascular tissues during blood 
feeding by an infected Aedes aegypti mosquito or Aedes albopictus mosquito (1). Both these 
vectors are now present in all tropical and sub-tropical areas of the world and in some temperate 
areas of the USA, Europe, Africa, and the Middle East. Following its rapid spread in recent years, 
DF/DHF is now endemic/epidemic in Latin America, South East Asia, India, Africa, and the 
Caribbean, and Pacific regions. 
According to the World Health Organization (WHO), over 2.5 billion people are now at risk from 
dengue in more than 100 countries in Africa, the Americas, the Eastern Mediterranean, South East 
Asia, and the Western Pacific. The Americas, South East Asia, and the Western Pacific regions 
are the most seriously affected. It is currently estimated that there may be 390 million dengue 
infections worldwide every year. An estimated 500 000 people with severe dengue require 
hospitalization, a large proportion of whom are children. About 2.5% of those affected die (2). 
Thus, according to WHO, there is an urgent need to develop a safe and effective method to 
prevent progression of this substantial public health issue (2) (3). 
Routine laboratory diagnosis of dengue infection is based on the detection of dengue virus-
specific antibodies (Abs), immunoglobulin (Ig) M and/or isolation of the virus or detection of 
viral ribonucleic acid (RNA) by reverse transcription-polymerase chain reaction (RT-PCR) or 
viral non-structural protein (NS) 1 antigen by enzyme-linked immunosorbent assay (ELISA) (4-
6). The diagnosis of dengue falls into 2 stages: Stage I, the acute fever period lasting a few days 
when viremia may be detected; and Stage II, the early post-febrile period lasting a few weeks 
when IgM and IgG Abs are increased. 
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Until recently, vector control, and personal protection were the only measures to prevent dengue 
infection and disease. Although some prevention and vector control campaigns are well-
documented successes, most of these successes have proved to be temporary as public health 
authorities were unable to sustain underlying control strategies in the face of social and/or 
environmental changes (7). It is now increasingly acknowledged that eliminating dengue as a 
public health burden will involve a safe and effective vaccine directed at the 4 serotypes of 
dengue virus responsible for the disease, in addition to preventive measures (7).  
Human Immunodeficiency Virus 
The HIV belongs to the family of retrovirus. It can be transmitted from human to human mostly 
through sexual intercourses, needle sharing among injecting drug users, and from mother to child 
during pregnancy (8). 
During infection, virus particles bind to host cells expressing principally CD4 receptors but also a 
range of host proteins (9). The hallmark of HIV infection is the progressive depletion of CD4+ T 
cells (CD4) leading, after a highly variable period of time, to the acquired immune deficiency 
syndrome (AIDS). At this stage, the HIV infection becomes symptomatic and the infected person 
experiences opportunistic infections, eventually leading to death. 
The development of ARTs regimen during the past 2 decades has transformed HIV infection from 
a progressive illness with a fatal outcome into a chronic manageable disease. In parallel, and 
following extensive national prevention campaigns, remarkable progresses have been made in 
terms of prevention-associated risk reduction. As for the development of an efficacious HIV 
vaccine, it is still facing important challenges, including the virus’s genetic diversity, uncertainty 
about what constitutes protective immunity, and difficulty in the development of antigens that are 
highly immunogenic (8). 
Despite advances on complementary fronts, HIV infection remains endemic worldwide, with 
higher incidence in low-income and middle-income countries, as a consequence of a limited 
access to health care (Asia, Sub-Saharan Africa, and Latin America). Globally, the number of new 
infections has decreased between 2000 and 2018. However, global prevalence of HIV has 
increased from 27.4 (23.1–32.6) million to 37.9 (32.7–44.0) million during the same period as 
ART has increased life expectancy of infected persons (10). In 2017, an estimated (10): 
• 37.9 million (32.7 million–44.0 million) people globally were living with HIV 
• 1.7 million (1.4 million–2.3 million) people became newly infected with HIV 
• 770 000 (570 000–1.1 million) people died from AIDS-related illnesses 
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Dengue and HIV co-infection 
Interactions between HIV and other infectious agents, particularly in tropical regions, has been 
associated with accelerated HIV/AIDS disease progression (11). However, the severity and 
characteristics of dengue and HIV co-infection and the reciprocal impact on disease progression 
remain elusive because of lack of systematic case–control analysis (12-14). An increased risk of 
severe dengue has not been described in HIV-positive subjects, but there are very limited data 
(11) (14-17). Thus far, case series have suggested that patients with dengue virus (DENV)-HIV 
co-infection have non-severe dengue outcome (18) and show no signs of accelerated progression 
of HIV disease (12-14). This may be due to the transient reduction of HIV viral load and no 
depletion of CD4+ T cells during acute dengue infection, plus the likely beneficial effect of the 
ART on the dengue infection course (13) (14) (17). Furthermore, it has also been observed that 
the DEN-2 NS5 protein inhibits HIV replication in CD4+ T cells in vitro (19). However, further 
research is still needed to understand DENV-HIV co-infection, especially since the number of 
cases is bound to increase in the coming years as life expectancy of HIV-positive persons 
increases. 
1.2 
Background of the Investigational Product 
The CYD dengue vaccine 
Sanofi Pasteur’s tetravalent CYD dengue vaccine, using recombinant technology to obtain a live-
attenuated vaccine, has been extensively evaluated in subjects from 9 months to 60 years. 
As of October 2018, the CYD dengue vaccine clinical development plan includes 31 clinical 
studies, completed (25) or ongoing (6): 5 Phase I, 17 Phase II, and 9 Phase III. As of today, more 
than 30 000 subjects from 9 months through 60 years of age have received at least one injection of 
the final tetravalent CYD dengue vaccine formulation, regardless of the administration schedule. 
Two large-scale Phase III efficacy studies were initiated during the clinical development of the 
CYD dengue vaccine: CYD14 and CYD15 (Phase III studies in multiple countries in Asia and 
Latin America, respectively). These efficacy studies were randomized, placebo-controlled, 
observer-blinded, and stratified by age. Each individual study was sufficiently powered to 
demonstrate significant efficacy of the CYD dengue vaccine in preventing the occurrence of 
virologically-confirmed dengue case (VCD) due to any serotype after 3 injections, given 6-month 
apart. Indeed, results from Phase III efficacy studies showed CYD dengue vaccine’s potential to 
reduce probability for subjects to have symptomatic VCD and severe and/or hospitalized VCD 
due to any of the 4 serotypes. 
Following per-protocol analysis, vaccine efficacy (VE) estimates against symptomatic VCD 
during the whole Active Phasea due to any of the 4 serotypes were 56.5% (95% confidence 
intervals (CI): 43.8; 66.4) for CYD14 and 60.8% (95% CI: 52.0; 68.0) for CYD15. In addition, 
efficacy against severe VCD cases and hospitalized VCD cases during the Active Phase was 
observed to be more than 70% (20) (21). VEs against dengue in participants who were 9 years of 
age or older were similar in the individual studies, with a pooled estimate of 65.6% (95% CI, 60.7 
                                                 
a  From the first injection until 13 months after the third injection. 
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to 69.9), as compared with 44.6% (95% CI, 31.6 to 55.0) among participants under the age of 9 
years (22). The reactivation of the active surveillance during the long-term follow-up in CYD14 
and CYD15 allowed to estimate a pooled VE against symptomatic VCD of 38.7% (95% CI: 11.1; 
57.8) 5 years after the first injection. 
Overall, the CYD dengue vaccine was demonstrated to be immunogenic. Also, vaccinal viremia 
was observed in less than 6% of subjects (across all age groups) after the first dose, and in less 
than 1% of subjects after the subsequent doses, in the studies in which it was assessed (pooled 
data from CYD04, CYD05, CYD06, CYD10, CYD11, CYD12, CYD17, CYD23, and CYD24). 
Specifically in adults, the viremia was observed in 4.5% of subjects (pooled data from CYD04, 
CYD06, CYD10, CYD11, CYD12, and CYD17). No clinical relevance of the vaccinal viremia 
has been reported. 
The first marketing authorization for the CYD Dengue vaccine (under the commercial name 
Dengvaxia®) was obtained in Mexico on 08 December 2015. As of November 2019 the CYD 
dengue vaccine is currently licensed in 21 countries in addition to the European Economic Area. 
Dengue serostatus before injection with the CYD dengue vaccine 
In July 2016, the WHO issued a position paper on Sanofi Pasteur’s CYD dengue vaccine based on 
the Strategic Advisory Group of Experts’ (SAGE) assessment that recognized its potential public 
health value when introduced in highly endemic countries. In addition, the SAGE also underlined 
the importance of addressing the question of the potential risk, over time, of hospitalized/severe 
dengue in individuals with no prior exposure to dengue before vaccination (23). 
Analyzing long-term safety according to dengue serostatus at baseline presented an important 
challenge as serostatus had only been assessed in a subset of subjects (the so-called 
immunogenicity subset) in each of the 3 efficacy studies (CYD14, CYD15 and CYD23/57). In 
order to overcome this challenge Sanofi Pasteur leveraged a recently developed dengue anti-NS1 
IgG ELISA assay to be able to infer the baseline dengue serostatus using specimens obtained 
approximately 1 month after the third vaccination collected from all study participants. In addition 
an efficient case-cohort design (including all subjects with outcomes of interest and a randomly 
selected “subcohort”), was used to obtain estimates of risk and efficacy with essentially the same 
power as the one it would have been obtained by including the entire study cohorts. This 
supplemental exploratory analysis was conducted on clinical data collected during the Phase IIb 
proof of concept efficacy study and the two Phase III efficacy studies. 
The results of thus supplemental analysis confirmed the clear and sustained benefit of the CYD 
dengue vaccine in individuals 9-16 years of age living in endemic areas and previously infected 
by dengue prior to dengue vaccination. The results also showed an increased risk of 
hospitalization for dengue and clinically severe dengue (predominantly DHF Grade I or II [WHO 
1997 (24)]) in seronegative individuals. Estimates from the long-term analysis suggest the onset 
of increased risk was mainly during the 3rd year following the first injection. 
Sanofi Pasteur presented the full data of this supplemental analysis to the Independent Data 
Monitoring Committee (IDMC) in an ad hoc meeting held on 3-4 November 2017. During this 
meeting, the IDMC reviewed the data from these extended safety and efficacy analyses. It 
concluded that, in the case of subjects exposed to dengue prior to vaccination (henceforth, 
‘exposed subjects’ or seropositive subjects), there is strong evidence that the vaccine protects 
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them from symptomatic dengue, hospitalized dengue and severe dengue. On the other hand, in the 
case of subjects not exposed to dengue before vaccination (henceforth, ‘unexposed’ subjects or 
seronegative subjects), the conclusion was that although vaccination may confer limited short-
term benefit against symptomatic dengue, it also induces an increased risk of severe disease in the 
longer term.  
Given these conclusions, the IDMC recommended that no further vaccination occur in unexposed 
subjects in ongoing or future trials, and on precautionary basis, including partially vaccinated 
subjects in ongoing trials. 
In its most recent position paper, the WHO acknowledged that the CYD dengue vaccine had been 
shown to be efficacious and safe in persons who have had a dengue virus infection in the past 
(seropositive individuals), but carries an increased risk of severe dengue in those who experience 
their first natural dengue infection after vaccination (seronegative individuals). The WHO 
underlined that countries should consider introducing the CYD dengue vaccine only if risk for 
seronegative individuals can be minimized (2). 
The WHO recommended strategy to minimize the risk of vaccinating seronegative persons is to 
perform a screening test on candidate vaccinees. It is acknowledged that laboratory-based 
serological assays testing for dengue virus IgG (eg, dengue IgG ELISA) would be impractical as 
results would not be available at the point of care in a timely manner. The WHO position paper 
underlines that rapid diagnostic tests (RDTs) would facilitate the implementation of the pre-
vaccination screening strategy, and that, despite the fact that no such test has yet been validated or 
licensed specifically for the detection of past dengue infection, they could be used in high 
transmission settings until better RDTs become available (2) (25). Detection of anti-dengue IgG 
using enzyme-linked immunosorbent assay (ELISA) is generally used to determine previous 
dengue infection status and is routinely used in serosurveys to characterize dengue seroprevalence 
(26). In general, dengue ELISAs were found to be more sensitive than IgG RDTs for identifying 
prior dengue infection cases (27-30). 
In this study, one RDT (OnSite™ Dengue IgG/IgM3.0 Combo Rapid Test commercialized by CTK 
Biotech, Inc.) or one ELISA (Anti-Dengue IgG ELISA commercialized by Euroimmun) will be 
used to screen potential study participants (25) (31). These tests were selected because of their 
high specificity, following an internal evaluation of different options.  
1.3 
Potential Benefits and Risks 
Detailed risk/benefit analysis is presented in the Investigator’s Brochure. 
1.3.1 
Potential Benefits to Subjects 
HIV-positive subjects are typically excluded from clinical studies involving live-attenuated viral 
vaccines. However, vaccination against a number of pathogens is still recommended as HIV-
positive individuals have an increased risk of getting some infections. For instance, the WHO 
recommends that HIV-positive subjects be vaccinated against diphtheria, pertussis, tetanus, 
measles, hepatitis B, Haemophilus influenzae type b, and Streptococcus pneumoniae (32). Thus, 
there could be a benefit for HIV-positive subjects living in areas endemic for dengue disease as 
subjects participating in the present clinical study and being injected with CYD dengue vaccine 
may acquire immunity and protection against dengue disease after vaccination. 
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Although efficacy has not been evaluated in subjects over 17 years, data from studies involving 
adults (18 to 45 years of age) (CYD22, and CYD47) suggest that adults respond well to the 
vaccine schedule used in efficacy studies as an increase of geometric mean of titers (GMTs) 
compared to baseline was observed. Indeed, post-injection (post-Inj) 3 Ab levels are generally 
higher than those seen in CYD14 and CYD15 where efficacy was demonstrated.  
The supplemental analyses (see Section 1.2) have provided strong evidences that, for subjects that 
were dengue seropositive prior to CYD dengue vaccination, the vaccine protects against 
symptomatic dengue, hospitalized dengue, and severe dengue disease. In this study, only persons 
that have previously been exposed to dengue will be enrolled. 
HIV infection has been associated with a reduced immunologic response to a number of 
inactivated and live-attenuated vaccines. For instance, the immune response following YF 
vaccination was found to be slightly inferior in HIV-positive individuals in comparison to that in 
uninfected persons. Nevertheless, higher CD4 counts as well as lower HIV viral load at the time 
of vaccination were predictors of higher neutralizing antibodies titers (33). Thus, HIV-positive 
persons with a clinically-stable condition under regular ART treatment that receive the CYD 
Dengue vaccination might develop an immunological response against the dengue virus. 
1.3.2 
Potential Risks to Subjects 
CYD dengue vaccine 
The data demonstrated that the reactogenicity profile after any injection of the CYD dengue 
vaccine is slightly increased compared to the placebo but appeared similar to licensed vaccines 
used in the age groups that have been studied.  
As of June 2018 a total of 24 886 subjects aged ≥ 9 years have received at least 1 injection of the 
final formulation of the CYD dengue vaccine according to the final schedule. Among these 
subjects, a total of 2606 adults (aged 18 years and over) received at least 1 dose of the CYD 
dengue vaccine (see the Investigator Brochure) (34). 
In the adult population, the most frequent solicited injection site reaction within 7 days after any 
CYD dengue vaccine injection was injection site pain (45.2%); erythema (7.9%) and swelling 
(2.4%) were less frequently reported. Injection site reactions tended to be reported with similar 
frequencies after each injection. 
The most frequent solicited systemic reactions within 14 days after any CYD dengue vaccine 
injection were headache (51.4%), malaise (44.3%), and myalgia (42.2%) followed by asthenia 
(28.3%). Fever (4.9%) was less frequently reported. The frequency of all solicited systemic 
reactions tended to decrease with subsequent injections, except fever, which was reported with 
low incidence at each injection. The adverse reactions (ARs) were usually mild to moderate in 
severity and of short duration (0 to 3 days).  
There were no anaphylactic reactions in adults. Allergic reactions based on the targeted list of 
preferred terms were reported in adults after any vaccine dose with frequency of 1.2%, versus 
0.3%, any placebo injection. However, as with any vaccine, risk of allergic (including 
anaphylactic) reaction cannot be excluded. 
Approximately three-quarter of adult subjects experienced at least one solicited reaction after any 
vaccination (73.2%), mainly solicited systemic reactions. Grade 3 solicited reactions were 
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reported by approximately 11% of adults and were mostly of the solicited systemic reactions 
category. 
As CYD dengue vaccine has an YF vaccine backbone, and YF vaccination has been rarely 
associated with viscerotropic and neurotropic AEs, this risk has to be considered (35). However, it 
is important to underline that this risk has been associated with the YF virus 17D envelope protein 
(36), a protein that is absent from CYD dengue vaccine constructs. This theoretical risk linked to 
viscerotropism and neurotropism is further addressed in the “Guidelines for assessing 
viscerotropic and neurotropic AE” document. In the previous studies conducted with the CYD 
dengue vaccine, no confirmed viscerotropic, or neurotropic AEs were reported after any dose in 
any age groups. 
It is to be noted that subjects not previously exposed to dengue are at an increased risk of 
hospitalization for dengue and clinically severe dengue (predominantly DHF Grade I or II [WHO 
1997 (24)]). For this reason, individuals assessed as dengue seronegative are not to be enrolled in 
this study. 
HIV-associated additional potential risks 
In its Guideline for the clinical evaluation of dengue vaccines in endemic areas (37) the WHO 
advises to include HIV-positive subjects at the post-licensure stage of vaccine development. 
As CYD dengue vaccine has YF vaccinal virus as backbone, HIV-associated potential risks can be 
expected to be similar to those observed following vaccination of HIV-positive subjects against 
other FV (ie, YF and Japanese encephalitis [JE]). The safety data from HIV-positive subjects 
vaccinated against YF is reportedly limited and insufficient to conclude on the vaccination’s 
safety (33). However, no SAEs were reported in these studies (32); and as of today, no evidence 
points to an increase in the number of confirmed viscerotropic and neurotropic AEs in HIV 
patients following YF vaccination (33). Also, outside the clinical context, only a few SAEs were 
reported in HIV-positive individuals following the 2007-2010 YF vaccination campaign 
conducted in West and Central Africa (38). Overall, and although few data are available on the 
safety and efficacy of YF vaccination in HIV-positive persons, YF 17D vaccine is considered 
sufficiently safe in HIV-positive subjects who are not symptomatic or demonstrably 
immunosuppressed, and vaccination is recommended for persons with CD4 counts > 200/mm3 
who are deemed to be at risk of exposure to YF virus (39). 
Likewise, the safety of vaccines against JE has been assessed in a very limited number of HIV-
positive subjects, all of whom were children. In 2 independent studies involving HIV-positive 
Thai children, no severe AEs were reported (40) (41). 
It was observed that the stimulation of the immune system with vaccination may transiently 
increase HIV viremia, through heterologous transactivation. This usually resolves within 4 weeks 
(42) (43). However, this increase does not have clinical implications, as it does not correspond to 
virologic failure and it is not related to ART resistance. Hence, there is a possibility that 
vaccination against dengue is associated with this phenomenon in some subjects (42). However, in 
patients who received a live-attenuated oral cholera vaccine, no such activation was observed and 
there were no significant changes in CD4 count and HIV-1 viral load between vaccine and 
placebo groups (44). As per Brazil National Recommendations on vaccination of HIV-positive 
population, CD4 cells count will be checked before each injection (43). 
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Thus, and based on the scarce data on the vaccination of HIV-positive subjects against other FV 
(YF and JE), no safety signals are expected to occur in this descriptive study. 
Placebo 
No ARs are expected from placebo, except local reactions due to the injection process (eg, 
bruising, local pain). 
All subjects 
Potential risks may also include the AEs of blood sampling (ie, the discomfort from having blood 
taken lasting only seconds to minutes) and/or bruising. 
1.4 
Rationale for the Study 
Dengue is endemic in most of Latin America and Caribbean. Despite the dengue control 
programs, case management guidelines, and vector control efforts, dengue virus transmission 
remains high and prevention remains a public health priority. The number of probable/suspected 
dengue cases and the incidence of dengue disease in Brazil have been among the highest of all 
Latin American countries. Table 1.1 offers an overview of the importance of dengue in Brazil in 
the last 6 years (45). 
Table 1.1: Number of Dengue cases (total and confirmed), incidence rate, and number of 
deaths reported in Brazil during the 2014-2019 period 
 
Number of 
total dengue 
cases* 
Number of 
laboratory-confirmed 
dengue cases 
Incidence rate of all 
dengue cases  
(per 100 000 population) 
Number 
of 
deaths 
Severe 
dengue† 
2019‡ 
2 070 170 
1 131 455 
992.91 
702 
1 321 
2018 
265 934 
174 724  
126.11 
155 
321 
2017 
252 054 
42 101 
120.43 
133 
378 
2016 
1 500 535 
316 687 
716.01 
642 
861 
2015 
1 649 008  
500 972 
809.70 
863 
1 569 
2014 
590 852 
220 537 
292.45 
409 
687 
*  
Report of all dengue cases: suspected, probable, confirmed, non-severe and severe cases, and deaths. 
Probable dengue case: Person who has a fever or history of fever for 2-7 days duration, 2 or more 
symptoms of dengue and one serological test positive or epidemiological nexus with confirmed dengue 
case 14 days before onset of symptoms.. 
†  
Includes severe dengue and haemorrhagic dengue fever 
‡  
Data up to Week 42 for 2019. 
 
 
Brazil is also plagued with a high burden of HIV/AIDS. In 2014, there were about 734 000 people 
living with HIV/AIDS with a prevalence of 0.4% in people above 15 years old. As regards HIV 
infection only, in Brazil, in 2017, 42 420 cases of HIV infection were reported to the Information 
System of Reportable Diseases (SINAN): 4306 of them from North region (10.2%), 9706 from 
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Northeast (22.9%), 16 859 from Southeast (39.7%), 8064 from South (19.0%) and 3485 from 
Midwest region (8.2%). From the beginning of the AIDS epidemic in 1980 through December 
2017, 327 655 deaths related to AIDS have been reported in Brazil (46). 
A recent publication has demonstrated that in a HIV-1 infected ART-naïve population in Brazil 
the mean reported value of CD4 count has slightly increased from 348 in the year 2003 to 389 in 
2009. Nevertheless, the values have increased as the ART was initiated and maintained (means of 
368 in the year 2001 to 414 in 2009 in HIV patients under ART). In terms of HIV viral load, the 
percentage of treated patients with undetectable viremia (< 50 copies/mL) has also increased from 
48% in the year 2001 to 77% in 2007. Furthermore, the resistance to antiretrovirals in the general 
HIV population of the country has remained stable over the last decade (around 25%) (47). 
In recent years, Brazil’s National Ministry of Health has published guidelines for the 
management, diagnosis, treatment and follow-up of HIV-positive persons (48). Adherence to 
these guidelines has been made possible through the universal access (ie, government-guaranteed 
access at no cost) to treatment and medical assistance (including control laboratories, ie, CD4 
count in some instances, HIV viral load, diagnosis exam) that is provided throughout the country, 
with laboratories available to follow patients in all regions of the country (48) (49). There are no 
major issues with shortages of antiviral drugs, and laboratories are available for the CD4 and HIV 
viral load assessments that are required for an appropriate follow-up of participants (49). 
The tetravalent CYD dengue vaccine is a recombinant, live-attenuated vaccine cultured on serum 
free Vero cells. The purpose of the CYD dengue vaccine is to provide coverage against serotypes 
1, 2, 3 and 4 and it has shown a positive benefits/risk balance in subjects aged 9 to 45 years living 
in endemic areas and previously exposed to dengue (20-22). So far, the CYD dengue vaccine has 
been tested on healthy subjects, and “at risk” populations have been excluded. As the product has 
been licensed in a number of countries, and as recommended by the WHO, it is now justified to 
widen clinical studies to all populations that may be exposed to dengue vaccination, and to 
evaluate whether the vaccine is safe and immunogenic in a population of special interest, such as 
HIV-positive adults. 
It is thus of prime importance to assess whether the CYD dengue vaccine is safe in HIV subjects 
as dengue and HIV are both endemic in many areas of the world (15) (50-52). In countries where 
dengue is endemic and where mass vaccination campaigns may be implemented, there is a need to 
document the safety in this population as HIV-positive persons could be inadvertently vaccinated 
with the CYD dengue vaccine. This study will provide data on the use of the vaccine in a HIV-
positive population and will be part of the Risk Management Plan. 
It is also important to assess whether an immunological response mediated by the development of 
neutralizing Ab levels of HIV-positive subjects injected with the CYD dengue vaccine can be 
expected. Likely, and as observed with YF and JE vaccines, the CYD dengue vaccine may induce 
a lower immune response than that observed in healthy subjects (33) (40) (41). Indeed, 2 
published studies providing immunogenicity data for YF vaccines in HIV-positive persons found 
lower rates of YF virus-specific neutralizing antibodies among HIV-positive persons, compared 
with uninfected controls at 10 to 12 months post-vaccination in both adults (53) and children (54). 
Although the mechanisms for the diminished immune response in HIV-positive persons are 
uncertain, an inverse correlation exists between immune response and HIV-1 RNA levels and a 
positive correlation with CD4 cell counts (55). It has also been suggested that the reduced and/or 
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less durable responses to YF vaccine in HIV-positive persons under ART are associated with 
lower CD4/CD8 cells ratio (56). More generally, the correlation between low CD4 count and low 
immunological response has also been observed following vaccination against other pathogens 
(57) (58). 
In order to pursue the development of the CYD dengue vaccine, the present study will 
descriptively assess the safety and the immunogenicity of the CYD dengue vaccine in a HIV-
positive population. It will involve 150 HIV-positive adults treated with ART (aged 18 to 50 
years) who will receive either 3 injections of CYD dengue vaccine or placebo at 0, 6, and 
12 months. 
2 
Study Objectives 
2.1 
Primary Objective 
Safety 
To describe the safety of each injection of CYD dengue vaccine in HIV-positive adults previously 
exposed to dengue. 
The endpoints for the primary objectives are presented in Section 9.1.1.2. 
2.2 
Secondary Objectives 
Immunogenicity: 
• To describe the humoral immune response to each dengue serotype at baseline and after each 
injection of CYD dengue vaccine in HIV-positive adults previously exposed to dengue 
Safety 
• To detect the CYD dengue vaccinal viremia post-Inj 1 in HIV-positive adults previously 
exposed to dengue 
• To describe changes in CD4 count and HIV RNA viral load after each injection of CYD 
dengue vaccine in HIV-positive adults previously exposed to dengue 
The endpoints for the secondary objectives are presented in Section 9.2.2.1 and Section 9.2.1.2 
respectively. 
2.3 
Observational Objective(s) 
Immunogenicity 
• To describe the FV (dengue, YF, and Zika) serological status in the study population at 
baseline. 
The endpoints for the observational objective are presented in Section 9.3.1.1. 
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3 
Investigators and Study Organization 
This study will be conducted in Brazil. The Principal Investigators and any sub-investigators at 
the individual sites will be coordinated by 1 Coordinating Investigator. Details of the study 
centers, the Investigators at each center, and the Coordinating Investigator are provided in the 
“List of Investigators and Centers Involved in the Trial” document. 
Safety evaluation team 
An internal safety evaluation team (SET) will perform a blinded early safety analysis on safety 
data collected from Days 0-14 post-first injection for the first 20 subjects having received the first 
injection. 
Independent Data Monitoring Committee 
Following the SET assessment, an IDMC will review the early safety data of the first 20 subjects 
and will provide a recommendation on whether to continue enrollment and administration of the 
second dose of vaccine to the 20 already enrolled subjects (Section 5.1.6). 
In addition, the IDMC will be involved in the regular review of hospitalized VCD cases, including 
assessment of severity. Related SAEs or deaths will be promptly reviewed by the IDMC. 
Lastly, the IDMC will also be promptly notified of any significant confirmed modification of a 
subject’s HIV infection status, as well as if any of the criteria for interruption of the study for 
safety reason are met (see Section 5.5). 
Others 
Biostatistics, data management, monitoring, pharmacovigilance, and medical writing will be 
either subcontracted to a contract research organization or performed in-house by the Sponsor. 
The laboratories involved in this study will be: 
• Sanofi Pasteur Global Clinical Immunology (GCI), Swiftwater, Pennsylvania, USA or 
outsourced laboratory under the management of GCI for: dengue, YF, and Zika serological 
status, dengue neutralizing Ab titration, vaccine viremia testing, and virological confirmation 
of dengue 
• Local laboratories for: screening tests (dengue IgG ELISA, hepatitis B surface antigen 
[HBsAg], hepatitis C virus [HCV] antibodies, hematology, and biochemistry), CD4 count, and 
HIV viral load assessments 
The Sponsor’s Responsible Medical Officer (the Responsible Medical Officer (RMO), the person 
authorized to sign this protocol and any amendments on behalf of the Sponsor) is Ana Paula de 
Almeida Salles Perroud, MD, MSc, and Clinical Team Leader (CTL) of this study. 
4 
Independent Ethics Committee / Institutional Review Board 
Before the investigational product can be shipped to the investigational site and before the 
inclusion of the first subject, this protocol, the informed consent form (ICF), subject recruitment 
procedures, and any other written information to be provided to subjects must be approved by, and 
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/ or receive favorable opinion from, the appropriate Independent Ethics Committee (IEC) or 
Institutional Review Board (IRB). 
In accordance with Good Clinical Practice (GCP) and local regulations, each Investigator and / or 
the Sponsor are responsible for obtaining this approval and / or favorable opinion before the start 
of the study. If the protocol is subsequently amended, approval must be re-obtained for each 
substantial amendment. Copies of these approvals, along with information on the type, version 
number, and date of document, and the date of approval, must be forwarded by the Investigator to 
the Sponsor together with the composition of the IEC / IRB (the names and qualifications of the 
members attending and voting at the meetings). 
The Investigator or the Sponsor will submit written summaries of the status of the study to the 
IEC / IRB annually, or more frequently if requested. All serious adverse events (SAEs) occurring 
during the study will be reported by the Investigator to the IEC / IRB, according to the IEC / IRB 
policy. 
5 
Investigational Plan 
5.1 
Description of the Overall Study Design and Plan 
5.1.1 
Study Design 
This is a multi-center, observer-blind, randomized, placebo-controlled, Phase II study of the CYD 
dengue vaccine in 150 HIV-positive adults (18 to 50 years) in Brazil. Potential participants 
fulfilling all inclusion criteria, including a previous exposure to dengue according to the RDT or 
ELISA, will be enrolled. Subjects will receive 3 injections of either CYD dengue vaccine or 
placebo at 0, 6, and 12 months. The enrollment of subjects will be carried out in 2 steps, including 
an early safety data review (ESDR) before the second step. 
Subjects HIV-positive and previously exposed to dengue according to RDT or ELISA will be 
randomized in a 2:1 ratio into 1 of 2 groups: 
• Group 1 (N=100): subjects will receive 3 doses of CYD dengue vaccine (live, attenuated, 
dengue serotype 1, 2, 3, 4 virus) 
• Group 2 (N=50): subjects will receive 3 doses of placebo (NaCl 0.9%) 
Each subject will have her / his dengue serostatus confirmed using dengue PRNT and anti-NS1 
IgG assay on the pre-injection blood sample. Subjects who are dengue-positive by RDT or ELISA 
at Screening Visit and dengue-negative by PRNT (sample collected before the first injection [at 
Visit 1] and assayed before second injection) will be considered as not previously exposed. 
Therefore, they will not receive any further injections and will be followed for safety until 6 
months after the last dose. In addition, if they received the vaccine, provisions for timely access to 
medical care will be offered for 10 years after the last dose, according to IDMC prior 
recommendations. 
All subjects are planned to be included in safety and immunogenicity analysis set. Blood samples 
will be taken at the Screening Visit (serology, hematology, biochemistry), and at several other 
time points throughout the study for baseline dengue, YF, and Zika serological status, CYD 
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dengue vaccine immunogenicity, dengue vaccinal viremia post-Inj 1, and HIV status monitoring 
assessments, depending on the time points. More details are provided in Section 5.1.3. 
The duration of each subject’s participation in the study will be approximately 18 months. 
At the end of the trial, subjects will be informed on whether they received the CYD dengue 
vaccine or placebo. For those who received placebo, and who have a prescription, the CYD 
dengue vaccine will be offered free of charge by Sanofi Pasteur through the study doctor, in 
accordance with the Brazilian laws and with vaccine indication in Brazil. This will be a decision 
between the subject and the study doctor since the vaccine offered will not be part of the trial. 
5.1.2 
Justification of the Study Design 
CYD50 study is designed to assess the CYD dengue vaccine safety and immunogenicity in a 
specific population: HIV-positive persons. The fact that the study will be randomized, observer-
blind and placebo-controlled will help reducing bias in the selection of subjects within this 
particular population and in the safety assessments. It will also help insulating the study vaccine’s 
safety and immunogenicity assessments from some confounding factors (eg, other underlying 
health issues, endemicity of other flavivirus in Brazil). It is noteworthy that this study will only be 
enrolling HIV-positive subjects with clinically-stable condition under regular ART regimen. Also, 
and in agreement with the WHO position paper (WHO 2018), the study will only be enrolling 
subjects with a previous exposure to dengue according to RDT or dengue IgG ELISA. These 
criteria will both help minimize potential risks to subjects’ safety and allow for a more 
homogeneous evaluation of the vaccine’s safety and immunogenicity. 
Specific inclusion and exclusion criteria have been drawn in order to evaluate the CYD dengue 
vaccine in this special population. Only subjects who will have had stable CD4 count (> 350 
cells/mm3) and undetectable viral load (< 50 copies/mL) for at least 1 year before consent, and 
who will have been on a stable ART regimen based on local HIV guidelines for at least 1 year 
before consent, will be included in this study (48). The rationale is to be able to follow stable 
subjects who are less likely to have complications during the study period. 
CD4 count and viral load will be monitored before the first injection to ensure that participants 
meet the requirements set by the Brazilian Guidelines for Vaccination in HIV population (48). 
Subjects who will have had previous CD4 count < 200 cells/mm3 (nadir) since HIV-1 diagnosis 
will be excluded from this study. 
All subjects will be screened according to a number of parameters (see Section 5.2.3) to ensure 
that i) they are dengue seropositive and ii) they do not have significantly altered hematological 
and biochemical parameters before the first injection in case of adverse drug reaction (from either 
ART or CYD dengue vaccine) and/or of dengue disease. Also, due to the risk of heterologous 
transactivation (ie, transitory increase of viral load after vaccination), subjects that are positive for 
HBsAg and/or HCV antibodies will be excluded from the study. Besides, subjects’ HIV infection 
will continue to be monitored throughout the trial according to local HIV guidelines (48). 
More specifically, this study will allow assessing 3 distinctive features of the vaccination of HIV-
positive subjects under a stable ART regimen (henceforth, the ART-population) with the CYD 
dengue vaccine: 
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How well is the CYD dengue vaccine tolerated in the ART-population. The safety of the CYD 
dengue vaccine in an ART-population needs to be assessed in light of the vaccine’s overall safety 
profile. Gathering data on the same safety endpoints assessed throughout dengue studies 
conducted by Sanofi Pasteur will be one of the key elements in weighing the potential risks of 
vaccination against the potential benefits in HIV-positive individuals. 
How immunogenic is the CYD dengue vaccine in the ART-population. As HIV-positive subjects 
have an altered immune function, the CYD dengue vaccine may not be as immunogenic as in 
immunocompetent persons (see Section 1.4). In order to find out whether this is also the case for 
the CYD dengue vaccine, this study will assess the immunogenicity of the vaccine in the ART-
population 28 days after each injection. 
How is the CYD dengue vaccine impacting some features of the HIV-positive subjects’ immune 
system. Whether the CYD dengue vaccine might raise safety concerns that are specific to the 
ART-population has to be assessed. In this study, 2 potential safety issues will be monitored. 
Firstly, and as the CYD dengue vaccine is a live-attenuated virus vaccine, there is the possibility 
that HIV-positive subjects develop a vaccinal viremia (viremia will be assessed at D7 and D14 
post-Inj 1 in all subjects). Viremia previously observed across all age groups in healthy subjects 
(less than 6% after the first injection, and less than 1% after subsequent injections) has not had 
clinical significance in the safety of subjects enrolled in earlier trials. Secondly, there is also the 
possibility that vaccination against dengue exerts influence in the HIV infection of some subjects 
(Section 1.3.2). In order to evaluate this potential risk, CYD50 will be assessing CD4 count and 
HIV-1 viral load 28 days after each vaccination. 
It is noteworthy that only HIV-1 viral load will be assessed throughout the trial. This decision is 
aligned with the current local practice due to the low prevalence of the HIV-2 in Brazil, and 
according to the procedures included in the local guidelines for the management of HIV subjects 
(48). 
Since cross-reactivity has been observed between FV Abs after vaccination or natural infection, 
previous exposure to dengue, yellow fever (YF), and Zika will be assessed at baseline using the 
appropriate neutralizing assays (59-61). This will allow evaluating the possible impact of recent 
outbreaks of Zika and YF on study participants safety and immunogenicity results (62) (63). This 
is especially important as the majority of Zika and YF cases are asymptomatic (64-66). 
Lastly, hospitalized suspected dengue cases occurring at any time in the study will be 
documented. Hospitalized suspected dengue disease is defined as an acute febrile illness with 
diagnosis of dengue requiring hospitalization (inpatient care). In such cases, 1 unplanned blood 
sample (acute sample) will be collected for virological confirmation within the first 5 days after 
fever onseta. A suspected hospitalized dengue case will be considered as a VCD case if there is a 
detection of wild-type (WT) dengue virus by non-structural protein 1 (NS1) antigen ELISA and/or 
wild-type dengue RT-PCR. Hospitalized VCD cases will be assessed by an IDMC for severity 
assessment. 
                                                 
a  Acute blood sample for all suspected hospitalized dengue cases should be collected within the pre-specified 
timeframe as described above. If this cannot be accomplished, this sample should still be obtained as soon as 
possible thereafter, for Independent Data Monitoring Committee (IDMC) severity assessment. 
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5.1.3 
Study Plan 
An overview of assessments and study vaccinations is provided in the Table of Study Procedures. 
Each potential subject will sign and date the ICF. In addition to the Screening Visit, included 
subjects will attend 8 study visits, will receive 4 follow-up phone calls, and will be contacted 
6 months after the last Visit for a safety follow-up. 
Vaccination 
All subjects will receive 3 injections of either CYD dengue vaccine or placebo at Day (D) 0, 
Month (M) 6, and M12. 
Blood sampling 
A number of immunological, hematological and biochemical parameters (see Section 5.2.3) will 
be assessed at screening (unless the tests have already been performed as part of routine follow-up 
within the 4-week time window). The subject’s dengue serostatus will be determined by a RDT or 
an ELISA during the Screening Visit.  
Dengue, YF, and Zika baseline status will be assessed at D0. 
Dengue vaccinal viremia will be assessed at D7 and D14 post-Inj 1. 
Dengue neutralizing antibody (Ab) levels will be assessed at baseline (V01; prior to Inj 1) and 
28 days after each injection. 
If no HIV viral load and CD4 count results are available prior to each injection (ie, tests have not 
been performed within 2 months before injection visit), tests will be performed to ensure that 
results are available at the time of injection visit. 
HIV viral load and CD4 count will be assessed 28 days after each injection. In case an increase in 
HIV viral load (plasma HIV-1 RNA > 1000 copies/mL 28 days post-injection after having been 
undetectable [< 50 copies/mL] pre-injection) or a decrease in CD4 count (decrease greater than 
30% 28 days post-injection compared to the pre-injection value) is observed, a second blood 
sample is to be taken 4 weeks later for confirmation, as it is current local practice to confirm 
abnormal and significant deterioration of HIV condition related results (48) (see Section 5.5). 
A summary of blood samplings is provided in Table 5.1. 
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Table 5.1: Blood Sampling Volume (mL) per Visit for all Assessments 
Visit (V) Number 
Scr. 
V01 
V02 
V03 
V04 
V05 
V06 
V07 
V08 
Trial timelines 
(Days/Months) 
-D28 to 
-D0 
Inj 1 
(D0) 
Inj 1 
+7D 
Inj 1 
+14D 
Inj 1 
+28D 
Inj 2 
(M6) 
Inj 2 
+28D 
Inj 3 
(M12) 
Inj 3 
+28D 
Time Windows (Days) 
 
 
+3 
+3 
+14 
±20 
+14 
±20 
+14 
Approximate volume for each assessment (mL) 
Serology 
(HBsAg, HCV Ab)* 
5 
 
 
 
 
 
 
 
 
Hematology 
(hemoglobin, hematocrit, platelet 
count, white blood cells count)* 
3 
 
 
 
 
 
 
 
 
Biochemistry 
(AST, ALT, urea, creatinine)* 
5 
 
 
 
 
 
 
 
 
Previous exposure to dengue 
using RDT or dengue ELISA 
1† 
 
 
 
 
 
 
 
 
Dengue, YF, and Zika 
serostatus 
 
5 
 
 
 
 
 
 
 
Dengue neutralizing Abs 
 
2 
 
 
2 
 
2 
 
2 
Serum sample for retesting 
 
2 
 
 
2 
 
2 
 
2 
Dengue vaccinal viremia 
 
 
4 
4 
 
 
 
 
 
CD4 count 
‡ 
 
 
 
10 
‡ 
10 
‡ 
10 
HIV-1 viral load 
‡ 
 
 
 
10 
‡ 
10 
‡ 
10 
Total volume for each subject 
14§ 
9 
4 
4 
24 
 
24 
 
24 
* HBsAg and HCV tests will not be performed in case information is already available in subject's medical history. If 
serology, hematology, and biochemistry results are available and were obtain within 4 weeks before first injection, 
tests do not need to be performed again. 
† Tests will be performed sequentially. RDT will be performed first, and IgG ELISA will only be performed on 
subjects who tested negative for RDT. Tests will be done by the Investigator, following the RDT or ELISA 
Manufacturer’s instructions. Subjects who previously tested negative by RDT can be re-screened using dengue IgG 
ELISA. 
‡ Pre-injection CD4 count and HIV viral load will come from routine periodical tests of subjects as per local 
guidelines. For subjects for whom CD4 count and HIV viral load have not been assessed within 2 months before the 
Screening Visit, the Investigator will perform tests to ensure that results are available at the time of Visit 1. 
Likewise, if CD4 count and HIV viral load have not been tested within 2 months before Inj 2 or Inj 3 (for checking 
contraindication), the Investigator will perform tests to ensure that results are available before the corresponding 
vaccination visit. 
§ This volume is indicative only as it may differ between local laboratories. It does not include the volume that might 
possibly be required for the assessment of baseline CD4 count (10 mL) or HIV viral count (10 mL) in some subject 
(ie, subjects for whom CD4 count and HIV viral count have not been assessed within 2 months before the Screening 
Visit). 
 
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Collection of safety data 
Safety data will be collected following each injection. Clinical site personnel will record 
immediate AEs that occur within the 30 minutes after injection. Subjects will record in the diary 
card (DC) information about solicited injection site reactions from D0 to D7 post-injection, about 
solicited systemic reactions from D0 to D14 post-injection, and unsolicited AEs occurring up to 
28 days post-injection. Information on SAEs will be reported throughout the study (See 
Section 10.1 and Operating Guidelines for more information). Serious and non-serious AEs of 
special interest (AESIs) will be collected in defined time windows according to the type of AESI. 
DCs will be provided to subjects to collect information on SAEs in-between injections (ie, from 
28 days to 6 months post-Inj 1; and from 28 days to 6 months post-Inj 2) A memory aid (MA) will 
be provided to subjects to help them record SAEs during the 6 months safety follow-up (from 28 
days post-Inj 3 to 6 months after last injection). Subjects are to contact the Investigator (within the 
first 5 days after fever onset) in case of hospitalization for suspected dengue disease at any time 
during the study for virological confirmation of the disease. 
Clinical site personnel will review the safety data with the subjects during post-injection visits. 
5.1.4 
Visit Procedures 
All information collected during the study visits must be reported into the source documents. For 
eligible subjects, the information collected will also be recorded in the electronic case report form 
(CRF) at V01. 
Screening Visit (Scr.; D-28 to D0): Inclusion, Physical/Clinical Examination and Blood 
Sample of Potential Subjects 
For all subjects (see Section 5.2.3) 
1) Present the study to the subject in more details, answer any of her/his questions, and ensure 
that she/he has been informed of all aspects of the study that are relevant to their decision to 
participate. 
2) Obtain the ICF signed and dated by the subject, and date and sign the ICF (only the 
Investigator or sub-Investigator). The Investigator will keep the original document and give 
the other one to the subject. 
3) Review the inclusion and exclusion criteria for eligibility. 
4) Check and collect the subject’s significant medical history (including ART-related 
information). 
5) Check and collect the subject's history of dengue infection/vaccination, YF 
vaccination/infection, and Zika infection. 
6) Perform a physical examination. 
7) Obtain the blood sample for screening tests (including assessment of previous exposure to 
dengue using the RDT or dengue IgG ELISA; see Section 7.1 for detailed instructions 
regarding the handling of blood samples), record the date of collection. 
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It is important to note that, if the attempt(s) to collect blood is (are) unsuccessful, the subject 
should be given the opportunity for another attempt, even on another day within the Visit window. 
If ultimately a blood sample cannot be obtained, the reason will be recorded in the source 
document. In that case, the subject will not participate in the study. 
8) Call the Interactive Response Technology (IRT) in order to get the subject’s inclusion number 
9) Remind the subject to call the study center if a serious medical event occurs 
10) Arrange an appointment for Visit 1 (V01) 
The Visit may be postponed once if the subject is temporarily not eligible at the Screening Visit. 
Notes:  
• Subjects who previously tested negative by RDT for previous exposure to dengue can be re-
screened using IgG ELISA. Subjects who are re-screened will be allocated a new subject 
number. 
• If a subject is eligible but not randomized during the ESDR hold, the subject will be asked to 
come back to the site after the hold. The subject will then be re-screened and randomized. 
However, the subject will not be re-tested for previous exposure to dengue by RDT or IgG 
ELISA. It is to be noted that subjects that are re-screened will be allocated a new subject 
number. 
Visit 1 (Inj 1 [D0]): Randomization, Blood Sample, and Vaccination of Eligible Subjects  
Once dengue previous exposure has been identified using RDT or dengue IgG ELISA, the Visit 1 
procedures may be undertaken. 
1) Review the inclusion and exclusion criteria and confirm the eligibility 
2) Collect demographic (year of birth and gender) and body stature (height and weight) data 
3) Check and collect the subject’s significant medical history (including ART-related 
information) 
4) Check and collect the subject's history of dengue vaccination/infection, of YF 
vaccination/infection, and of Zika infection  
5) Perform a physical examination and record the subject's axillary temperature before injection 
6) Check concomitant medications and record every reportable medication ongoing at the time 
of vaccination 
7) Perform a urine pregnancy test for all women enrolled in the study 
8) Obtain a blood sample (see Section 7.1 for detailed instructions regarding the handling of 
blood samples), record the date of collection 
It is important to note that, if the attempt(s) to collect blood is (are) unsuccessful, the subject 
should be given the opportunity for another attempt. If a blood sample cannot be obtained, the 
reason will be recorded in the blood sampling page of the CRF. 
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9) The person in charge of injections (“vaccinator”) or authorized designee contacts the IRT to 
obtain the assigned product to be administered 
10) Inject the appropriate investigational product 
11) Record the date of injection, the site, and side of injection and the route of administration, as 
well as the dose number of the vaccine 
12) Affix the vaccine labels in the subject’s source documents 
13) Keep the subject under observation for 30 minutes, and record any immediate AE reaction in 
the source document 
14) Give the subject the first DC (DC1) to record any injection site reactions and systemic AEs, 
together with instructions for its completion, including explanations on the definition and use 
of intensity scales for collection of AEs 
15) Give the subject a ruler to measure the size of any injection site reaction and a thermometer 
for temperature measurement, and instructions on how to use them 
16) Remind the subject to call the study center if a serious medical event occurs 
17) Arrange an appointment for the next visit (V02; at V01 + 7D [+ 3 day]). 
18) Complete the relevant CRF pages for this Visit. 
The visit may be postponed once if the subject is temporarily not eligible at Visit 1. 
Note: The Screening Visit and Visit 1 can be simultaneous for subjects tested positive by RDT 
and whose tests have been performed in appropriate time windows (within 4 weeks before 
injection for hepatitis serology, hematology, and biochemistry; within 2 months for CD4 count 
and HIV viral load) as part of the subject’s routine follow-up. 
Visit 2 (Inj 1+7D [+3 days]): Collection of Safety Information and Blood Sample 
1) Check the information entered into DC1 by interviewing the subject and request information 
concerning any medical event, serious, or not, that may have occurred since Visit 1 
2) Record any injection site reactions or systemic AEs and any reportable concomitant 
medications 
3) Perform a physical examination and record the subject's axillary temperature (if necessary) 
4) Obtain a blood sample (see Section 7.1 for detailed instructions regarding the handling of 
blood samples), record the date of collection 
It is important to note that, if the attempt(s) to collect blood is (are) unsuccessful, the subject 
should be given the opportunity for another attempt within the Visit window. If a blood sample 
cannot be obtained, the reason will be recorded in the blood sampling page of the CRF. 
5) Remind the subject to call the study center if a serious medical event occurs. 
6) Arrange an appointment for the next visit (V03; at V01 + 14D [+ 3 days]). 
7) Complete the relevant CRF pages for this visit. 
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Visit 3 (Inj 1+14D [+3 days]): Collection of Safety Information and Blood Sample 
1) Check the information entered into DC1 by interviewing the subject and request information 
concerning any medical event, serious, or not, that may have occurred since Visit 2 
2) Record any AEs and any reportable concomitant medications 
3) Perform a physical examination and record the subject's axillary temperature (if necessary) 
4) Obtain a blood sample (see Section 7.1 for detailed instructions regarding the handling of 
blood samples), record the date of collection 
It is important to note that, if the attempt(s) to collect blood is (are) unsuccessful, the subject 
should be given the opportunity for another attempt within the Visit window. If a blood sample 
cannot be obtained, the reason will be recorded in the blood sampling page of the CRF. 
5) Remind the subject to call the study center if a serious medical event occurs. 
6) Arrange an appointment for the next visit (V04; at V01 + 28D [+14 days]). 
7) Complete the relevant CRF pages for this visit. 
Visit 4 (Inj 1+28D [+14 days]): Collection of Safety Information and Blood Sample 
1) Collect DC1 and check the information entered into it by interviewing the subject and request 
information concerning any medical event, serious, or not, that may have occurred since 
Visit 3 
2) Record any AEs and any reportable concomitant medications 
3) Perform a physical examination and record the subject's axillary temperature (if necessary) 
4) Obtain a blood sample (see Section 7.1 for detailed instructions regarding the handling of 
blood samples), record the date of collection 
It is important to note that, if the attempt(s) to collect blood is (are) unsuccessful, the subject 
should be given the opportunity for another attempt within the Visit window. If a blood sample 
cannot be obtained, the reason will be recorded in the blood sampling page of the CRF. 
5) Remind the subject to call the study center if a serious medical event occurs 
6) Provide the subject with DC2 and remind her/him to bring it back when she/he returns for 
Visit 5 
7) Arrange an appointment for the next visit (V05; at V01 + 6 months (M6) [±20 days]) 
8) Complete the relevant CRF pages for this visit 
Visit 5 (Inj 2 [M6; ±20 days]): Collection of safety information and vaccination 
1) Collect DC2 and check the information entered into it by interviewing the subject and request 
information concerning any medical event, serious, or not, that may have occurred since last 
Visit 
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2) Record any reportable concomitant medications 
3) Perform a physical examination and record the subject's axillary temperature before injection 
4) Check any contraindication to vaccination 
5) Check for confirmation of previous exposure to dengue (from PRNT laboratory results) 
6) Perform a urine pregnancy test for all women enrolled in the study 
7) The person in charge of injections (“vaccinator”) or authorized designee contacts the IRT to 
obtain the assigned product to be administered 
8) Inject the appropriate investigational product 
9) Record the date of injection, the site, and side of injection and the route of administration, as 
well as the dose number of the vaccine 
10) Affix the vaccine labels in the subject’s source documents 
11) Keep the subject under observation for 30 minutes, and record any immediate AE in the 
source document 
12) Give the subject the DC3 to record any injection site reactions and systemic AEs, together 
with instructions for its completion, including explanations on the definition and use of 
intensity scales for collection of AEs 
13) Ensure subject still has the ruler to measure the size of any injection site reaction and the 
thermometer for temperature measurement 
14) Remind the subject to call the study center if a serious medical event occurs 
15) Arrange an appointment for the next visit (V06; at V05 + 28D [+ 14 days]). Remind the 
subject that she/he will be contacted twice by phone (PC1; at V05+ 7D [+3 days]; PC2; at 
V05 + 14D [+3 days]) by study staff. 
16) Complete the relevant CRF pages for this visit. 
Phone Call 1 (Inj 2+7D [+3 days]): Safety Follow-up Phone Call 
Note: If PC1 falls on a weekend or a holiday, the telephone call may be made on the following 
business day. 
1) Record relevant information concerning the subject’s health status on the source document. If 
a SAE occurred follow the instructions in Section 10 for reporting it. 
2) Remind the subject to call the study center if a serious medical event occurs. 
3) Remind the subject to record any AEs in the DC3. 
4) Remind the subject of the appointment for the next visit (V06; at V05 + 28D [+14 days]). 
Note: A follow-up visit can be arranged depending on the information provided during the phone 
call, at the Investigator’s discretion. 
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Phone Call 2 (Inj 2+14D [+3 days]): Safety Follow-up Phone Call 
Note: If PC2 falls on a weekend or a holiday, the telephone call may be made on the following 
business day. 
1) Record relevant information concerning the subject’s health status on the source document. If 
a SAE occurred follow the instructions in Section 10 for reporting it. 
2) Remind the subject to call the study center if a serious medical event occurs. 
3) Remind the subject to record any AEs in the DC3, and to bring it back when she/he returns 
for Visit 6. 
4) Remind the subject of the appointment for the next Visit (V06; at V05 + 28D [+14 days]). 
Note: A follow-up visit can be arranged depending on the information provided during the phone 
call, at the Investigator’s discretion. 
Visit 6 (Inj 2+28D [+14 days]): Collection of Safety Information and Blood Sample 
1) Collect DC3 and check the information entered into it by interviewing the subject and request 
information concerning any medical event, serious, or not, that may have occurred since 
Visit 5 
2) Record any AEs and any reportable concomitant medications 
3) Perform a physical examination and record the subject's axillary temperature (if necessary) 
4) Remind the subject to call the study center if a serious medical event occurs 
5) Obtain a blood sample (see Section 7.1 for detailed instructions regarding the handling of 
blood samples), record the date of collection 
It is important to note that, if the attempt(s) to collect blood is (are) unsuccessful, the subject 
should be given the opportunity for another attempt within the Visit window. If a blood sample 
cannot be obtained, the reason will be recorded in the blood sampling page of the CRF. 
6) Provide the subject with DC4 and remind her/him to bring it back when she/he returns for 
Visit 7 
7) Arrange an appointment for the next visit (V07; at V01 + 12 months (M12) [±20 days]) 
8) Complete the relevant CRF pages for this visit 
Visit 7 (Inj 3 [M12; ±20 days]): Collection of safety information and vaccination 
Same procedure as for Visit 5. Subject is provided with DC5. 
Phone Call 3 (Inj 3+7D [+3 days]): Safety Follow-up Phone Call 
Same procedures as for Phone Call 1. 
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Phone Call 4 (Inj 3+14D [+3 days]): Safety Follow-up Phone Call 
Same procedures as for Phone Call 2. 
Visit 8 (Inj 3+28D [+14 days]): Collection of Safety Information and Blood Sample 
1) Collect DC5 and check the information entered into it by interviewing the subject and request 
information concerning any medical event, serious, or not, that may have occurred since 
Visit 7 
2) Record any AEs and any reportable concomitant medications 
3) Perform a physical examination and record the subject's axillary temperature (if necessary) 
4) Obtain a blood sample (see Section 7.1 for detailed instructions regarding the handling of 
blood samples), record the date of collection 
It is important to note that, if the attempt(s) to collect blood is (are) unsuccessful, the subject 
should be given the opportunity for another attempt within the Visit window. If a blood sample 
cannot be obtained, the reason will be recorded in the blood sampling page of the CRF. 
5) Remind the subject to call the study center if a serious medical event occurs 
6) Provide the subject with a MA 
7) Remind the subject about the 6 months safety follow-up phone call (at M12 + 6 months 
[+30 days]). 
8) Complete the relevant CRF pages for this visit and the End of Study CRF. 
Safety Follow-up Telephone Call (6 months after last injection [+30 days]): Collection of SAEs 
1) Ask the subject if she/he has experienced any SAE since the last injection. If an SAE 
occurred, follow the instructions in Section 10 for reporting it. 
2) Complete the relevant case report book (CRB) form. 
Note: A follow-up visit can be arranged depending on the information provided during the phone 
call. 
Follow-up of subjects with Related AEs or with AEs That Led to Study/Vaccination 
Discontinuation: 
A subject who experiences an AE (whether serious or non-serious) during the study must be 
followed until the condition resolves, becomes stable, or becomes chronic (even after the end of 
the subject’s participation in the study) if either of the following is true: 
• The AE is considered by the Investigator to be related to the product administered 
• The AE caused the discontinuation of the subject from the study or from vaccination 
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5.1.5 
Planned Study Calendar 
The following dates are approximate. The actual dates may differ as, for example, the study will 
not start until all the appropriate regulatory and ethical approvals have been obtained. 
Planned study period – FVFS (first Visit, first subject) to LCLS (last contact, last subject): 
November 2019 to March 2022 
Planned inclusion period – FVFS to FVLS (first visit, last subject): November 2019 to September 
2020 
Planned vaccination period: November 2019 to September 2021 
Planned end of study: March 2022 
Planned date of final clinical study report: Q4 2022 
5.1.6 
Early Safety Data Review 
The safety of the CYD dengue vaccine will be continuously monitored by the Sponsor. In the 
context of this study (ie, HIV-positive adults), a blinded ESDR will be performed, the goal of 
which is to allow for a cautious, stepwise approach to vaccine administration. An initial safety 
review for this study is planned when the first 20 subjects have received the first injection and 
have provided safety data for Days 0-14 post-injection 1. During the ESDR, study recruitment 
(and second injection for first 20 subjects, in case the safety review has not been completed at the 
time of second injection) will be paused.  
The safety data collected will be entered into the CRF, and will be summarized, and reviewed by 
the Sponsor. The SET will review the blinded and unclean data and prepare a recommendation 
that will be reviewed by the IDMC. The IDMC will also review the safety data and then provide 
recommendation as to whether vaccination of the first enrollees and the enrollment of remaining 
subjects should resume or not. The ESDR will be assessing the following safety parameters: 
• Immediate (within 30 minutes) AEs 
• Solicited injection site and systemic reactions 
• Unsolicited AEs reported as related by the Investigator within 14 days after the first injection 
• SAEs and AESIs (including serious and non-serious AESIs) 
Case unblinding may be performed if required. Moreover, some unblinded analyses may be 
provided by an independent Sanofi Pasteur statistician (ie, not involved either in the study or in 
the Dengue project) upon IDMC request. 
The decision regarding the continuation of vaccination of the 20 first enrollees and the enrollment 
of the remaining 130 subjects will be communicated to the Investigators and will be sent to the 
involved IECs/IRBs and to the IDMC for information. 
5.2 
Enrollment and Retention of Study Population 
5.2.1 
Recruitment Procedures 
Before the start of the study, Investigators and/or study staff will prepare a pre-screening data log 
listing eligible participants identified at least 4 weeks before the site begins recruitment. Using the 
most appropriate methods they will contact a pool of potential subjects and invite them to 
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participate in the study. Each site will ensure that all advertisements or materials planned to be 
used to recruit subjects (eg, letters, pamphlets, posters) are submitted to Sanofi Pasteur for review 
prior to submission to the IEC/IRB for approval. 
Enrollment will begin once the first site enrolls the first subject into CYD50. A review of the 
enrollment at each site will be made by the Sponsor on a monthly basis with the aim of identifying 
potential issues with the completion of enrollment within the planned timelines. Should the 
Sponsor consider that a site is at risk of not meeting its expected target enrollment (ie, 50 
subjects), this will be discussed with the site. If, after this discussion, there remains a risk to 
completion, Sanofi Pasteur reserves the right to re-allocate subject recruitment target from this site 
to another site. 
5.2.2 
Informed Consent Procedures 
Informed consent is the process by which a subject voluntarily confirms his or her willingness to 
participate in a particular study. Informed consent must be obtained before any study procedures 
are performed. The process is documented by means of a written, signed, and dated ICF. 
In accordance with GCP, prior to signing, and dating the consent form, the subject must be 
informed by appropriate study personnel about all aspects of the study that are relevant to making 
the decision to participate, and must have sufficient time and opportunity to ask any questions. 
If the subject is not able to read and sign the ICF, then it must be signed and dated by an impartial 
witness who is independent of the Investigator. A witness who signs and dates the consent form is 
certifying that the information in this form and any other written information had been accurately 
explained to and understood by the subject or his / her guardian / representative. 
The actual ICF used at each center may differ, depending on local regulations and IEC / IRB 
requirements. However, all versions must contain the standard information found in the sample 
ICF provided by the Sponsor. Any change to the content of the ICF must be approved by the 
Sponsor and the IEC / IRB prior to the form being used. 
If new information becomes available that may be relevant to the subject’s willingness to continue 
participation in the study, this will be communicated to him / her in a timely manner. Such 
information will be provided via a revised ICF or an addendum to the original ICF. 
ICFs will be provided in duplicate of the signed consent will be made. The original will be kept by 
the Investigator, and the copy will be kept by the subject. 
Documentation of the consent process should be recorded in the source documents. 
5.2.3 
Screening Criteria 
The Screening Visit will take place within 4 weeks before the first injection. After a potential 
participant has signed an IEC/IRB-approved ICF, she/he will have a blood sample drawn in order 
to be screened for previous exposure to dengue, HBsAg, HCV antibodiesa, and for any 
hematological (hemoglobin, hematocrit, platelet count, white blood cells count) or biochemical 
(aspartate aminotransferase, alanine aminotransferase, urea, and creatinine) abnormalities. If 
                                                 
a  Unless documented information on previous infections is already available at the time of screening. 
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serology, hematology, and biochemistry results are available and were obtained within 4 weeks 
before first injection, tests do not need to be performed again. 
Pre-injection HIV viral load and CD4 count will come from routine periodical tests of subjects as 
per local guidelines. For subjects for whom HIV viral load and CD4 count have not been assessed 
within 2 months before the Screening Visit, the Investigator will perform tests to ensure that 
results are available at the time of Visit 1. 
Subjects’ previous exposure to dengue will be assessed using a RDT (OnSite™ Dengue 
IgG/IgM3.0 Combo Rapid Test commercialized by CTK Biotech, Inc.) or an ELISA (Anti-
Dengue IgG ELISA commercialized by Euroimmun) if the RDT result is negative. Only subjects 
identified as dengue seropositive will be eligible to participate in the study.  
It is to be noted that subjects who previously tested negative by RDT for previous exposure to 
dengue can be re-screened using IgG ELISA. 
During the Screening Visit, applicable inclusion and exclusion criteria will be checked and a 
physical / clinical examination will be performed. 
5.2.4 
Inclusion Criteria 
Consent will be provided once at the Screening Visit. Inclusion criteria will be checked at 
Screening Visit and again at the first vaccination visit (V01 at D0). 
An individual must fulfill all of the following criteria to be eligible for study enrollment: 
1) Aged 18 to 50 years on the day of first study vaccination (study product administration) (“18 
to 50” means from the day of the 18th birthday to the day before the 51th birthday) 
2) ICF has been signed and dated 
3) Able to attend all scheduled visits and to comply with all trial procedures 
4) Documented seropositivity for HIV-1 infection based on the Brazilian HIV Guidelines’ 
laboratory criteria (ie, 2 positive results obtained from different and independent 
determination methods) or detectable HIV-1 viral load results in the past 
5) Stable HIV condition according to Brazilian HIV Guidelines (ie, with both CD4 count 
> 350 cells/mm3 and sustainable and undetectable HIV viral load [< 50 copies/mL]) for at 
least 1 year before consent 
6) Stable ART regimen based on local HIV protocol for at least 1 year before consent 
7) Previous exposure to dengue confirmed by RDT or dengue IgG ELISA 
5.2.5 
Exclusion Criteria 
Exclusion criteria will be checked at Screening Visit and again at the first vaccination visit (V01 
at D0). An individual fulfilling any of the following criteria is to be excluded from study 
enrollment: 
An individual fulfilling any of the following criteria is to be excluded from trial enrollment: 
1) Subject is pregnant, or lactating, or of childbearing potential (to be considered of non-
childbearing potential, a female must be pre-menarche or post-menopausal for at least 1 year, 
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surgically sterile, or using an effective method of contraception or abstinence from at least 
4 weeks prior to the first vaccination until at least 4 weeks after the last vaccination). 
2) Participation at the time of study enrollment (or in the 4 weeks preceding the first trial 
vaccination) or planned participation during the present trial period in another clinical trial 
investigating a vaccine, drug, medical device, or medical procedure. 
3) Receipt of any vaccine in the 4 weeks preceding the first trial vaccination or planned receipt 
of any vaccine in the 4 weeks following any trial vaccination. 
4) Previous vaccination against dengue disease with either the trial vaccine or another vaccine. 
5) Receipt of immune globulins, blood or blood-derived products in the past 3 months. 
6) Self-reported or suspected congenital or acquired immunodeficiency, except HIV; or receipt 
of immunosuppressive therapy such as anti-cancer chemotherapy or radiation therapy within 
the preceding 6 months; or long-term systemic corticosteroid therapy (prednisone or 
equivalent for more than 2 consecutive weeks within the past 3 months). 
7) Previous AIDS, defined as the occurrence of opportunistic infection in the last 2 years before 
consent. 
8) Known systemic hypersensitivity to any of the vaccine components, or history of a life-
threatening reaction to the vaccines used in the trial or to a vaccine containing any of the 
same substances. 
9) Deprived of freedom by an administrative or court order, or in an emergency setting, or 
hospitalized involuntarily. 
10) Current alcohol abuse or drug addiction. 
11) Chronic illness that, in the opinion of the Investigator, is at a stage where it might interfere 
with trial conduct or completion. 
12) Moderate or severe acute illness/infection (according to Investigator judgment) or febrile 
illness (temperature ≥ 38.0°C) on the day of vaccination. A prospective subject should not be 
included in the study until the condition has resolved or the febrile event has subsided. 
13) Identified as an Investigator or employee of the Investigator or study center with direct 
involvement in the proposed study, or identified as an immediate family member (ie, parent, 
spouse, natural or adopted child) of the Investigator or employee with direct involvement in 
the proposed study. 
14) Previous CD4 count < 200 cells/mm3 (nadir) since diagnosis of HIV 
15) History of chronic and active hepatitis B infection or HBsAg-positive 
16) History of chronic and active hepatitis C infection or HCV Ab-positive 
17) Aspartate aminotransferase (AST), alanine aminotransferase (ALT), urea and creatinine 
> 3 times the upper limit of normal range (ULN) 
18) Hemoglobin (Hb) < 10 g/dL 
19) White blood cell count (WBC) < 1500 cells/mm3 
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20) Platelets < 100 000 cells/mm3 
If the subject has a primary physician who is not the Investigator, the site should contact this 
physician with the subject’s consent to inform him / her of the subject’s participation in the study. 
In addition, the site should ask this primary physician to verify exclusion criteria relating to 
previous therapies, such as receipt of blood products or previous vaccines. 
5.2.6 
Medical History 
Prior to enrollment, subjects will be assessed for pre-existing conditions and illnesses, both past, 
and ongoing. Any such conditions will be documented in the source document. Significant 
(clinically relevant) medical history (reported as diagnosis) including conditions/illnesses for 
which the subject is or has been followed by a physician or conditions/illnesses that could resume 
during the course of the study or lead to an SAE or to a repetitive outpatient care will be collected 
in the CRB. The significant medical history section of the CRB contains a core list of body 
systems and disorders that could be used to prompt comprehensive reporting, as well as space for 
the reporting of specific conditions and illnesses. 
For each condition, the data collected will be limited to: 
• Diagnosis (this is preferable to reporting signs and symptoms) 
• Presence or absence of the condition at enrollment 
The reporting of signs and symptoms in lieu of a diagnosis is strongly discouraged. 
Dates, medications, and body systems are not to be recorded, and the information collected will not 
be coded. Its purpose is to assist in the later interpretation of safety data collected during the 
study. 
5.2.7 
Contraindications for Subsequent Vaccinations 
The CYD dengue vaccine should not be administered to seronegative persons. 
5.2.7.1 
Temporary Contraindications 
Should a subject experience one of the conditions listed below, the Investigator will postpone 
further vaccination until the condition is resolved. Postponement must still be within the 
timeframe for vaccination indicated in the Table of Study Procedures. 
• Moderate or severe acute illness/infection (according to Investigator judgment) or febrile 
illness (temperature ≥ 38.0°C) or any clinical condition on the day of vaccination, that 
according to the Investigator’s judgment could increase the risk of the subject in case of a new 
injection (this includes abnormal biological parameters [ie, hematic biometry, biochemistry] 
performed as per routine management of HIV assessment prior to injection). A subject should 
not receive a further injection until the condition has resolved or the febrile event has 
subsided. 
• Receipt of any vaccine within the 4 weeks preceding vaccination. 
• CD4 count pre-injection ≤ 350 cells/mm3 and/or detectable HIV viral load (≥50 copies/mL) 
based on a second confirmatory test 4 weeks later. A subject should not receive a further 
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vaccination until the CD4 count is > 350 cells/mm3 and the HIV viral load is undetectable 
(<50 copies/mL). Time windows for the next vaccination should be respected. 
5.2.7.2 
Definitive Contraindications 
Should a subject experience 1 of the conditions listed below, the Investigator will discontinue 
vaccination: 
1) Pregnancy, as indicated by a positive urine test 
2) Dengvaxia® administered inadvertently during the study (eg, as part of a vaccination 
campaign) 
3) An anaphylactic or other significant allergic reaction to the previous dose of vaccine 
4) Abnormal laboratory parameter of Grade 2 or 3 and assessed by the Investigator as related to 
the previous dose of vaccine 
5) Subject deprived of freedom by an administrative or court order, or in an emergency setting, 
or hospitalized without her/his consent 
6) Self-reported or suspected congenital or acquired immunodeficiency, except HIV, or receipt 
of immunosuppressive therapy such as anti-cancer chemotherapy or radiation therapy within 
the preceding 6 months, or long-term systemic corticosteroids therapy (prednisone or 
equivalent for more than 2 consecutive weeks within the past 3 months) 
7) Ongoing clinical AE related to the previous study vaccination, and in the Investigator's 
opinion, contraindicating further vaccination 
8) SAE related to the study vaccine following the previous study vaccination 
9) Confirmed CD4 count < 200 cells/mm3 
Subjects will not be withdrawn due to contraindication but will be followed-up for safety. Subjects 
will not be replaced. 
If a female subject who has already received at least one injection becomes pregnant during the 
study, she will continue to be followed for safety assessments until delivery or until 6 months after 
the last injection, whichever is the latest. No additional injections will be administered. 
Subjects with a definitive contraindication will continue to be followed-up for the study-defined 
safety and immunogenicity assessments, as applicable. 
5.2.8 
Conditions for Withdrawal 
Subjects will be informed that they have the right to withdraw from the study at any time. 
For example, a subject may be withdrawn from the study: 
• At the discretion of the Investigator or Sponsor due to safety concerns (withdrawal) or to 
significant non-compliance with the protocol (based on the Investigator’s judgment), without 
the subject’s permission 
• At the request of the subject (dropout) 
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The reason for a withdrawal or dropout should be clearly documented in the source documents 
and on the CRB. 
The Investigator must determine whether voluntary withdrawal is due to safety concerns (in which 
case, the reason for discontinuation will be noted as “AEs”) or for another reason. 
Withdrawn subjects will not be replaced. 
5.2.9 
Lost to Follow-up Procedures 
In the case of subjects who fail to return for a follow-up examination, documented reasonable 
effort (ie, documented telephone calls and certified mail) should be undertaken to locate or recall 
them, or at least to determine their health status while fully respecting their rights. These efforts 
should be documented in the source documents. 
5.2.10 Classification of Subjects Who Discontinue the Study 
For any subject who discontinues the study prior to completion, the most significant reason for 
early termination will be checked in the CRB. Reasons are listed below from the most significant 
to the least significant (refer to the CRF completion instructions for additional details and 
examples): 
Serious 
Adverse Event 
To be used when a subject drops out of or is withdrawn from the study by the 
Investigator because of the occurrence of an SAE, as defined in Section 9.1.1.1 
Adverse Event 
To be used when the subject is permanently terminated from the study because of an 
AE (including an SAE), as defined in Section 9.1.1.1. 
This category also applies if the subject experiences a definitive contraindication that 
is an SAE or AE. 
Non 
Compliance 
with Protocol 
To be used when the Investigator withdraws a subject from the study because of 
failure to follow the protocol, including when it is retrospectively discovered that a 
subject did not fulfill the eligibility criteria. The Investigator will provide a comment 
as to the specific cause of non-compliance. 
Lost to Follow-
up 
To be used when the subject cannot be found or contacted in spite of efforts to locate 
him/her before the date of his/her planned last visit, as outlined in Section 5.2.9. The 
certified letter was sent by the Investigator and returned unsigned, and the subject or 
parent/guardian did not give any other news and did not come to any following visit. 
Protocol 
Deviation 
To be used: 
• 
In case of significant non-compliance with the protocol (eg, deviation of the 
Inclusion / Exclusion criteria, non-compliance with time windows, blood 
sampling, or vaccination refusal, missed injection/treatment, or error in the 
vaccine/treatment administration) 
• 
If the subject experiences a definitive contraindication that is not an SAE or AE 
• 
The subject or the parent/guardian signed the certified letter sent by the 
Investigator but did not give any other news and did not come to any following 
visit 
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Withdrawal by 
Subject  
To be used: 
• 
When the subject or parent/guardian indicated unwillingness to continue in the 
study 
• 
When the subject or parent/guardian made the decision to discontinue 
participation in the study for any personal reason other than an SAE/AE (eg, 
subject is relocating, inform consent withdrawal, etc.) 
5.2.11 Follow-up of Discontinuations 
The site should complete all scheduled safety follow-ups and contact any subject who has 
prematurely terminated the study because of an AE or a protocol deviation. 
For subjects where the reason for early termination was lost to follow-up or if the subject 
withdrew informed consent and specified that they do not want to be contacted again and it is 
documented in the source document, the site will not attempt to obtain further safety information. 
If the subject’s status at the end of the study is “Withdrawal by Subject”, the site will attempt to 
contact them for the 6-month follow-up except if they specified that they do not want to be 
contacted again and it is documented in the source document. 
5.2.12 Follow-up and Reporting of Pregnancies 
Pregnancy is an exclusion criterion for enrollment in this study, but a subject could potentially 
become pregnant during her participation. In case of pregnancy during the study and if at least 1 
dose of the study vaccine(s) has been administered, the subject will not be discontinued from the 
study, but no further vaccination will be administered until after delivery (if applicable and still 
within the study vaccination window). However, the subject will be followed for safety 
assessment (and may be followed for immunogenicity assessment, if applicable). 
All pregnancy cases should be reported if they occurred during the study. To report the pregnancy 
case, the Investigator must fill out Pregnancy Reporting forms in the electronic data capture 
(EDC) system and inform the Sponsor within 1 month of identifying a pregnancy case. 
If the EDC system is not available, the Investigator must fill out a paper Pregnancy Reporting 
Form (provided by the Sponsor at the start of the study) and inform the Sponsor within 1 month of 
identifying a pregnancy case. 
Study staff must then maintain contact with the subject to obtain information about the outcome 
(ie, details about the delivery and the newborn, or about pregnancy termination) and must update 
the Pregnancy Reporting forms even after the end of the study. This information should be 
provided to the Sponsor within 1 month of delivery. 
Pregnancy itself is not considered an AE, but any complications during pregnancy are to be 
considered as AEs, and in some cases could be considered SAEs. Spontaneous abortions, blighted 
ovum, fetal death, stillbirth, and congenital anomalies reported in the baby are always considered 
as SAEs, and the information should be provided to the Global Pharmacovigilance (GPV) 
Department regardless of when the SAE occurs (eg, even after the end of the study). 
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5.3 
Safety Emergency Call 
If, as per the Investigator's judgment, a subject experiences a medical emergency, the Investigator 
may contact the Sponsor's RMO for advice on study related medical question or problem. If the 
RMO is not available, then the Investigator may contact the Call Center – available 24 hours a 
day, 7 days a week – that will forward all safety emergency calls to the appropriate primary or 
back-up Sanofi Pasteur contact, as needed. The toll-free contact information for the Call Center is 
provided in the Operating Guidelines. 
This process does not replace the need to report an SAE. The Investigator is still required to 
follow the protocol-defined process for reporting SAEs to the GPV Department (please refer to 
Section 10). 
In case of emergency code-breaking, the Investigator is required to follow the code-breaking 
procedures described in Section 6.4. 
5.4 
Modification of the Study and Protocol 
Any amendments to this study plan and protocol must be discussed with and approved by the 
Sponsor. If agreement is reached concerning the need for an amendment, it will be produced in 
writing by the Sponsor, and the amended version of the protocol will replace the earlier version. 
All substantial amendments (eg, those that affect the conduct of the study or the safety of subjects) 
require IEC / IRB approval, and must also be forwarded to regulatory authorities. 
An administrative / non-substantial amendment to a protocol is one that modifies some 
administrative, logistical, or other aspect of the study but does not affect its scientific quality or 
have an impact on the subjects’ safety. The IECs / IRBs and regulatory authorities must be notified 
of administrative changes and will provide approval according to local regulations. 
The Investigator is responsible for ensuring that changes to an approved study, during the period 
for which IEC / IRB approval has already been given, are not initiated without IEC / IRB review 
and approval, except to eliminate apparent immediate hazards to subjects. 
5.5 
Interruption of the Study 
The detection/fulfillment of the following safety signals will put the study on a temporary hold: 
• With regard to investigational products: 
• 
15% of the total subjects included in the study experience a Grade 3 solicited 
systemic reaction occurring within 14 days after any study injection and persisting 
for at least 48 hours and judged as related to the vaccination by the Investigator and 
not explained by any other possible etiology. 
and/or 
• 
3 SAE (including serious AESI) considered as related to the vaccination by the 
Investigator or the Sponsor, except for the SAEs corresponding to the HIV condition 
included below. 
• With regard to HIV condition: 
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• In 20% of the total subjects included in the study: Confirmed plasma HIV-1 RNA 
> 1000 copies/mL 28 days post-injection after having been undetectable 
(< 50 copies/mL) pre-injection, not explained by non-adherence to ART and not 
explained by any other possible etiology. 
or 
• 
In 10% of the total subjects included in the study: Confirmed decrease in CD4 
count greater than 30% assessed 28 days post-injection compared to the pre-injection 
value, not explained by non-adherence to ART and not explained by any other 
possible etiology. 
It is to be noted that any case of an increase in HIV-1 RNA > 1000 copies/mL or decrease in CD4 
count greater than 30% observed 28 days post-injection, not explained by non-adherence to ART 
and not explained by any other possible etiology, will be considered as an SAE. This increase in 
HIV viral load or decrease in CD4 count will be considered as “confirmed” if a second test taken 
4 weeks after the first (ie, approximately 2 months post-injection) shows the same value/trend. 
The IDMC will be immediately notified if either or both criteria occur in any of the subjects 
enrolled in the study. 
The IDMC will also be immediately notified when the percentage of subjects defined in one of the 
4 safety signals described above has been reached. The IDMC will then assess and recommend in 
an expedited way whether study enrollment and injections can continue, and/or whether other 
actions should be completed. In this scenario, additional biological tests may be required to assess 
the evolution of the subjects and to decide on the study continuation. 
Apart from the temporary hold following the enrollment of the first 20 subjects 
(see Section 5.1.6), and apart from a possible temporary hold following the detection of a safety 
signal, the study may be discontinued if new data about the investigational product resulting from 
this or any other studies become available; or for administrative reasons; or on advice of the 
Sponsor, the Investigators, the regulatory authorities in Brazil, and/or the IECs/IRBs. 
If the study is prematurely terminated or suspended, the Sponsor shall promptly inform the 
Investigators, the regulatory authorities, and the IECs/IRBs of the reason for termination or 
suspension, as specified by the applicable regulatory requirements. 
The Investigator will promptly inform the study subjects and assure appropriate therapy and/or 
follow-up for them. 
6 
Vaccines Administered 
6.1 
Identity of the Investigational Products 
Subjects will receive either 3 doses of the trial product, CYD dengue vaccine, or 3 doses of 
placebo as control product. 
These products will be administered on D0, D0 + 6 months, and D0 + 12 months. This study will 
be using the monodose presentation of the CYD dengue vaccine. 
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6.1.1 
Identity of Study Products 
Product: 
CYD Dengue Vaccine 
Vaccine: 
Live, attenuated, tetravalent dengue virus vaccine 
Presentation: 
Monodose 
Form: 
powder and solvent for suspension for injection 
Dose volume: 
0.5 milliliters (mL) of the reconstituted vaccine 
Route: 
Subcutaneous (SC) injection 
Batch number: 
To be defined 
6.1.1.1 
Composition 
Each 0.5 mL dose of reconstituted vaccine contains the following components: 
• Active Ingredients: 4.5–6 log10 cell-culture infectious dose 50% (CCID50) of each live, 
attenuated, recombinant, dengue virus serotype 1, 2, 3, 4 
• Excipients: essential amino acids, non-essential amino acids, L-arginine chlorhydrate, 
saccharose, D-trehalose dihydrate, D-sorbitol, Tris (hydroxymethyl) aminomethane, and urea 
• Solvent: NaCl 0.4% 
6.1.1.2 
Preparation and Administration 
Sanofi Pasteur’s CYD dengue vaccine consists of a powder and solvent for suspension for 
injection and must be stored between +2°C and +8°C (ie, in a refrigerator) and protected from 
light. 
The vaccine must be removed from the refrigerator, reconstituted with the solvent supplied for 
this purpose, and used immediately after reconstitution. 
The vaccine is to be administered subcutaneously in the deltoid region of the upper arm in a 
volume of 0.5 mL. 
Prior to administration, all study products must be inspected visually for cracks, broken seals, 
correct label content (see Section 6.3.1), and extraneous particulate matter and / or discoloration, 
whenever solution, and container permit. If any of these conditions exists, the vaccine must not be 
administered. A replacement dose is to be used, and the event is to be reported to the Sponsor. 
Subjects must be kept under observation for 30 minutes after each vaccination to ensure their 
safety, and any reactions during this period will be documented in the CRB. Appropriate medical 
equipment and emergency medications, including epinephrine (1:1000), must be available on site 
in the event of an anaphylactic, vasovagal, or other immediate allergic reaction. 
If a vial or syringe is accidentally broken and the product spilled out, appropriate disinfection 
procedures must be used (please refer to the Operating Guidelines and/or study center’s 
procedures). 
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6.1.1.3 
Dose Selection and Timing 
The CYD dengue vaccine will be administered in 3 doses with a 6-month interval between each 
dose as per the indication obtained for the vaccine licensed in Brazil. 
6.1.2 
Identity of Control Product 
6.1.2.1 
Composition 
Product: 
Placebo 
Form: 
Solution 
Vaccine: 
NaCl 0.9% 
Route: 
SC 
Batch number: 
To be determined 
6.1.2.2 
Preparation and Administration 
The product must be stored between +2°C and +8°C. 
The placebo must be removed from refrigerator. The placebo should not be used if particles are 
present in the solution. The placebo will be administered subcutaneously in the deltoid region of 
the upper arm in a volume of 0.5 mL. 
6.1.2.3 
Dose Selection and Timing 
Not applicable. 
6.2 
Identity of Other Product 
Not applicable. 
6.3 
Product Logistics 
6.3.1 
Labeling and Packaging 
CYD dengue vaccine and placebo will be supplied in vials/syringes and will be labeled and 
packaged according to national regulations. The information on the label will include: 
• Study code 
• Name of product and Group assignment 
• Route of injection 
• Investigational use only statement 
• Storage conditions 
• Batch number 
• Name of Sponsor 
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• Expiry date 
All the products will be identified for Group assignment by a dose number 
6.3.2 
Product Shipment, Storage, and Accountability 
6.3.2.1 
Product Shipment 
The Clinical Logistics Coordinator or designee will contact the Investigator or a designee to 
determine the dates and times of delivery of products. 
Each vaccine shipment will include a temperature-monitoring device to verify maintenance of the 
cold-chain during transit. On delivery of the product to the site, the person in charge of product 
receipt will follow the instructions given in the Operating Guidelines, including checking that the 
cold-chain was maintained during shipment (ie, verification of the temperature recorders). If there 
is an indication that the cold-chain was broken, this person should immediately quarantine the 
product, alert the Sanofi Pasteur representative, and request authorization from Sanofi Pasteur to 
use the product. 
6.3.2.2 
Product Storage 
The Investigator will be personally responsible for product management or will designate a staff 
member to assume this responsibility. 
At the site, products must be kept in a secure place with restricted access. Vaccines will be stored 
in a refrigerator at a temperature ranging from +2°C to +8°C and should be protected from light. 
The vaccines must not be frozen. The temperature must be monitored and documented (see the 
Operating Guidelines) for the entire time that the vaccine is at the study site. In case of accidental 
freezing or disruption of the cold-chain, vaccines must not be administered and must be 
quarantined, and the Investigator, or authorized designee should contact the Sanofi Pasteur 
representative for further instructions. 
6.3.2.3 
Product Accountability 
The person in charge of product management at the site will maintain records of product delivery 
to the study site, product inventory at the site, the dose(s) given to each subject, and the disposal 
of, or return to the Sponsor of unused doses. 
The necessary information on the product labels is to be entered into the source document and the 
CRB. If applicable, information may also be entered into the subject’s vaccination card. 
The Sponsor’s monitoring staff will verify the study site’s product accountability records against 
the record of administered doses in the CRBs and the communication from the IRT (if applicable). 
In case of any expected or potential shortage of product during the study, the Investigator, or an 
authorized designee should alert the Sanofi Pasteur representative as soon as possible, so that a 
shipment of extra doses can be arranged. 
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6.3.3 
Replacement Doses 
If a replacement dose is required (eg, because the syringe broke or particulate matter was 
observed in the syringe), the site personnel must either contact the IRT to receive the new dose 
allocation, or follow the instructions given in the Operating Guidelines. 
6.3.4 
Disposal of Unused Products 
Unused or wasted products will be either disposed of or returned to the Sponsor in accordance 
with the instructions in the Operating Guidelines. Product accountability will be verified 
throughout the study period. 
6.3.5 
Recall of Products 
If the Sponsor makes a decision to launch a retrieval procedure, the Investigators will be informed 
of what needs to be done. 
6.4 
Blinding and Code-breaking Procedures 
An observer-blind procedure will be followed for the injection of CYD dengue vaccine or 
placebo. Neither the observer Investigator, nor the Sponsor, nor the subjects know which product 
will be administered. The “vaccinator” will be in charge of preparing and administering the 
products and will not be authorized to collect any safety data, nor will she/he be involved in safety 
assessment. In addition, the “vaccinator” or authorized designee will have to ensure that the 
documents on randomization are stored in a secure place where only she/he has access. 
The code may be broken in the event of an AE only when the identification of the vaccine 
received could influence the treatment of the subject. Code-breaking should be limited to the 
subject(s) experiencing the AE. 
The blind can be broken by the Investigator or a delegate through the IRT system, as explained in 
the code-breaking procedures described in the Operating Guidelines. Once the emergency has 
been addressed by the site, the Investigator, or a delegate must notify the Sanofi Pasteur RMO if a 
subject’s code was broken. All contact attempts with the Sponsor prior to unblinding are to be 
documented in the source documents, and the code-breaking CRF is to be completed. 
A request for the code to be broken may also be made: 
• by the GPV Department through an internal system for reporting to health authorities in the 
case of an SAE as described in International Conference on Harmonisation (ICH) E2A. In this 
case, the code will be broken only for the subject(s) in question. The information resulting 
from code-breaking (ie, the subject’s vaccine or Group assignment) will not be communicated 
to either the Investigator or the immediate team working on the study, except for the GPV 
representative. 
• by the IDMC if needed to facilitate their assessment of safety. 
The IEC / IRB must be notified of the code-breaking. All documentation pertaining to the event 
must be retained in the site’s study records and in the Sanofi Pasteur files. Any intentional or 
unintentional code-breaking must be reported, documented, and explained, and the name of the 
person who requested it must be provided to the Sponsor. 
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Although the ESDR performed when the 20 first subjects have received the first injection does not 
require the unblinding of data, unblinding can be performed at this review, if required. Moreover, 
some unblinded analyses may be provided by an independent Sanofi Pasteur statistician (ie, not 
involved either in the study or in the Dengue project) upon IDMC request. 
A planned analysis will be performed on data collected up to 28 days post-Inj 3 of the last subject 
enrolled. This analysis will require the unblinding of data. 
A second and final analysis will be performed at the end of the study. 
Testing performed within GCI and GCI outsourced laboratories are blinded with respect to study 
treatment Group assignment. The code(s) linking information on sample vials to study treatment 
Group assignment are retained by the Clinical Department and cannot be accessed by GCI or 
contract laboratory testing personnel. 
6.5 
Randomization and Allocation Procedures 
Each eligible subject (ie, meets inclusion criteria, and does not fulfill any exclusion criteria) will 
be randomly assigned to 1 of the 2 groups via an IRT, according to a 2:1 ratio (2 subjects included 
in the CYD Dengue Vaccine Group for 1 subject included in the control Group). Site staff will 
connect to the IRT, enter identification and security information, and confirm a minimal amount 
of data in response to IRT prompts. The IRT will then state the vaccine assignment (code 
number). Subject numbers will be recorded in the CRB and will not be reassigned for any reason. 
The full detailed procedures for randomization are described in the Operating Guidelines. 
Subject numbers that are assigned by the IRT system will consist of a 12-digit string (a 3-digit 
country code, a 4 digit study center identifier, and a 5-digit subject identifier connected by “-”). 
For example, Subject 0760001-00001 is the first subject enrolled in center number 1 in Brazil 
(076 being Brazil country code). Subject numbers should not be reassigned for any reason. The 
randomization codes will be kept securely in the IRT. 
Randomization will be performed with permuted block method with stratification by site. 
A double randomization system will be used, this implies that the subject treatment allocation will 
be separated from doses dispensing. Each dose will have both a code number and a dose number. 
The code number will be used by the IRT while the dose number will be entered in the CRB. The 
unique dose numbers will be defined according to a random list to ensure that dose numbers 
cannot be used to distinguish between treatment groups. 
The R&D Site Quality Operations Department at Sanofi Pasteur will hold the randomization 
codes in a secured location. 
Notes:  
• Subjects who previously tested negative by RDT for previous exposure to dengue can be re-
screened using IgG ELISA. Subjects who are re-screened will be allocated a new subject 
number. 
• If a subject is eligible but not randomized during the ESDR hold, the subject will be asked to 
come back to the site after the hold. The subject will then be re-screened and randomized. 
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However, the subject will not be re-tested for previous exposure to dengue by RDT or IgG 
ELISA. The subject will be allocated a new subject number. 
6.6 
Treatment Compliance 
The following measures will ensure that the vaccine doses administered comply with those planned, 
and that any non-compliance is documented so that it can be accounted for in the data analyses: 
• All vaccinations will be administered by qualified study personnel 
• The person in charge of product management at the site will maintain accountability records 
of product delivery to the study site, product inventory at the site, dose(s) given to each 
subject, and the disposal of unused or wasted doses 
6.7 
Concomitant Medications and Other Therapies 
At the time of enrollment, ongoing medications and other therapies (eg, blood products) should be 
recorded in the source document as well as new medications prescribed for new medical 
conditions / AEs during study participation. 
Documentation in the CRB of ongoing concomitant medication(s) will be limited to specific 
categories of medication(s) of interest beginning on the day of vaccination. This may include 
medications of interest that were started prior to the day of vaccination. 
Reportable medications will be collected in the CRB from the day of each vaccination to the end 
of the solicited and unsolicited follow-up period (eg, 28-day safety follow-up) as they may impact 
the response to the vaccination and impact the consistency of the information collected on 
concomitant medications at any vaccination. 
Reportable medications include medications that impact or may impact the consistency of the safety 
information collected after any vaccination and/or the immune response to vaccination. Three standard 
categories of reportable medications are defined: 
• Category 1: medications impacting or that may have an impact on the evaluation of the safety 
(eg, antipyretics, analgesics, and non-steroidal anti-inflammatory drugs [NSAIDs], 
steroids/corticosteroids). Note: inhaled and topical steroids should not be captured. 
• Category 2: medications impacting or that may have an impact on the immune response. 
• 
Immunosuppressive therapy such as anti-cancer chemotherapy or radiation therapy or 
long-term systemic corticosteroids (for more than 2 consecutive weeks) in the 4 weeks 
after study injection 
• 
Immune globulins, blood or blood-derived products in the 3 months before the first study 
injection, in the 4 weeks before second and third injection, and in the 4 weeks after any 
injection 
• 
Any vaccine (other than the study vaccine) in the 4 weeks before second and third 
injection, and in the 4 weeks after any injection 
• Category 3: medications impacting or that may have an impact on both the safety and the 
immune response (eg, steroids/corticosteroids) 
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The information reported in the CRB for each reported medication will be limited to: 
• Trade name. 
• Origin of prescription: prophylaxis Yes/No. Medication(s) prescribed for AE prophylaxis will 
be recorded in the Action Taken of the AE collection tables. 
• Medication category (1, 2, or 3). 
• Start and stop dates. 
Dosage and administration route, homeopathic medication, topical, and inhaled steroids, as well 
as topical, ophthalmic, and ear treatments will not be recorded. Topical analgesics should not be 
applied at the site of vaccination; however, if they are applied inadvertently to the vaccination site, 
they should be recorded as a Category 1 medication in this specific instance. 
Medications given in response to an AE will be captured in the “Action Taken” section of the AE 
CRF only. No details will be recorded in the concomitant medication CRF unless the medication(s) 
received belongs to one of the pre-listed categories. Medications will not be coded. 
7 
Management of Samples 
Blood samples for the assessment of: 
• Screening characteristics will be collected at Screening Visit (if results not already available 
from routine periodical tests) 
• Dengue, YF, and Zika baseline status will be collected at Visit 1 
• Dengue neutralizing Abs, CD4 count, and HIV viral load will be collected at Visits 4, 6, and 8 
• Dengue vaccinal viremia will be collected at Visits 2 and 3 
See the Table of Study Procedures and Section 5.1 for details of the sampling schedule. 
7.1 
Sample Collection 
7.1.1 
Blood Samples 
All the following blood samples will be collected in tubes provided by or recommended by the 
Sponsor. Immediately prior to the blood draw, the staff member performing the procedure will 
verify the subject’s identity; will write the assigned subject's number on the pre-printed label that 
contains that subject’s number and the sampling stage; and will attach the label to the tube. When 
vaccination and blood sample collection occur at the same Visit and vaccine is given only in one 
of the arms, blood is to be taken from the limb opposite to the one that will be used for 
vaccination. 
7.1.1.1 
Blood Sample for Screening Characteristics Assessment 
Approximately 14 mL (according to local laboratories) of blood will be collected from potential 
subjects in order to perform laboratory tests, including assessment of previous exposure to 
dengue, HBsAg, HCV Ab, hematology (hemoglobin, hematocrit, platelet count, white blood cells 
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count), biochemistry (AST, ALT, urea, and creatinine)a. For subjects for whom HIV viral load 
and CD4 count have not been assessed within 2 months before the Screening Visit, an additional 
volume of blood (10 mL per test) will be required before the Screening Visit to perform the tests. 
The screening analyses will be performed at local laboratories. For subjects for whom these tests 
have been performed in appropriate time windows (within 4 weeks before injection for hepatitis 
serology, hematology, and biochemistry; within 2 months for HIV viral load and CD4 count) as 
part of the subject’s routine follow-up, no new tests will be required. 
Also, subject’ previous exposure to dengue will be assessed using a RDT (OnSite™ Dengue 
IgG/IgM3.0 Combo Rapid Test commercialized by CTK Biotech, Inc.) or ELISA (Anti-Dengue 
IgG ELISA commercialized by Euroimmun).  
7.1.1.2 
Blood Sample for Dengue, YF, and Zika Serostatus, Dengue Neutralizing 
Antibodies, CD4 Count, and HIV Viral Load Assessments 
At V01 (before first vaccination injection) for all subjects, 9 mL of blood will be collected in 
order to assess dengue, YF, and Zika status, as well as baseline dengue neutralizing Ab levels 
(PRNT). 
At V04, V06, and V08 for all subjects, 24 mL of blood will be collected in order to assess dengue 
neutralizing Ab levels, CD4 count, and HIV viral load, 28 days post-injection. See Table 5.1 for 
blood samples volumes for each laboratory test. 
In addition, for subjects for whom HIV viral load and CD4 count have not been assessed within 
2 months before Inj 2 (Visit 5) or Inj 3 (Visit 7), an additional volume of blood (10 mL per test) 
will be required before injection visits to perform the tests and check the contraindication to 
further vaccination. The tests will be performed at local laboratories. 
7.1.1.3 
Blood Sample for Dengue Vaccinal Viremia 
At V02 and V03 for all subjects, 4 ml of blood will be collected in order to evaluate post-Inj 1 
vaccinal viremia. 
7.1.2 
Blood Sample for Virological Confirmation of Suspected Hospitalized Dengue 
Disease and Assessment of Disease Severity 
In case of hospitalized suspected dengue disease, a 3 mL acute blood sample will be collected 
(within the 5 days after the fever onset). The acute blood sample for all suspected hospitalized 
dengue cases should be collected within the pre-specified timeframe as described above. If this 
cannot be accomplished, this sample should still be obtained as soon as possible thereafter, for 
IDMC severity assessment. This blood sample will be used to confirm dengue disease, and upon 
confirmation of infection to identify the WT dengue virus serotype. 
Additionally, and for all hospitalized suspected dengue cases, the Investigator must ensure that 
key biological parameters (hematocrit, platelet count, AST, and ALT) have been checked or are 
                                                 
a HBsAg and HCV tests will not be performed in case documented information is already available in subject's 
medical history 
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planned to be checked as part of local standard of care at the hospital (ideally within the 5 days 
after the fever onset). If these parameters have not been measured, additional blood specimens 
will be takena. The aim of these tests is the assessment of severity according to the WHO/IDMC 
classification. 
Table 7.1 presents the additional serum aliquots in the event of a suspected hospitalized dengue 
disease at any time during the study. 
 
Table 7.1: Blood Sampling Volume (mL) for Suspected Hospitalized Dengue Case 
 
Blood volume (mL) 
GCI (USA) or GCI 
outsourced laboratory 
 
Dengue Screen RT-PCR & 
Simplexa™ dengue RT-PCR 
1 
Serum sample for retesting 
1 
Dengue NS1 Ag ELISA 
1 
Local laboratory (if needed) 
x* 
TOTAL 
 
3 + x 
*The volume of blood samples will depend on local laboratory needs. 
More detailed instructions are provided in the Operating Guidelines. 
7.1.3 
Urine Samples for Pregnancy Test 
A minimum of 6 mL of first-stream urine will be collected directly in 2 sterile tubes before any 
vaccination (ie, at V01, V05, and V07). Labeling procedures will be done the same way as for 
blood samples (see Section 7.1.1). 
7.2 
Sample Preparation 
Detailed instructions on how to prepare blood samples for assessment of immune response are 
contained in the Operating Guidelines provided to the site. An overview of the procedures is 
provided here. 
7.2.1 
Blood Sample Preparation 
7.2.1.1 Screening Characteristics Assessment 
The preparation of the blood samples for the assessment of screening characteristics (ie, serology, 
hematology, biochemistry) will be done according to local laboratories. The determination of 
previous dengue exposure will be done according to the RDT and ELISA Manufacturer’s 
instructions. 
                                                 
a  The volume of blood samples will depend on local laboratory needs. 
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7.2.1.2 
CD4 Count and and HIV-1 Viral Load 
The preparation of the blood samples for the CD4 count and for the HIV viral load assessment 
will be done according to local laboratories. 
7.2.1.3 
Dengue, YF, and Zika Serostatus at Baseline; Dengue Neutralizing Abs, Vaccinal 
Viremia, and Wild-Type Dengue Viremia 
Following the blood draw, the sampling tube should be stored at room temperature for a minimum 
of 60 minutes and a maximum of 2 hours to allow the blood to clot before centrifugation. The tube 
must be stored vertically and will not be shaken. Beyond 2 hours, the sampling tube must be 
refrigerated at a temperature of 2°C to 8°C and must be centrifuged within a maximum of 
24 hours. 
After being allowed to clot, blood samples for serum Ab response, vaccinal viremia, and WT 
dengue viremia assessments will be centrifuged before being divided into appropriate aliquots of 
serum. Samples will then be handled one subject at a time to avoid a mix-up of subjects’ blood 
tubes. Serum will be transferred to the appropriate number of tubes, pre-labeled with adhesive 
labels that clearly identify the subject’s number and sampling stage or Visit number. 
The subject’s identification number, the date of sampling, the number of aliquots obtained, and 
the date and time of preparation are to be specified on a sample identification list and recorded in 
the source document. Space is provided on this list for comments on the quality of samples. 
Serum will be aliquoted and frozen as specified in the Operating Guidelines. 
7.2.2 
Urine Samples 
Urine samples for pregnancy tests at the vaccination visits will be taken and analyzed at the study 
center. 
7.3 
Sample Storage and Shipment 
During storage, serum tubes are to be kept in a freezer whose temperature is set and maintained at 
-70°C or below. The temperature will be monitored and documented on the appropriate form 
during the entire study. If it rises above -10°C for any period of time, the Clinical Logistics 
Coordinator must be notified. See the Operating Guidelines for further details. 
Shipments to the laboratories will be made only after appropriate monitoring, and following 
notification of the Clinical Logistics Coordinator. Sera will be shipped frozen, using dry ice to 
maintain them in a frozen state, in the packaging container provided by the carrier. Again, 
temperatures will be monitored. Shipments must be compliant with the United Nations Class 6.2 
specifications and the International Air Transport Association (IATA) 602 packaging instructions. 
Samples will be shipped to GCI at Sanofi Pasteur. The address is provided in the Operating 
Guidelines. 
7.4 
Future Use of Stored Biological Samples for Research 
Any unused part of the serum samples may be used for additional tests related to dengue immune 
response that may not be available at the writing of this protocol. These serum samples will be 
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securely stored at the Sanofi Pasteur serology laboratory (GCI) for up to 10 years. Storage for a 
longer period is possible but will require approbation from Brazilian Authorities. In agreement 
with Brazilian local regulation, these samples will not be used for any testing other than that 
related to the present study (eg, retesting of dengue neutralizing Abs, assessment of FV status). 
These samples are being retained in long-term storage to support answers to regulatory questions 
related to the product’s licensure and the potential revalidation of the study results. 
The other biological samples collected to qualify the subject for inclusion in the study or to 
monitor the subject’s health are dedicated for immediate use. In case they are not completely used 
up, they will be destroyed at the latest at the end of the study or after the time requested by local 
law. 
Any new research to be done using the biological samples collected in the study will be submitted 
for IEC/IRB approval. The subject will have to provide her/his consent to every new research that 
might be performed with their stored samples. When it is not possible to obtain the subject’s 
consent, Sanofi Pasteur will request the IEC/IRB’s authorization to use biological samples stored 
at GCI. 
8 
Clinical Supplies 
Sanofi Pasteur will supply the study sites with protocols, ICFs, CRBs, SAE reporting forms, diary 
cards, MAs, and other study documents, as well as with the following study materials: all study 
vaccines, blood collection tubes, cryotubes, cryotube storage boxes, cryotube labels, temperature 
recorders, shipping containers, rulers, and digital thermometers. 
The means for performing EDC will be defined by Sanofi Pasteur. If a computer is provided by 
Sanofi Pasteur, it will be retrieved at the end of the study. 
The Investigator will supply all vaccination supplies, phlebotomy, and centrifugation equipment, 
including biohazard and / or safety supplies. The biohazard and safety supplies include needles 
and syringes, examination gloves, laboratory coats, sharps disposal containers, and absorbent 
countertop paper. The site will ensure that all biohazard wastes are autoclaved and disposed of in 
accordance with local practices. The Investigator will also supply appropriate space in a 
temperature-monitored refrigerator for the storage of the products and for the blood samples, and 
appropriate space in a temperature-monitored freezer for serum aliquots. 
In the event that additional supplies are required, study staff must contact Sanofi Pasteur, 
indicating the quantity required. Contact information is provided in the Operating Guidelines. 
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9 
Endpoints and Assessment Methods 
9.1 
Primary Endpoints and Assessment Methods 
9.1.1 
Safety 
9.1.1.1 
Safety Definitions 
The following definitions are taken from the ICH E2A Guideline for Clinical Safety Data 
Management: Definitions and Standards for Expedited Reporting. 
Adverse event (AE): 
An AE is any untoward medical occurrence in a patient or in a clinical investigation subject 
administered a medicinal product and which does not necessarily have a causal relationship with 
this treatment. An AE can therefore be any unfavorable and unintended sign (including an 
abnormal laboratory finding, for example), symptom, or disease temporally associated with the 
use of a medicinal product, whether, or not considered related to the medicinal product. 
Therefore an AE may be: 
• A new illness 
• The worsening of a pre-existing condition 
• An effect of the vaccination, including the comparator 
• A combination of the above 
All AEs include serious and non-serious AEs. 
Surgical procedures are not AEs; they are the actions taken to treat a medical condition. It is the 
condition leading to the action taken that is the AE (if it occurs during the study period). 
Pre-existing medical conditions are not to be reported as AEs. However, if a pre-existing medical 
condition worsens following study interventions in frequency or intensity, or if according to the 
Investigator there is a change in its clinical significance, this change should be reported as an AE 
(exacerbation). This applies equally to recurring episodes of pre-existing conditions (eg, asthma) 
if the frequency or intensity increases post-vaccination. 
Serious adverse event (SAE): 
Serious and severe are not synonymous. The term severe is often used to describe the intensity of 
a specific event as corresponding to Grade 3. This is not the same as serious, which is based on 
subject / event outcome or action criteria usually associated with events that pose a threat to a 
subject’s life or functioning. Seriousness, not severity, serves as a guide for defining regulatory 
reporting obligations. 
An SAE is any untoward medical occurrence that at any dose 
• Results in death 
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• Is life-threateninga 
• Requires inpatient hospitalization or prolongation of existing hospitalizationb 
• Results in persistent or significant disability / incapacityc 
• Is a congenital anomaly / birth defect 
• Is an important medical event (IME) 
Medical and scientific judgment should be exercised in deciding whether expedited reporting 
is appropriate in other situations, such as IMEs that may not be immediately life-threatening or 
result in death or hospitalization but may jeopardize the health of the subject or may require 
intervention to prevent one of the other outcomes listed in the definition above. These IMEs 
should also usually be considered serious. Examples of such events include allergic 
bronchospasm requiring intensive treatment in an emergency room or at home, blood 
dyscrasias or convulsions that do not result in inpatient hospitalization, or the development of 
drug dependency or drug abuse, new-onset diabetes, or autoimmune disease. 
Adverse reaction: 
All noxious and unintended responses to a medicinal product related to any dose should be 
considered AR. 
(The phrase “responses to a medicinal product” means that a causal relationship between a 
medicinal product and an AE is at least a reasonable possibility) 
The following additional definitions are used by Sanofi Pasteur: 
Immediate event/reaction: 
Immediate events are recorded to capture medically relevant unsolicited systemic AEs (including 
those related to the product administered) that occur within the first 30 minutes after vaccination. 
Solicited reaction: 
A solicited reaction is an “expected” adverse reaction (sign or symptom) observed and reported 
under the conditions (nature and onset) pre-listed in the protocol and CRB (eg, injection site pain 
between D0 and D7 post-vaccination, or headache between D0, and D7). 
By definition, solicited reactions are to be considered as being related to the product administered. 
For injectable vaccines, solicited reactions can either be solicited injection site reactions or 
solicited systemic reactions. 
                                                 
a  The term “life-threatening” refers to an event in which the subject was at risk of death at the time of the event; it 
does not refer to an event which hypothetically might have caused death if it were more severe. 
b  All medical events leading to hospitalizations will be recorded and reported as SAEs, with the exception of: 
hospitalization planned before inclusion into the study or outpatient treatment with no hospitalization. 
c  “Persistent or significant disability or incapacity” means that there is a substantial disruption of a person’s ability 
to carry out normal life functions. 
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 Unsolicited AE / AR: 
An unsolicited AE is an observed AE that does not fulfill the conditions pre-listed in the CRB in 
terms of diagnosis and/or onset window post-vaccination. For example, if headache between D0 
and D7 is a solicited reaction (ie, pre-listed in the protocol and CRB), then a headache starting on 
D7 is a solicited reaction, whereas headache starting on D8 post-vaccination is an unsolicited AE. 
Unsolicited AEs includes both serious (SAEs) and non-serious unsolicited AEs. 
Injection site reaction: 
An injection site reaction is an AR at and around the injection site. Injection site reactions are 
commonly inflammatory reactions. They are considered to be related to the product administered. 
Systemic AE: 
Systemic AEs are all AEs that are not injection or administration site reactions. They therefore 
include systemic manifestations such as headache, fever, as well as localized or topical 
manifestations that are not associated with the vaccination or administration site (eg, erythema 
that is localized but that is not occurring at the injection site). 
Adverse event of special interest (AESI): 
An adverse event of special interest is one of scientific and medical concern specific to the 
Sponsor’s product or program, for which ongoing monitoring, and rapid communication by the 
Investigator to the Sponsor can be appropriate. Such an event might warrant further investigation 
in order to characterize and understand it. Depending on the nature of the event, rapid 
communication by the study Sponsor to other parties (eg, regulators) might also be warranted. 
9.1.1.2 
Safety Endpoints 
The primary endpoints for the evaluation of safety are: 
• 
Occurrence of any unsolicited systemic AE reported within 30 minutes after each 
injection 
• 
Occurrence of solicited (ie, pre-listed in the subject's DC and in the CRB) injection site 
reactions (pain, erythema, and swelling) occurring up to 7 days after each injection 
• 
Occurrence of solicited systemic reactions (fever, headache, malaise, myalgia, and 
asthenia) occurring up to 14 days after each injection 
• 
Occurrence of unsolicited AEs occurring up to 28 days after each injection 
• 
Occurrence of serious and non-serious AESIs in defined time windows according to the 
type of AESI 
• 
Occurrence of SAEs throughout the trial (ie, from D0 through the end of the study) 
• 
Occurrence of hospitalized VCD cases throughout the study (ie, from D0 through the end 
of the study) 
Other endpoints will be recorded or derived as described in the Statistical Analysis Plan. 
Depending on the item, these could include: nature (Medical Dictionary for Regulatory Activities 
[MedDRA] preferred term), time of onset, duration, number of days of occurrence, Grade of 
severity, relationship to vaccine, action taken, whether the event/reaction led to early termination 
from the study, seriousness, or outcome. 
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9.1.1.3 
Safety Assessment Methods 
At each vaccination Visit, the Investigator or a delegate will perform a clinical or medically-
driven physical examination, and will ask the subject about any solicited reactions and unsolicited 
AEs recorded in the diary card, as well as about any other AEs that may have occurred since the 
previous Visit. All relevant data will be transcribed into the CRB according to the instructions 
provided by the Sponsor. 
9.1.1.3.1 
Immediate Post-vaccination Observation Period 
Subjects will be kept under observation for 30 minutes after each vaccination to ensure their 
safety. The post-vaccination observation should be documented in the source document. Any AE 
that occurs during this period will be noted on the source document and recorded in the CRB, as 
follows: 
• Unsolicited systemic AEs will be recorded as immediate AEs in the CRB (presence marked as 
“yes” and details collected) 
• Solicited and unsolicited injection site reactions and solicited systemic reactions will be 
recorded in the CRB in the same way as any reactions starting on the day of vaccination 
• SAEs will be recorded in the CRB and reported to the Sponsor in the same way as any other 
SAEs, according to the procedures described in Section 10. 
9.1.1.3.2 
Reactogenicity (Solicited Reactions From Day 0 to Day 7/D14 After Each 
Vaccination) 
After the first vaccination, subjects will be provided with a diary card, a digital thermometer, and 
a flexible ruler, and will be instructed how to use them. The following items will be recorded by 
the subjects in the diary card on the day of vaccination and for the next 7 days (ie, D0 to D7) until 
resolution: 
• Daily temperature, with the route by which it was taken 
• Daily measurement or intensity Grade of all other solicited injection site and systemic 
reactions 
• Action taken for each event (eg, medication) 
The action(s) taken by the subject to treat and/or manage any solicited reactions will be 
classified in the CRB using the following list (all applicable items should be checked): 
• None 
• Medication 
• Health care provider contact 
• Hospitalized 
• Discontinuation of study vaccination 
Table 9.1 and Table 9.2 present, respectively, the injection site reactions and systemic reactions 
that are pre-listed in the diary cards and CRB, together with the intensity scales. 
 
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Table 9.1: Solicited injection site reactions: terminology, definitions, and intensity scales 
CRB term 
(MedDRA lowest 
level term [LLT]) 
Injection site pain 
Injection site erythema 
Injection site swelling  
Diary card term 
Pain 
Redness 
Swelling 
Definition 
Pain either present spontaneously or when the 
injection site is touched or injected limb is mobilized 
Presence of a redness including the 
approximate point of needle entry 
Swelling at or near the injection site 
Swelling or edema is caused by a fluid 
infiltration in tissue or cavity and, 
depending on the space available for the 
fluid to disperse, swelling may be either soft 
(typically) or firm (less typical) to touch and 
thus can be best described by looking at the 
size of the swelling 
Intensity scale* 
 
Grade 1: A type of AEs that is usually transient and 
may require only minimal treatment or therapeutic 
intervention. The event does not generally interfere 
with usual activities of daily living. 
Grade 2: A type of AEs that is usually alleviated 
with additional therapeutic intervention. The event 
interferes with usual activities of daily living, 
causing discomfort but poses no significant or 
permanent risk of harm to the research participant. 
Grade 3: A type of AEs that interrupts usual 
activities of daily living, or significantly affects 
clinical status, or may require intensive therapeutic 
intervention. 
Grade 1: ≥ 25 to ≤ 50 mm 
Grade 2: ≥ 51 to ≤ 100 mm 
Grade 3: > 100 mm 
Grade 1: ≥ 25 to ≤ 50 mm 
Grade 2: ≥ 51 to ≤ 100 mm 
Grade 3: > 100 mm 
* For the subjective reaction of pain, subjects will record the intensity level (Grade 1, 2, or 3) in the diary card. For the measurable reactions of redness and swelling, they will record 
just the size of the reaction, and the classification as Grade 1, 2, or 3 will be assigned at the time of the statistical analysis 
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Table 9.2: Solicited systemic reactions: terminology, definitions, and intensity scales 
CRB term 
(MedDRA 
lowest level 
term [LLT]) 
Fever 
Headache 
Malaise 
Myalgia 
Asthenia 
Diary card 
term 
Temperature 
Headache 
Feeling unwell 
Muscle aches and pains 
Weakness 
Definition 
Elevation of 
temperature to 
≥°38.0°C 
Pain or discomfort in the head or 
scalp. Does not include migraine 
General ill feeling. 
Malaise is a generalized feeling of 
discomfort, illness, or lack of well-
being that can be associated with a 
disease state. It can be accompanied 
by a sensation of exhaustion or 
inadequate energy to accomplish 
usual activities. 
Muscle aches and pains are common 
and can involve more than one muscle 
at the same time. Muscle pain can also 
involve the soft tissues that surround 
muscles. These structures, which are 
often referred to as connective tissues, 
include ligaments, tendons, and fascia 
(thick bands of tendons). 
Does not apply to muscle pain at the 
injection site which should be reported 
as injection site pain 
Generalized 
weakness 
Intensity 
scale* 
Grade 1: 
≥ 38.0°C to 
≤ 38.4°C 
Grade 1: A type of AEs that is 
usually transient and may require 
only minimal treatment or 
therapeutic intervention. The event 
does not generally interfere with 
usual activities of daily living 
Grade 1: A type of AEs that is 
usually transient and may require 
only minimal treatment or 
therapeutic intervention. The event 
does not generally interfere with 
usual activities of daily living. 
Grade 1: A type of AEs that is usually 
transient and may require only minimal 
treatment or therapeutic intervention. 
The event does not generally interfere 
with usual activities of daily living 
Grade 1: No 
interference with 
activity. 
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CRB term 
(MedDRA 
lowest level 
term [LLT]) 
Fever 
Headache 
Malaise 
Myalgia 
Asthenia 
 
Grade 2: 
≥ 38.5°C to 
≤ 38.9°C 
Grade 2: A type of AEs that is 
usually alleviated with additional 
therapeutic intervention. The event 
interferes with usual activities of 
daily living, causing discomfort but 
poses no significant or permanent 
risk of harm to the research 
participant 
Grade 2: A type of AEs that is 
usually alleviated with additional 
therapeutic intervention. The event 
interferes with usual activities of 
daily living, causing discomfort but 
poses no significant or permanent 
risk of harm to the research 
participant. 
Grade 2: A type of AEs that is usually 
alleviated with additional therapeutic 
intervention. The event interferes with 
usual activities of daily living, causing 
discomfort but poses no significant or 
permanent risk of harm to the research 
participant 
Grade 2: Some 
interference with 
activity. 
 
Grade 3: 
≥ 39.0°C 
Grade 3: A type of AEs that 
interrupts usual activities of daily 
living, or significantly affects 
clinical status, or may require 
intensive therapeutic intervention 
Grade 3: A type of AEs that 
interrupts usual activities of daily 
living, or significantly affects 
clinical status, or may require 
intensive therapeutic intervention. 
Grade 3: A type of AEs that interrupts 
usual activities of daily living, or 
significantly affects clinical status, or 
may require intensive therapeutic 
intervention 
Grade 3: 
Significant; 
prevents daily 
activity 
*  For all reactions but fever, subjects will record the intensity level (Grade 1, 2, or 3) in the diary card. For fever, they will record the body temperature, and the classification as 
Grade 1, 2, or 3 will be assigned at the time of the statistical analysis based on the unit used to measure the temperature and the intensity scale. 
 
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Important notes for the accurate assessment of temperature: 
Subjects are to measure body temperature once per day, preferably always at the same time. The 
optimal time for measurement is the evening, when body temperature is the highest. Temperature 
is also to be measured at the time of any apparent fever. The observed daily temperature and the 
route of measurement are to be recorded in the diary card, and the highest temperature will be 
recorded by the site in the CRB. The preferred route for this study is the axillary route. Pre-
vaccination temperature is also systematically collected by the Investigator on the source 
document. Tympanic thermometers must not be used. 
9.1.1.3.3 
Unsolicited Adverse Events 
In addition to recording solicited reactions, subjects will be instructed to record any other medical 
events that may occur during the 28-day period after each injection. Space will be provided in the 
diary card for this purpose. 
Information on SAEs will be collected and assessed throughout the study. SAEs related to study 
procedures and occurring between the Screening Visit and the first injection visit (V01), if 
applicable, will be first reported using a paper SAE Reporting Form, and then reported in the CRB 
for enrolled subjects. SAEs occurring from V01 until 6 months after the last injection will be 
directly reported in the CRB of subjects. Any SAE occurring at any time during the study will be 
reported by the Investigator in the CRB according to the completion instructions provided by the 
Sponsor; this includes checking the “Serious” box on the AE CRF and completing the appropriate 
Safety Complementary Information CRFs. All information concerning the SAE is to be reported 
either as part of the initial reporting or during follow-up reporting if relevant information became 
available later (eg, outcome, medical history, results of investigations, copy of hospitalization 
reports, and verbal autopsy questionnaire if used.).See Section 10 for further details on SAE 
reporting. 
For each unsolicited AE (whether serious or non-serious), the following information is to be 
recorded: 
• Start and stop datesa 
• Intensity of the event: 
For measurable unsolicited AEs that are part of the list of solicited reactions, the size of the 
AE as well as the temperature for fever will be collected and analyzed based on the 
corresponding scale used for solicited reactions (see Table 9.1 and Table 9.2). 
All other unsolicited AEs will be classified according to the following intensity scale: 
• Grade 1: A type of AEs that is usually transient and may require only minimal treatment or 
therapeutic intervention. The event does not generally interfere with usual activities of 
daily living. 
                                                 
a  The stop date of all related AEs will be actively solicited. For other events, the investigator will provide the stop 
date when it becomes available. AEs for which no stop date was obtained during the course of the study will be 
considered as ongoing at the end of the study. 
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• Grade 2: A type of AEs that is usually alleviated with additional therapeutic intervention. 
The event interferes with usual activities of daily living, causing discomfort but poses no 
significant or permanent risk of harm to the research participant. 
• Grade 3: A type of AEs that interrupts usual activities of daily living, or significantly 
affects clinical status, or may require intensive therapeutic intervention. 
• Whether the AE was related to the investigational product (for unsolicited systemic AEs) 
The Investigator will assess the causal relationship between the AE and the investigational 
product as either “Not related” or “Related”, as described in Section 9.1.1.3.5. 
• Action taken for each AE (eg, medication) 
The action(s) taken by the subject to treat and/or manage any unsolicited AEs will be 
classified in the CRB using the following list (all applicable items should be checked): 
• None 
• Medication 
• Health care provider contact 
• Hospitalized 
• Discontinuation of study vaccination 
• Whether the AE was serious 
For each SAE, the Investigator will complete all seriousness criteria that apply (outcome, 
elapsed time, and relationship to study procedures) 
• Whether the AE caused study discontinuation 
9.1.1.3.4 
Adverse Events of Special Interest 
Serious AESIs 
The following serious AESIs will be considered: 
• Serious hypersensitivity/allergic reactions occurring in all subjects within 7 days after 
vaccination 
• Serious viscerotropic disease occurring in all subjects within 30 days after vaccination 
• Serious neurotropic disease occurring in all subjects within 30 days after vaccination 
• Serious dengue disease requiring hospitalizationa occurring in all subjects at any time during 
the study 
Specific guidelines are provided to the Investigator to help in the assessment of AEs that may be 
indicative of viscerotropic or neurotropic disease (see Guidelines for Assessing Viscerotropic and 
Neurotropic AE). 
                                                 
a  A hospitalized subject is any subject admitted to hospital or any healthcare institution and providing in-patient 
care. 
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Non-Serious AESIs 
The following non-serious AESIs will be considered: 
• Hypersensitivity/allergic reactions occurring in all subjects within 7 days after vaccination. 
9.1.1.3.5 
Assessment of Causality 
The Investigator will assess the causal relationship between each unsolicited systemic AE and the 
product administered as either not related or related, based on the following definitions: 
Not related – The AE is clearly / most probably caused by other etiologies such as an 
underlying condition, therapeutic intervention, or concomitant therapy; or the delay 
between vaccination and the onset of the AE is incompatible with a causal relationship; or 
the AE started before the first vaccination (screening phase, if applicable) 
Related – There is a “reasonable possibility” that the AE was caused by the product 
administered, meaning that there is evidence or arguments to suggest a causal relationship 
Note: By convention, all AEs reported at the injection site (whether solicited or unsolicited) and 
all solicited systemic AEs are considered to be related to the administered product and therefore 
are referred to as reactions and do not require the Investigator’s opinion on relatedness. 
Adverse events likely to be related to the product, whether serious, or not, that persist at the end of 
the study will be followed-up by the Investigator until their complete disappearance or the 
stabilization of the subject’s condition. The Investigator will inform the Sponsor of the date of 
final disappearance of the event or the date of “chronicity” establishment. 
9.1.1.4 
Methods for Virological Confirmation of Suspected Dengue Disease and 
Assessment of Disease Severity 
In the event of a suspected hospitalized dengue case, the following tests will be performed based 
on the process described below. 
Dengue Screen RT-PCR 
Dengue screen RT-PCR test will be performed by Sanofi Pasteur GCI, Swiftwater, USA or GCI 
designated laboratory. 
Assessment and quantitation of dengue viremia is determined by testing serum samples with a 
nucleic-acid based assay. RNA is extracted from the serum to discard potential Taq polymerase 
inhibitors or interfering factors, using a commercial kit. Then, a RT-PCR is carried out with 
primers from a gene sequence conserved among dengue viruses. Due to a virus standard included 
in each run, results can be expressed as a concentration of log10 plaque forming unit (PFU)/mL. 
SimplexaTM Dengue RT-PCR 
Serotype identification of post-infectious dengue viremia is determined by testing serum samples 
with a nucleic-acid based assay. Briefly, RNA is extracted from the serum to discard potential 
polymerase inhibitors or interfering factors, using a commercial kit. Then the Simplexa™ dengue 
RT-PCR assay is carried out which incorporates serotype-specific primers from dengue 
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sequences. The results are expressed qualitatively and reported for each dengue serotype as 
detected or not detected.  
This assay will be used on all Dengue Screen RT-PCR positive or Dengue NS1 Ag ELISA (see 
below) positive samples for serotype identification. In addition sequencing analysis may be 
attempted on isolates from the serotyped samples. 
Dengue NS1 Ag ELISA  
The NS1 Ag ELISA will be performed using a commercially available kit: “PlateliaTM Dengue 
NS1 Ag” from Bio-Rad (Marnes-la-Coquette, France). The manufacturer’s instructions are 
followed. The Dengue NS1 Ag test is a one-step sandwich-ELISA based assay that enables 
detection of NS1 Ag in serum. The test uses murine monoclonal antibodies (MAbs) for capture 
and revelation. Samples and controls are directly and simultaneously incubated with the conjugate 
within the microplate wells coated with MAb. If NS1 Ag is present in the sample, an immune-
complex MAb-NS1-MAb/peroxidase will be formed. The presence of immune-complex is 
demonstrated by addition of a chromogenic solution that initiates a color development reaction. 
After 30 minutes of incubation at room temperature, the enzymatic reaction is stopped by addition 
of an acid solution. The optical density (OD) reading obtained with a spectrophotometer set at 
450/620 nm is proportional to the amount of NS1 Ag present in the sample. The presence of NS1 
Ag in an individual sample is determined by comparing the OD reading of the sample to the OD 
of the cutoff control serum. 
Sample ratios of < 0.5, ≥ 0.5 to ≤ 1.0, and > 1 will be indicative of negative, equivocal, and 
positive results, respectively. 
Hematology – Biochemistry 
Hematology and biochemistry parameters (hematocrit, platelet count, AST, and ALT) will be 
measured by local laboratories using standard methods as per routine standard of care in Brazil. 
However, the measurement of any of these biological parameters may be undertaken (or 
repeated), based on the Investigator’s judgment, to ensure the adequate evaluation of dengue 
disease severity. It is noteworthy that hematocrit and platelet counts are required parameters in the 
WHO/IDMC severity assessment protocol. These results will be collected in the eCRF. 
The assessment of biological parameters will be: within normal range or outside normal range. 
Normal ranges for each biological parameter will be provided by the local laboratory and 
collected in the eCRF. 
Interpretation of results 
If a sample is positive for the Dengue Screen RT-PCR (ie, ≥lower limit of quantification [LLOQ]) 
and/or the NS1 assay is positive and/or the Simplexa™ dengue RT-PCR is positive, this will be 
classified as a VCD infection. 
9.1.2 
Immunogenicity 
There are no primary objectives for immunogenicity. 
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9.1.3 
Efficacy 
There are no primary objectives for efficacy. 
9.2 
Secondary Endpoints and Assessment Methods 
9.2.1 
Safety 
9.2.1.1 
Safety Definitions 
The safety definitions are presented in Section 9.1.1.1. 
9.2.1.2 
Safety Endpoints 
• CYD dengue vaccinal viremia at 7 and 14 days post-Inj 1 
• CD4 count and HIV RNA viral load 28 days after each injection of CYD dengue vaccine 
9.2.1.3 
Safety Assessment Methods 
Vaccinal viremia 
YF RT-PCR (Non-Serotype-Specific Vaccine Viremia) 
Quantitation of non-serotype-specific vaccine viremia is determined by testing serum samples 
with a nucleic-acid based assay. YF virus RNA is extracted from the serum to discard potential 
Taq polymerase inhibitors or interfering factors, using a commercial kit. Then, a RT-PCR is 
carried out with primers from the YF core gene sequence. The inclusion of a standard in each run 
allows results to be expressed as a concentration of log10 PFU equivalents/mL or log10 Genomic 
Equivalents (GEq)/mL. 
This assay will be performed on blood samples taken at V02 and V03 on all subjects. 
CYD RT-PCR (Serotype-Specific Vaccine Viremia) 
Four RT-PCRs will be used to perform quantitation and serotype identification of post-vaccinal 
serotype-specific dengue vaccine viremia from serum samples displaying a positive YF RT-PCR 
result. Virus RNA is extracted from the serum to discard potential Taq polymerase inhibitors or 
interfering factors, using a commercial kit. Then a RT-PCR is carried out with serotype-specific 
primers from the envelope-NS1 junction gene sequence. Based on the dengue virus plasmidic 
standards included in each run, results can be expressed as a concentration of log10 GEq/mL. 
This assay will be performed only for YF RT-PCR-positive samples. 
CD4+ T-cell count 
Numeration of CD4 is determined by flow cytometry on unlyzed whole blood. When whole blood 
is added to the reagent tube (commercial kit), fluorochrome-labeled antibodies in the reagents 
bind specifically to white blood cell surface CD4+ antigens, and a fluorescent nuclear dye binds to 
the nucleated blood cells. After a fixative solution is added, the sample is run on the flow 
cytometer. As reagent tubes contain a known number of fluorescent reference beads, it is possible 
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to calculate the CD4 counts (cells/mm3) by comparing cellular events to bead events. This test 
will be performed in local laboratories. 
HIV-1 RNA viral load 
RT-PCR will be used to perform quantitation of HIV-1 viral load from serum samples using a 
commercial kit. After the amplification of a HIV-1 conserved target region, a fluorescent probe 
hybridizing with the target region allows quantifying the number of amplified HIV-1 RNA copies. 
Based on standards included in each run, results can be expressed as a number of copies/mL. This 
test will be performed in local laboratories following the local regulations on routine management 
of HIV-positive patients (48). 
9.2.2 
Immunogenicity 
9.2.2.1 
Immunogenicity Endpoints 
• Neutralizing Ab levels (measured by plaque reduction neutralization test [PRNT]) against 
each of the 4 parental dengue virus strains of CYD dengue vaccine construct at baseline and 
28 days after each injection 
9.2.2.2 
Immunogenicity Assessment Methods 
Dengue Neutralizing Abs 
Dengue neutralizing Ab levels will be measured by PRNT50 (using parental dengue virus strains 
of CYD dengue vaccine constructs) by Sanofi Pasteur GCI, Swiftwater, USA (or outsourced with 
a GCI selected external laboratory). 
Serial, twofold dilutions of serum to be tested (previously heat-inactivated) are mixed with a 
constant challenge-dose of each dengue virus serotype 1, 2, 3 or 4 (expressed as PFU/mL). The 
mixtures are inoculated into wells of a microplate with confluent Vero cell monolayers. After 
adsorption, cell monolayers are incubated for a few days. The presence of dengue virus infected 
cells is indicated by formation of plaques. A reduction in virus infectivity due to neutralization by 
Ab present in serum samples is detected. The reported value (end point neutralization titer) 
represents the highest dilution of serum at which ≥ 50% of dengue challenge virus (in plaque 
counts) is neutralized when compared to the mean viral plaque count in the negative control wells 
which represents the 100% virus load. The end point neutralization titers are presented as 
continuous values. The LLOQ of the assay is 10 (1/dilution [dil]). 
This assay will be performed on blood samples taken at baseline and 1 month after each vaccine 
injection (V01, V04, V06, and V08). 
9.2.3 
Efficacy 
There are no secondary objectives for efficacy. 
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9.3 
Observational Endpoints and Assessment Methods 
9.3.1 
Immunogenicity 
9.3.1.1 
Immunogenicity Endpoints 
• Anti-NS1 IgG at baseline 
• Neutralizing Ab levels against YF at baseline 
• Neutralizing Ab levels against Zika at baseline 
9.3.1.2 
Immunogenicity Assessment Methods 
Anti-NS1 IgG 
Antibodies to dengue NS1 antigen will be measured using the Dengue anti-NS1 IgG ELISA 
performed at the Sponsor’s laboratory in Swiftwater, PA, USA. 
Briefly, equimolar concentrations of all 4 serotypes of Dengue NS1 antigen is coated onto a 
microtiter plate and serial 2-fold dilutions of human serum samples are added and incubated to 
allow binding to NS1. Then an HRP-conjugated anti-human IgG detection antibody is added 
followed by colorimetric substrate. The concentration of IgG antibodies to Dengue NS1 are 
calculated over 8-serial fold dilutions relative to assay reference with an assigned value (ELISA 
Units /mL). 
YF Neutralizing Abs 
YF neutralizing Ab levels will be measured by a neutralization test by Sanofi Pasteur GCI, 
Swiftwater, USA, or GCI outsourced laboratory. 
Briefly, serial twofold dilutions of serum to be tested (previously heat-inactivated) are mixed with 
a constant concentration of the YF vaccinal strain 17D. The mixtures are inoculated in duplicate 
into wells of a plate of confluent Vero cells. After adsorption, cell monolayers are overlaid, and 
incubated for a few days. The reported value (end point neutralization titer) represents the highest 
dilution of serum at which ≥ 50% of YF challenge virus is neutralized when compared to the 
negative control wells, which represents the 100% virus load. The LLOQ of this assay is 10 
(1/dilution). This method will be performed on blood sample taken at baseline (V01) to determine 
FV status. 
Zika Neutralizing abs (Microneutralization assay) 
Zika neutralizing Ab levels will be measured by Sanofi Pasteur GCI, Swiftwater, USA or GCI 
outsourced laboratory.  
Serial, two-fold dilutions of serum to be tested (previously heat-inactivated) are mixed with a 
constant concentration of Zika virus. The mixtures are inoculated in duplicate into wells of a 96-
well microplate with permissive cells. After adsorption, cell monolayers are incubated for a few 
days. A reduction in virus infectivity (viral antigen production) due to neutralization by antibody 
present in serum samples is detected by ELISA. After washing and fixation, Zika viral antigen 
production in cells is detected by successive incubations with Zika-specific MAbs, anti-mouse Ig 
conjugate, and a chromogenic substrate. The resulting OD is measured using a microplate reader. 
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The reduction in Zika virus infectivity as compared to that in the virus control wells constitutes a 
positive neutralization reaction indicating the presence of neutralizing antibodies in the serum 
sample. On the other hand, the infection of cells indicates the absence of neutralizing antibodies in 
the serum sample. 
10 Reporting of Serious Adverse Events 
To comply with current regulations on SAE reporting to health authorities, the Investigator must 
document all SAEs regardless of causal relationship, and notify the Sponsor and the Clinical 
Research Associate (CRA) within the notification timelines stated in the following sections. The 
Investigator will give access and provide the Sponsor and the CRA with all necessary information 
to allow the Sponsor to conduct a detailed analysis of the safety of the investigational product(s). 
It is the responsibility of the Investigator to request all necessary documentation (eg, medical 
records, discharge summary, physical autopsy report if performed and verbal autopsy 
questionnaire if used) in order to provide comprehensive safety information. All relevant 
information must then be transcribed onto the AE CRF and the appropriate Safety Complementary 
Information CRFs. 
10.1 Initial Reporting by the Investigator 
SAEs occurring during a subject’s participation in the study or experiment must be reported 
within 24 hours to the Sponsor’s GPV Department and to the CRA. Every SAE must be reported, 
even if the Investigator considers that it is not related to the vaccine. The Investigator (licensed 
physician [MD or D.O.]) must validate the information entered on the AE CRF by completing the 
Investigator validation form. 
The Investigator must indicate on the AE CRF that the event was serious and must complete the 
relevant SAE section of this form as well as the appropriate Safety Complementary Information 
CRFs. An e-mail alert will automatically be sent by the EDC system to the GPV mailbox, the 
CRA and the CTL with relevant SAE information details. 
If the EDC system is unavailable, the site must notify the Sponsor, using the paper version of the 
CRB, as described in the Operating Guidelines. 
The Investigator must complete the paper copies of the AE CRF and of the appropriate Safety 
Complementary Information CRFs and send them to the Sponsor by one of the following means: 
• By fax, to the following number: + 33 4 37 37 71 32 
• In PDF format to the following e-mail address, using a method of transmission that 
includes password protection: PV.outsourcing@sanofi.com 
• By express mail, to the following address: 
Sanofi Pasteur 
Global PharmacoVigilance Department 
14, Espace Henry Vallée 
69007 Lyon 
France 
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When the EDC system becomes available, the Investigator must transcribe the information from 
the paper forms into the EDC system. 
If there is need for urgent consultation, the Investigator is to contact the RMO. If the RMO cannot 
be reached, the Investigator may contact the Call Center as described in Section 5.3. 
10.2 Follow-up Reporting by the Investigator 
The AE CRF completed initially must be updated within 24 hours after the Investigator has 
become aware of any new relevant information concerning the SAE (eg, outcome, precise 
description of medical history, results of the investigation). All relevant information must be 
included directly in the AE CRF and the appropriate Safety Complementary Information CRFs. 
An e-mail alert will be sent automatically to the GPV Department and to the CRA. Copies of 
documents (eg, medical records, discharge summary, autopsy) may be requested by the GPV 
Department. 
The anonymity of the subject must always be respected when forwarding this information. 
10.3 Reporting of SAEs Occurring After a Subject Has Completed the Study 
Any SAE that occurs after a subject has completed the study but that is likely to be related to the 
investigational product(s), other products (eg, a benefit vaccine), or to the experiment must also be 
reported as soon as possible. In such a case, the reporting procedure to be followed is identical to 
that described in Section 10.1. 
10.4 Assessment of Causality 
The causal relationship between the SAE and the product administered will be evaluated by the 
Investigator as described in Section 9.1.1.3.5. 
Following this, the Sponsor’s Global Safety Officer will also assess the causal relationship to the 
product, based on the available information and current medical knowledge. 
The causal relationship to study procedures will be also assessed in the CRB. 
The decision to modify or discontinue the study may be made after mutual agreement between the 
Sponsor and the Investigator(s). 
10.5 Reporting SAEs to Health Authorities and IECs / IRBs 
The Sponsor will inform the relevant health authorities of any reportable SAEs according to the 
local regulatory requirements. Reporting to the health authorities will be according to the 
Sponsor’s standard operating procedures. 
The Sponsor’s RMO will notify the Investigators in writing of the occurrence of any reportable 
SAEs. The Investigators will be responsible for informing the IECs or IRBs that reviewed the 
study protocol. 
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10.6 Using a Verbal Autopsy Questionnaire to Aid in Determining the Cause of 
Death 
In case of the absence or inadequacy of health information that would allow a thorough evaluation 
of the causes of the death of a subject participating in the study, the verbal autopsy procedure may 
be triggered by either the Investigator or the Sponsor. Detailed instructions on the use of the 
verbal autopsy questionnaire, as well as the questionnaire itself, are provided in the Operating 
Guidelines. 
10.7 Special Considerations on CD4 Count- and HIV-1 Viral Load Safety Signals 
Reporting 
In this study, an increase in HIV viral load (plasma HIV-1 RNA > 1000 copies/mL 28 days post-
injection after having been undetectable [< 50 copies/mL] pre-injection) or a decrease in CD4 
count (decrease in CD4 greater than 30% assessed 28 days post-injection compared to the pre-
injection value), not explained by non-adherence to ART and not explained by any other possible 
etiology, is to be reported as an SAE according to the procedure described above (Section 10.1). 
Follow-up reporting 
The eSAE Form completed initially will be updated within 24 hours after the Investigator has 
received the results from the second blood sample. After validation, an e-mail alert will be sent 
automatically to the GPV Department and to the CRA. All relevant information must be included 
directly in the eSAE form. Copies of documents (eg, medical records, discharge summary, 
autopsy) may be requested by the GPV Department. Upon reception of second blood sample 
confirmatory results, criteria for holding the study will be checked (see Section 5.5). 
The anonymity of the subject must always be respected when forwarding this information. 
Assessment of causality 
The causal relationship between the SAE and the product will be assessed as described above 
(Section 10.4). Upon meeting a safety criterion for holding the study (see Section 5.5), the 
Sponsor alongside the IDMC and the Investigator(s) will decide whether to modify or discontinue 
the study. 
Reporting to health authorities and IECs/IRBs 
See Section 10.5. 
11 Data Collection and Management 
11.1 Data Collection and CRB Completion 
Individual diary cards, specifically designed for this study by the Sponsor and provided to the 
study sites, will be given to study participants for the recording of daily safety information as 
described in Section 9.1.1.3. These diary cards will include pre-listed terms and intensity scales 
(see Table 9.1 and Table 9.2) as well as areas for free text to capture additional safety information 
or other relevant details. Subjects will also be provided with rulers for measuring the size of 
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injection site reactions, and with standard digital thermometers for measuring daily temperatures. 
To ensure consistency of reporting, the study sites will instruct subjects on how to correctly use 
these tools. 
The 6-month follow-up will be done by interviewing subjects either during a Visit or over the 
telephone using a questionnaire to capture SAEs and AESIs, if applicable. A MA will be provided 
to the subjects at the preceding study Visit to help them record information on events occurring 
between this Visit and the 6-month follow-up. In case a follow-up Visit is planned, a diary card 
may be provided to the subject. 
Relevant information will be transcribed into the AE CRF. Any SAEs captured during this 6-
month follow-up period will be reported and followed-up as per the normal process for reporting 
SAEs. 
At specified intervals, the Investigator or an authorized designee will interview the subjects to 
collect the information recorded in the diary card, and will attempt to clarify anything that is 
incomplete or unclear. All clinical study information gathered by the study site will be reported 
electronically by the Investigator or authorized designee using a web-based CRB. (Any 
information that was not documented in the diary card will first be captured in the source 
document and then reported electronically.) The CRB has been designed specifically for this study 
under the responsibility of the Sponsor, using a validated Electronic Records / Electronic 
Signature-compliant platform (21 CFR Part 11). 
To ensure the correct and consistent completion of the CRBs, the Sponsor or authorized 
representative will provide all necessary tools, instructions, and training to all site staff involved 
in data entry prior to study start. Additional instructional documents such as training manuals and 
completion instructions will be provided to assist with data entry during the course of the study. 
Upon completion of training, each user requiring access to the EDC system will be issued a 
unique username and password. In the event of a change in study personnel, each newly assigned 
individual will receive a unique username and password; the username and password of a 
previous user may not be reissued. If any study personnel leave the study, the Investigator is 
responsible for informing the Sponsor immediately so that their access is deactivated. An audit 
trail will be initiated in the EDC system at the time of the first data entry to track all modifications 
and ensure database integrity. 
The Investigator is responsible for the timeliness, completeness, and accuracy of the information 
in the CRBs; must provide explanations for all missing information; and must sign the CRB using 
an e-signature. 
11.2 Data Management 
Management of SAE and pregnancy data 
During the study, SAE data (reported on the AE, Death, and Safety Complementary Information 
CRFs) and pregnancy data (reported by the Investigator on ePregnancy Forms) will be integrated 
into the Sponsor’s centralized GPV database upon receipt of these forms and after a duplicate 
check. Each case will be assigned a case identification number. Each case will be assessed by the 
case management platform or its delegate before being reported to the relevant authorities as 
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necessary. The assessment of related cases will be done in collaboration with the Global Safety 
Officer and the RMO. Follow-up information concerning a completed case will be entered into the 
GPV database, and a new version of the case will be created. 
The information from the GPV database cases will be reconciled with that in the clinical database. 
Management of clinical and laboratory data 
Clinical data, defined as all data reported in the CRB, and laboratory data will be handled by the 
Sponsor’s Clinical Data Management (CDM) platform or authorized representative. 
During the study, clinical data reported in the CRBs will be integrated into the clinical database 
under the responsibility of the Sanofi Pasteur CDM platform. Data monitoring at the sites and 
quality control in the form of computerized logic and / or consistency checks will be 
systematically applied to detect errors or omissions. In addition, data reviews may be performed 
several times by the Sponsor’s staff in the course of the study. Any questions pertaining to the 
reported clinical data will be submitted to the Investigator for resolution using the EDC system. 
Each step of this process will be monitored through the implementation of individual passwords to 
maintain appropriate database access and to ensure database integrity. 
The validation of the immunogenicity data will be performed at the laboratory level following the 
laboratory’s procedures. Information from the laboratory will be checked for consistency before 
integration into the clinical Datawarehouse. 
After integration of all corrections in the complete set of data, and after the SAE information 
available from CDM and the GPV Department has been reconciled, the database will be released for 
statistical analysis. 
11.3 Data Review 
A blind review of the data is anticipated through the data review process led by data management 
before database lock. 
12 Statistical Methods and Determination of Sample Size 
12.1 Statistical Methods 
All statistical analyses will be performed under the responsibility of the Sponsor’s Biostatistics 
Platform using the SAS® software, at least version 9.3 (SAS Institute, Cary, NC, USA). 
A statistical analysis plan (SAP) will be written and peer reviewed before any analyses. In 
accordance with the protocol, the SAP will describe all analyses to be performed under the 
responsibility of the Sponsor and all the conventions to be taken. 
A statistical analysis of the safety and immunogenicity data obtained up to Day 28 after the last 
injection of the last subject enrolled will be conducted once data are available and an interim 
database lock has been conducted. A final analysis will be conducted once the 6-month safety data 
have been collected and the final database lock has occurred. No multiplicity adjustment is 
necessary because no hypotheses will be tested. 
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12.1.1 Hypotheses and Statistical Methods for Primary Objective 
12.1.1.1 Hypotheses 
No hypotheses will be tested. 
12.1.1.2 Statistical Methods 
All analyses will be descriptive. Safety will be assessed after each and any dose of CYD dengue 
vaccine. 
For the main parameters, 95% CIs of point estimates will be calculated using the normal 
approximation for quantitative data and the exact binomial distribution (Clopper-Pearson method) 
for single proportions. 
The analysis of safety will address the number and percentage of subjects with injection site or 
systemic AEs until 28 days following each injection (solicited systemic reactions from D0 to D14, 
solicited injection site reactions from D0 and D7 and unsolicited AEs until D28, including AESIs, 
and immediate reactions, ie, occurring within 30 minutes after each vaccination). 
Solicited reactions will be described according to their intensity and according to time to onset, 
number of days of occurrence, action taken, and according to whether they lead to trial 
discontinuation. 
Unsolicited AEs will be described by MedDRA System-Organ Class and preferred term definition 
according to their relationship, severity, time to onset, and duration. 
Serious AESIs (in defined time windows according to the type of AESI) and SAEs (throughout 
the trial; including the 6-month follow-up) will be described by MedDRA preferred term, 
outcome, and relationship to vaccination. 
12.1.2 Hypotheses and Statistical Methods for Secondary Objective(s) 
12.1.2.1 Hypotheses 
No hypotheses will be tested. 
12.1.2.2 Statistical Methods 
The proportion of subjects with a detected and quantified CYD dengue vaccinal viremia (ie, above 
the detection level) whatever the serotype (as assessed by YF RT-PCR) and for each of the 4 
dengue serotypes (by serotype-specific RT-PCR method) after the first CYD dengue vaccine 
injection will be presented. 
A summary of CD4 count and HIV-1 RNA viral load over time will be presented. 
Analysis of dengue neutralizing antibody levels will be performed in each vaccine Group before 
first injection (at baseline) and 28 days after each injection using: 
• GMTs against each serotype with the parental dengue virus strains 
• GM of individual titer ratio (GMTR) against each serotype with the parental dengue virus 
strains (post-Injection 2/pre-Injection 1, and post-Injection 3/pre-Injection 1) 
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12.2 Analysis Sets 
12.2.1 Full Analysis Set 
The full analysis set (FAS) is defined as the subset of randomized subjects who received either 
CYD dengue vaccine or placebo and had blood sample drawn and valid post-injection serology 
results (ie, a result different from “not reportable” [“NR”] or missing, for at least one dengue 
serotype). 
Subjects will be analyzed by the vaccine treatment Group to which they were randomized. 
12.2.2 Safety Analysis Set 
The safety analysis set (SafAS) is defined as those subjects who have received at least one dose of 
the study vaccinea. All subjects will have their safety analyzed after each dose according to the 
vaccine they actually received. 
Safety data recorded for a vaccine received out of the protocol design will be excluded from the 
analysis (and listed separately). 
12.2.3 Per-Protocol Analysis Set 
The per-protocol analysis set (PPAS) is a subset of the FAS. The subjects presenting with at least 
one of the following relevant protocol deviations will be excluded from the PPAS: 
• Subject did not meet all protocol-specified inclusion criteria or met at least one of the 
protocol-specified exclusion criteria 
• Subject did not complete the vaccination schedule 
• Subject received a vaccine other than the one that he / she was randomized to receive 
• Preparation and / or administration of vaccine was not done as per-protocol 
• Subject did not receive vaccine in the proper time window 
• Subject did not provide post-dose serology sample in the proper time window or a post-dose 
serology sample was not drawn 
• Subject received a protocol-prohibited medications (see Section 6.7) 
• Subject’s post-injection serology sample did not produce a valid test result (ie, a result 
different from “NR” or missing, for at least one dengue serotype) 
A PP set will be defined for each vaccination. Subjects will remain in the corresponding 
population as long as they do not meet one of the above criteria. 
12.2.4 Other Analysis Set 
Not applicable 
                                                 
a  for which safety data are scheduled to be collected 
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12.2.5 Populations Used in Analyses 
12.2.6 Populations Used in Analyses 
The SafAS will be used for the description of clinical safety data. Subjects will be analyzed 
according to the product they actually received. 
The immunogenicity analyses will be performed on the PPAS, and will be confirmed on the FAS. 
12.3 Handling of Missing Data and Outliers 
12.3.1 Safety 
No replacement will be done. 
12.3.2 Immunogenicity 
For the computation of GMTs, a titer reported as < LLOQ will be converted to a value of 
0.5 LLOQ. 
For calculating GMTR, < LLOQ will be converted to 0.5 LLOQ for a numerator and < LLOQ 
will be converted to LLOQ for a denominator. Any titer reported as > upper limit of quantitation 
(ULOQ) will be converted to ULOQ. 
Missing data will not be imputed. No test or search for outliers will be performed. 
12.3.3 Efficacy 
No clinical efficacy data will be obtained in the trial. 
12.4 Interim / Preliminary Analysis 
No analyses are planned. 
12.5 Determination of Sample Size and Power Calculation 
The objective of the trial is to provide descriptive safety and immunogenicity results and therefore 
the sample size is arbitrarily set to 100 subjects for the CYD dengue vaccine Group and 
50 subjects for the Placebo Group. There is a 95% probability of observing an event that has a true 
incidence of 3% for the CYD dengue vaccine Group. 
13 Ethical and Legal Issues and Investigator / Sponsor Responsibilities 
13.1 Ethical Conduct of the Study / Good Clinical Practice 
The conduct of this study will be consistent with the standards established by the Declaration of 
Helsinki and compliant with the ICH guidelines for GCP as well as with all local and / or national 
regulations and directives. 
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13.2 Source Data and Source Documents 
“Source data” are the data contained in source documents. Source documents are original 
documents or certified copies, and include, but are not limited to, diary cards, medical, and 
hospital records, screening logs, informed consent / assent forms, telephone contact logs, and 
worksheets. The purpose of study source documents is to document the existence of subjects and 
to substantiate the integrity of the study data collected. Investigators must maintain source 
documents so that they are accurate, complete, legible, and up to date. 
For missing or discrepant data on a diary card, the study coordinator will obtain verbal clarification 
from the subject, enter the response into the “Investigator’s comment” page of the diary card, and 
transfer the information to the CRB. 
The subject pre-screening log should list all individuals contacted by the Investigators to 
participate in the study, regardless of the outcome. 
The Investigator must printa any Electronic Records on an ongoing basis, sign and date them 
immediately after creation, and keep the printouts on file as source documents that can be verified 
by the Sponsor or an inspector against the Electronic Records. Any subsequent changes of an 
electronic record require the record to be re-printed, dated (with an indication of the date of 
change), and signed. Such records must also be kept together with the original printed copy. 
Good Documentation Practice should be followed by the Investigator and the site staff managing 
source documents. 
13.3 Confidentiality of Data, Data Protection, and Access to Subject Records  
Prior to initiation of the study, the Investigator will sign a fully executed confidentiality agreement 
with Sanofi Pasteur. 
In the event a subject’s medical records are not at the investigational site, it is the responsibility of 
the Investigator to obtain those records if needed. 
All personal data collected related to subjects, Investigators, or any person involved in the study, 
which may be included in the Sponsor’s databases, shall be treated in compliance with all 
applicable laws and regulations, including the GDPR (Global Data Protection Regulation). Data 
collected must be adequate, relevant and not excessive, in relation to the purposes for which they 
are collected. Each category of data must be properly justified and in line with the study objective. 
Subjects will be assigned a unique identifier by the Sponsor. Any subject records or datasets that 
are transferred to the Sponsor will contain the identifier only; subject names or any information 
that would make the subject identifiable will not be transferred. 
The subject must be informed that his/her personal study-related data will be used by the Sponsor 
in accordance with local data protection law. The level of disclosure must also be explained to the 
subject. 
                                                 
a  Unless the electronic medical records are managed by validated computerized systems that are compliant with US 
21 CFR Part 11, in which case they are acceptable on their own. 
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The subject must be informed that his/her medical records may be examined by Clinical Quality 
Assurance auditors or other authorized personnel appointed by the Sponsor, by appropriate 
IRB/IEC members, and by inspectors from regulatory authorities. 
When archiving or processing personal data pertaining to the Investigator and/or to the subjects, 
the Sponsor shall take all appropriate measures to safeguard and prevent access to this data by any 
unauthorized third party. 
13.4 Monitoring, Auditing, and Archiving 
13.4.1 Monitoring 
Before the start of the study (ie, before the inclusion of the first subject), the Investigators and the 
Sponsor’s staff or a representative will meet at the site-initiation Visit to discuss the study 
protocol and the detailed study procedures. Emphasis will be placed on inclusion and exclusion 
criteria, Visit timing, safety procedures, informed consent procedures, SAE reporting procedures, 
CRB completion, and the handling of samples and products. The Sponsor’s staff or a 
representative will ensure and document that all material to be used during the study has been 
received at the site; and that the study Investigator team and local Sponsor/delegate staff have 
been properly informed about the study, GCP and regulatory requirements, and the Sponsor’s 
procedures. Specific training sessions for the study Investigator team and the CRAs on these 
topics may be performed as necessary, and should be documented. 
The following instruction manuals will be provided: the CRF Completion Instructions for entering 
data into the CRB, and the Operating Guidelines for detailed study procedures such as the product 
management and sample-handling procedures. 
After the start of the study, the Sponsor’s staff or a representative will be in regular contact with 
the investigational team through telephone calls and regular follow-up visits. The Investigator or 
delegate must be available for these visits, and must allow the Sponsor/delegate staff direct access 
to subject medical files and CRBs. During these visits, the Sponsor/delegate staff will: 
• Evaluate the quality of the study progress (adherence to protocol and any study-specific 
guidelines, quality of data collection, and document completion, signature of consent forms, 
occurrence of SAEs, sample, and product management, cold-chain monitoring, archiving). 
• Source-verify completed CRBs and any corresponding answered queries. 
• Determine the number of complete or ongoing issues identified at monitoring visits (eg, 
protocol deviations, SAEs). Any identified problems will be discussed with the Investigator, 
and corrective, or preventive actions will be determined, as appropriate. 
• After all protocol procedures have been completed and the data have been entered into the 
CRB, the Investigator must still be available to answer any queries forwarded by the Sponsor. 
All data-related queries must be completed prior to database lock. 
At the end of the study, a close-out Visit will be performed to ensure that: 
• The center has all the documents necessary for archiving 
• All samples have been shipped to the appropriate laboratories 
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• All unused materials and products have been either destroyed or returned to the Sponsor 
13.4.2 Audits and Inspections 
A quality assurance audit may be performed at any time by the Sponsor’s Clinical Quality 
Assessment department (CQA) or by independent auditors to verify that the study has been 
conducted according to the protocol, GCP and ICH requirements, and other applicable 
regulations. An inspection may be conducted by regulatory authorities. The Investigator must 
allow direct access to study documents during these inspections and audits. 
13.4.3 Archiving 
The Investigator and the study site shall retain and preserve 1 copy of the study file containing the 
essential documents related to the study and records generated during the study (“Study File”) for 
the longer of the 2 following periods (“Retention Period”): 
• 25 years after the signature of the final study report or  
• such longer period as required by applicable regulatory requirements 
If during the Retention Period, the study site is no longer able to retain the Study File due to 
exceptional circumstances (such as bankruptcy), the study site shall contact the Sponsor to 
organize the transfer of the Study File to the Sponsor’s designee at the Sponsor’s expense. 
Following the Retention Period, the Investigator and/or the study site are responsible to dispose of 
the Study File according to the applicable regulations. Patient medical records shall be retained in 
compliance with local regulations. 
Archived data may be held on Electronic Records, provided that a back-up exists and that a hard 
copy can be obtained if required. The protocol, documentation, approvals, and all other documents 
related to the study will be kept by the Sponsor in the Trial Master File (TMF). Data on AEs are 
included in the TMF. All data and documents will be made available if requested by relevant 
authorities. 
13.5 Financial Contract and Insurance Coverage 
A CTA will be signed by all the parties involved in the study’s performance, if relevant. The 
Sponsor has an insurance policy to cover any liabilities that may arise from use of the product and 
/ or the study protocol. 
13.6 Stipends for Participation 
Expenses that are directly related to the subject’s participation in the study (for example cost of 
transportation for attending visits) will be compensated. Subjects will not receive any 
remuneration for participation in the study. 
13.7 Publication Policy 
Data derived from this study are the exclusive property of Sanofi Pasteur. Any publication or 
presentation related to the study must be submitted to Sanofi Pasteur for review before submission 
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of the manuscript. After publication of the results of the study, any participating center may 
publish or otherwise use its own data provided that any publication of data from the study gives 
recognition to the study Group. In addition, Sanofi Pasteur shall be offered an association with all 
such publications, it being understood that Sanofi Pasteur is entitled to refuse the association. 
Sanofi Pasteur must have the opportunity to review all proposed abstracts, manuscripts, or 
presentations regarding this study at least 90 days prior to submission for publication / 
presentation. Any information identified by Sanofi Pasteur as confidential must be deleted prior to 
submission, it being understood that the results of this study are not to be considered confidential. 
Sanofi Pasteur’s review can be expedited to meet publication guidelines. 
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15 Signature Page 
 
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Document Number
CLI_1574799
Version Number
3.0
Project Code
Dengue Vaccine
Artifact Name
Protocol Body
Approver Name
Date
(Universal Time)
Reason for Signature
Approval
I am approving this document
 
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