A Maternal Short Course of Tenofovir Disoproxil Fumarate and Infant Vaccine to Prevent Mother-to-child Transmission of Hepatitis B Virus
Phase: PHASE3
Conditions: Hepatitis B, Pregnancy
Sponsor: Institut de Recherche pour le Developpement

 
Page 1 of 37 
 
Protocol 
Last version 
for the study: 
 
 
Title:  
A Maternal Short Course of Tenofovir Disoproxil Fumarate and Infant Vaccine to Prevent Mother-
to-Child Transmission of Hepatitis B Virus 
 
Short title:  
Antiviral Prophylaxis and Infant Vaccination to Prevent Perinatal Hepatitis B Infection 
 
ClinicalTrials.gov identifier: 
NCT03343431 
 
ID/Acronym:  
iTAP-2 
 
Last version (1.4):  
December 2, 2020 
 
 
Contact: gonzague.jourdain@cmu.ac.th, gonzague.jourdain@phpt.org

 
Page 1 of 37 
 
 
Protocol 
 
 
 
 
A Maternal Short Course of  
Tenofovir Disoproxil Fumarate and Infant Vaccine 
to Prevent Mother-to-Child Transmission of 
Hepatitis B Virus 
 
 
Short title: 
Antiviral prophylaxis and infant vaccination 
to prevent perinatal hepatitis B infection 
 
 
 
Version 1.4 
December 2, 2020 
 
 
 
 
 
 
Study Coordination Center:  
AMS-PHPT (Chiang Mai University – Institut de recherche pour le development Collaboration) 
110 Intawaroros Rd. T. Sripoom, Muang 
Chiang Mai 50200, Thailand 
Telephone: +66 5324 0910 (up to 12) 
Fax: +66 5324 0913 
E-mail: gonzague.jourdain@phpt.org 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 2 of 37 
Table of Contents  
1
 .  
Study Title.................................................................................................................................. 4 
2. 
Protocol team and investigators’ names and contact information ............................................... 4 
3. 
Project Summary ....................................................................................................................... 8 
4. 
Background information ........................................................................................................... 10 
4.1 
Background ...................................................................................................................... 10 
4.2 
Study Rationale ................................................................................................................ 12 
5. 
Study specific objectives .......................................................................................................... 13 
5.1 
Study objectives ............................................................................................................... 13 
5.2 
Study Design .................................................................................................................... 14 
6. 
Study sites and duration of the study ....................................................................................... 15 
6.1 
Study sites ........................................................................................................................ 15 
7. 
Workplan ................................................................................................................................. 16 
7.1 
Study population ............................................................................................................... 16 
7.1.1 
Eligibility .................................................................................................................... 16 
7.1.2 
Inclusion criteria ........................................................................................................ 17 
7.1.3 
Exclusion criteria ....................................................................................................... 17 
7.1.4 
Discontinuation criteria .............................................................................................. 17 
7.2 
Implementation, data collection, and monitoring procedures ............................................. 17 
7.2.1 
Follow-up and study procedures ............................................................................... 17 
7.2.2 
Laboratory assessments ........................................................................................... 19 
7.2.3 
Data collection .......................................................................................................... 20 
7.2.4 
Reporting .................................................................................................................. 20 
7.2.5 
Study implementation onsite monitoring .................................................................... 20 
7.3 
Study drugs ...................................................................................................................... 21 
7.4 
Biohazard Containment .................................................................................................... 21 
7.5 
Statistical considerations .................................................................................................. 21 
7.5.1 
Justifications for the design ....................................................................................... 21 
7.5.2 
Endpoints .................................................................................................................. 21 
7.5.3 
Sample size .............................................................................................................. 22 
7.5.4 
Analyses for the primary objective ............................................................................ 22 
7.5.5 
Analyses for the secondary objectives/endpoints ...................................................... 23 
7.6 
Data and Safety Monitoring Board .................................................................................... 23 
8
 .  
Ethical considerations .............................................................................................................. 24 
8.1 
Potential Risks to Participants .......................................................................................... 24 
8.1.1 
Maternal risks associated with the use of tenofovir disoproxil fumarate (TDF) during 
pregnancy ............................................................................................................................... 24 
8.1.2 
Infant risks associated with the lack of HBIg administration ...................................... 25 
8.1.3 
Infant risks associated with in utero exposure to tenofovir ......................................... 25 
8.2 
Adequacy of Protection Against Risks .............................................................................. 25 
8.2.1 
 Recruitment and informed consent .......................................................................... 25 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 3 of 37 
8.2.2 
Protection against risk ............................................................................................... 26 
8.3 
Potential Benefits of the Proposed Research to the Participants and Others .................... 27 
8.3.1 
Mothers ..................................................................................................................... 27 
8.3.2 
Expected infant close contacts .................................................................................. 27 
8.3.3 
Infants ....................................................................................................................... 27 
8.4 
Importance of the knowledge to be gained ....................................................................... 27 
9. 
References .............................................................................................................................. 28 
Appendix 1: Cockcroft-Gault formula for women ............................................................................. 31 
Appendix 2: Amendment dated 19 July 2019 .............................................................................. 32 
Appendix 3: Exempted Congenital Anomalies/Birth Defects (19 July 2019 Amendment) ............ 33 
3.1. Listed by Body Site .......................................................................................................... 33 
3.2. Listed Alphabetically ........................................................................................................ 34 
Appendix 4: 15 January 2020 Amendment (stamped by the Ethics Committee) .......................... 35 
Appendix 5: 2 December 2020 Amendment (approved by the Ethics Committee) ....................... 37 
 
 
 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 4 of 37 
1. Study Title 
A maternal short course of tenofovir disoproxil fumarate and infant 
vaccine to prevent mother-to-child transmission of hepatitis B virus 
 
Short title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection 
2. Protocol team and investigators’ names and contact information 
 
Leaders: 
Gonzague Jourdain, MD, PhD (Principal 
Investigator) 
PHPT – IRD UMI 174 
Faculty of Associated Medical Sciences 
Chiang Mai University 
110 Intawaroros Rd., T. Sripoom, Muang, 
Chiang Mai 50200 
Tel: +66 5324 0910-12 - Fax: +66 5324 0913 
Email: Gonzague.Jourdain@phpt.org 
gjourdai@hsph.harvard.edu 
Suchada Jiamsiri, MD, MPH 
Viral Hepatitis Unit 
Department of Disease Control, Ministry of 
Public Health, Thailand 
88/21 Tiwanon Rd. Talard-Kwan,  
Nonthaburi 11000 
Tel: +66 2 590 3000 
Email: bregreta@hotmail.com, 
sjiamsiri@post.harvard.edu 
 
Team: other members 
Nicole Ngo-Giang-Huong, PharmD, PhD 
PHPT – IRD UMI 174 
Faculty of Associated Medical Sciences 
Chiang Mai University 
110 Intawaroros Rd. T. Sripoom, Muang, 
Chiang Mai 50200 
Tel: +66 5324 0910-12 - Fax: +66 5324 0913 
Email: Nicole.Ngo-Giang-Huong@phpt.org 
Tim Roy Cressey, PhD 
PHPT – IRD UMI 174 
Faculty of Associated Medical Sciences 
Chiang Mai University 
110 Intawaroros Rd. T. Sripoom, Muang,  
Chiang Mai 50200 
Tel: +66 5324 0910-12 - Fax: +66 5324 0913 
Email: Tim.Cressey@phpt.org 
Nicolas Salvadori, MSc 
PHPT – IRD UMI 174 
Faculty of Associated Medical Sciences 
Chiang Mai University 
110 Intawaroros Rd. T. Sripoom, Muang, 
Chiang Mai 50200 
Tel: +66 5324 0910-12 - Fax: +66 5324 0913 
Email: nicolas.salvadori@phpt.org 
Vatthanaphone Latthaphasavang, MD 
Pediatrics Department 
Infectious Diseases Center 
Mahosot Hospital, Kaognot Village, 
Vientiane Capital, Lao PDR 
Tel: +856 20 55526189 
Email:vatthanaphone.latthaphasavang@phpt.org 
Woottichai Khamduang, PhD 
Faculty of Associated Medical Sciences 
Chiang Mai University 
110 Intawaroros Rd. T. Sripoom, Muang, 
Chiang Mai 50200 
Tel: +66 5324 0910-12 - Fax: +66 5324 0913 
Email: woottichai.khamduang@phpt.org 
Camlin Tierney, PhD 
Harvard School of Public Health  
Center for Biostatistics in AIDS Research  
FXB Building 514 
651 Huntington Ave Boston, MA 02115, USA 
Tel: +1 6174320547 
Email: tierney@sdac.harvard.edu 
Kanawee Thetket, MD 
Nakornping Hospital 
Department of Internal Medicine 
159 M.10 Chotana Rd., T. Don Keaw,  
Mae Rim, Chiang Mai 50180 
Tel: +66 5399 9200 - Fax: +66 5322 2152 
Email: kanawee@hotmail.com 
Wasna Sirirungsi, PhD 
Faculty of Associated Medical Sciences 
Chiang Mai University 
110 Intawaroros Rd. T. Sripoom, Muang,  
Chiang Mai 50200 
Tel: +66 5394 5063 Fax : +66 5394 6042 
Email: wasna.s@cmu.ac.th 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 5 of 37 
Thanyawee Puthanakit, MD 
King Chulalongkorn Memorial Hospital 
Chulalongkorn University 
Phayathai Road, Wangmai, Pathum Wan, 
Bangkok 10330 
Tel: +66 2 256 4000 
Email: thanyawee.p@hivnat.org 
Sombat Thanprasertsuk, MD, MPH 
Department of Disease Control 
Ministry of Public Health 
Tivanont Road, Muang, 
Nonthaburi 11000, Thailand 
Tel: +66 2590 3201 - Fax: +66 2 591 8413 
Email: stpss@health.moph.go.th 
Raymond T. Chung, MD 
Massachusetts General Hospital 
Gastrointestinal Unit 
55 Fruit St  
Boston, MA 02114, USA 
Tel: +1 617/724-7562 - Fax: +1 617/643-0446 
Email: rtchung@partners.org 
Stanislas Pol, MD, PhD 
Department of Hepato-Gastroenterology, Cochin 
University Hospital,  
27 rue du Faubourg Saint-Jacques, 75679 Paris 
Cedex 14, France 
Tel: +33 1 58 41 19 55 
Email: stanislas.pol@cch.aphp.fr 
 
Co-investigators at participating sites 
 
Thailand 
 
Health Promotion Center Region 1 
Suraphan Sangsawang, MD 
Obstetrics & Gynecology Department 
51 Prachasumphan Rd., T. Changklan, Muang, 
Chiang Mai 50100 
Tel: +66 5327 2740 - Fax: +66 5327 4015 ext 119 
Email: suraphan3107@hotmail.com  
Health Promotion Center Region 1 
Chotiros Phanpong, MD 
Pediatrics Department 
51 Prachasumphan Rd., T. Changklan, Muang, 
Chiang Mai 50100 
Tel: +66 5327 2740 - Fax: +66 5327 4015 ext 119 
Email: choti001@hotmail.com 
Lamphun Hospital 
Wanmanee Matanasarawut, MD 
Obstetrics & Gynecology Department 
177 Sai Rim Ping Rd., T. Tonthong, Muang, 
Lamphun 51000 
Tel: +66 5356 9100 ext 2150 - Fax: +66 5356 9123 
Email: obgyn.lph@gmail.com 
Lamphun Hospital 
Rosalin Somsamai, MD 
Pediatrics Department 
177 Sai Rim Ping Rd., T. Tonthong, Muang, 
Lamphun 51000 
Tel: +66 5356 9100 - Fax: +66 5356 9123 
Email: Ross_noi@hotmail.com 
Chiangrai Prachanukroh Hospital 
Jullapong Achalapong, MD 
Obstetrics & Gynecology Department 
1039 Sathanpayaban Rd., T. Rop Wiang, Muang 
Chiang Rai 57000 
Tel: +66 5391 0600 ext 1217 - Fax: +66 5371 3044 
Email: jullapong.achalapong@phpt.org 
Chiangrai Prachanukroh Hospital 
Chulapong Chanta, MD 
Pediatrics Department 
1039 Sathanpayaban Rd., T. Rop Wiang, Muang,  
Chiang Rai 57000 
Tel: +66 5391 0600 ext 1274 - Fax: +66 5371 3044 
Email: Chul_chan@yahoo.com 
Chiang Kham Hospital 
Chaiwat Putiyanun, MD 
Obstetrics & Gynecology Department 
244 M.4 T. Yuan, Chiang Kham, Phayao 56110 
Tel: +66 54 451 300-1 - Fax: +66 54 416 615 
Email: putiyanun@hotmail.com 
Chiang Kham Hospital 
Thanthida Koopitakkajorn, MD 
Pediatrics Department 
244 M.4 T. Yuan, Chiang Kham, Phayao 56110 
Tel: +66 54 451 300-1 - Fax: +66 54 416 615 
Email: Thanthida@hotmail.com 
Prapokklao Hospital 
Sirida Kositchaiwat, MD 
Obstetrics & Gynecology Department 
38 Leibnern Rd., Muang Chantaburi 22000 
Tel: +66 39 324975 ext. 5253 - Fax: +66 3931 1511 
Email: Barbieaee@hotmail.com 
Prapokklao Hospital 
Kanokkorn Swasdichai, MD 
Pediatrics Department 
38 Leibnern Rd., Muang Chantaburi 22000 
Tel: +66 3932 4975 ext. 5253 Fax: +66 3931 1511 
Email: kswasdichai@yahoo.com 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 6 of 37 
Banglamung Hospital 
Prateep Kanjanavikai, MD 
Obstetrics & Gynecology Department 
669 M.5 Phattaya-Naklua T. Naklua, 
Banglamung, Chonburi 20150 
Tel: +66 3841 1551-2 - Fax: +66 3842 8464 
Email: prateep48@hotmail.com 
Banglamung Hospital 
Siriluk Phanomcheong, MD 
Pediatrics Department 
669 M.5 Phattaya-Naklua T. Naklua, Banglamung, 
Chonburi 20150 
Tel: +66 3841 1551-2 - Fax: +66 3842 8464 
Email: siriluk_lukk@yahoo.com 
Chonburi Hospital 
Nantasak Chotivanich, MD 
Obstetrics & Gynecology Department 
69 M. 2 Sukumvith Rd., T. Ban Suan, Muang, 
Chonburi 20000  
Tel: +6638931000 - Fax: +6638797382 
Email: nantasak.cho@gmail.com 
Chonburi Hospital 
Ketesiree Kornsitthikul, MD  
Pediatrics Department 
69 M. 2 Sukumvith Rd., T. Ban Suan, Muang, 
Chonburi 20000  
Tel: +66 3827 4000-7 - Fax: +66 3827 4911 
Email: tarenaruk@hotmail.com 
Nakornping Hospital 
Yuri Yanase, MD 
Obstetrics & Gynecology Department 
159 M.10 Chotana Rd., T. Don Keaw, Mae Rim, 
Chiang Mai 50180 
Tel: +66 5399 9200 - Fax: +66 5322 2152 
Email: yuletides@hotmail.com 
Nakornping Hospital 
Arunrat Suwannarat, MD 
Pediatrics Department 
159 M.10 Chotana Rd., T. Don Keaw, Mae Rim, 
Chiang Mai 50180 
Tel: +66 5399 9200 - Fax: +66 5322 2152 
Email: arunrat11@yahoo.com 
Nopparat Rajathanee Hospital 
Orada Patamasingh Na Ayudhaya, MD 
Obstetrics & Gynecology Department 
679 Ram-Indra Rd., Kannayao, 
Bangkok 10230 
Tel: +66 2517 4270-9 - Fax: +66 2917 8800 
Email: oradaaom@hotmail.com 
Nopparat Rajathanee Hospital 
Anita Luvira, MD 
Pediatrics Department 
679 Ram-Indra Rd., Kannayao,  
Bangkok 10230 
Tel: +66 2517 4270-9 - Fax: +66 2917 8800 
Email: aluvira@yahoo.com 
Samutsakhon Hospital 
Chatdao Sujarit, MD 
Obstetrics & Gynecology Department 
1500 Akekachai Rd., T. Mahachai, Muang, 
Samutsakorn 74000 
Tel: +66 34427099-104 - Fax: +66 34411488 
Email: csutjarit@yahoo.com 
Samutsakhon Hospital 
Sawitree Krikajornkitti, MD 
Pediatrics Department 
1500 Akekachai Rd., T. Mahachai, Muang, 
Samutsakorn 74000 
Tel: +66 3442 7099-104 - Fax: +66 3441 1488 
Email: yuiwitree@gmail.com 
Kalasin Hospital 
Phaiboon Wanasiri, MD 
Obstetrics & Gynecology Department 
283 Kalasin Rd., T. Kalasin, Muang,  
Kalasin 46000 
Tel: +66 43 811 020 - Fax: +66 43 812 962 
Email: piboon_wan@hotmail.com 
Kalasin Hospital 
Sakulrat Srirojana, MD 
Pediatrics Department 
283 Kalasin Rd., T. Kalasin, Muang,  
Kalasin 46000 
Tel: +66 43 811 020 - Fax: +66 43 812 962 
Email: sakulrats@yahoo.com 
Samutprakarn Hospital 
Apichart Akarawiputh, MD 
Obstetrics & Gynecology Department 
71 Chakapak Rd., T. Pak Nam, Muang, 
Samutprakarn 10280 
Tel: +66 27018 132-9, +66 2387 0053 
Fax: +66 2173 8551 
Email: apichart97@gmail.com 
Samutprakarn Hospital 
Achara Puangsombat, MD 
Pediatrics Department 
71 Chakapak Rd., T. Pak Nam, Muang, 
Samutprakarn 10280 
Tel: +66 27018 132-9, +66 2387 0053 
Fax: +66 2173 8551 
Email: mayachara@yahoo.com 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 7 of 37 
Lampang Hospital 
Prateung Liampongsabuddhi, MD 
Obstetrics & Gynecology Department 
280 Paholyothin Rd., T. Huawieng, Muang, 
Lamphang 52000 
Tel: +66 5422 3623-7 - Fax: +66 5422 6126 
Email: prateung@yahoo.com 
Lampang Hospital 
Kultida Pongdetudom, MD 
Pediatrics Department 
280 Paholyothin Rd., T. Huawieng, Muang, 
Lamphang 52000 
Tel: +66 5422 3623-7 - Fax: +66 5422 6126 
Email: pongdetudom@yahoo.com 
Songkhla Hospital 
Peeranan Kaewsuksai, MD 
Obstetrics & Gynecology Department 
666 Songkhla-Ranode Rd., T. Pawong, 
Muangsongkhla, Songkhla 90100 
Tel: +66 74 447 607 - Fax: +66 74 480 058 
Email: peeranan.kaewsuksai@gmail.com 
Songkhla Hospital 
Eakaphop Uthaisaeng, MD 
Pediatrics Department 
666 Songkhla-Ranode Rd., T. Pawong,  
Muangsongkhla, Songkhla 90100 
Tel: +66 74 447 607 - Fax: +66 74 480 058 
Email: ekapop.u@hotmail.com 
Maharaj Nakhon Si Thammarat Hospital 
Rujira Panpob, MD 
Obstetrics & Gynecology Department 
198 Rajadamnern Rd., T. Nai Muang, Muang,  
Nakhon Si Thammarat 80000 
Tel: +66 7534-0250 - Fax: +66 7534 3405 
Email: ruparapob@gmail.com 
Maharaj Nakhon Si Thammarat Hospital 
Somsri Kotchawet, MD 
Pediatrics Department 
198 Rajadamnern Rd., T. Nai Muang, Muang, 
Nakhon Si Thammarat 80000 
Tel: +66 7534-0250 - Fax: +66 7534 3405 
Email: somsrikot@yahoo.com 
 
Lao PDR 
Mother and New born Health (MNH) Hospital 
Touy CHANTHALANSY, MD 
Obstetrics & Gynecology Department 
Nongphaya, Xaythany, 
Vientiane Capital  
Tel: +856 21 617 051 
Email: patouy.c@gmail.com 
Mother and New born Health (MNH) Hospital 
Phetsamone PHATHAVONG, MD 
Nongphaya, Xaythany, 
Vientiane Capital  
Tel: +856 21 617 051 
Email: phet15184@gmail.com 
Setthathirath Hospital 
Khamla CHOUMLIVONG, MD 
Khamphengmuang Road, 
Donkoi Village, Sisattanak, 
Vientiane Capital, Lao PDR 
Email: khamla_choumlivong@yahoo.com 
Setthathirath Hospital 
Vatsana PHONSENA, MD 
Khamphengmuang Road, 
Donkoi Village, Sisattanak, 
Vientiane Capital, Lao PDR 
Email: Vatsana-phonsena@hotmail.com 
Mahosot Hospital 
Anan SACKPRASEUTH, MD 
Obstetrics & Gynecology Department 
Kaognot Village,  
Vientiane Capital  
Tel: +856 21 214 018, +856 21 214 023 
Email: anansps@yahoo.com 
Mahosot Hospital 
Phimmasone SIRIMANOTHAM, MD 
Obstetrics & Gynecology Department  
Kaognot Village, 
Vientiane Capital 
Tel: +856 21 214 018, +856 21 214 023 
Email:sirimanothamp@yahoo.com 
Champasak Province Hospital 
Savannakhet Province Hospital 
Bolikhamxay Province Hospital 
Luang Prabang Provincial Hospital 
Xayaboury Province Hospital 
103 Hospital 
Center of Infectiology Lao Christophe 
Mérieux 
Philavanh Sitbounlang, MD 
Samsenthai Road, Kaoyot Village, Sisathanak 
District, Vientiane Capital, Lao PDR 
Tel: +856 21 260 357 
Email: philavanh@ccm-laos.org 
Center of Infectiology Lao Christophe Mérieux 
Phimpha PABORIBOUNE, MD 
Samsenthai Road, Kaoyot Village,  
Sisathanak District, Vientiane Capital  
Tel: +856 21 260 357  
 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 8 of 37 
3. Project Summary 
Full title: A maternal short course of tenofovir disoproxil fumarate and infant vaccine to prevent 
mother-to-child transmission of hepatitis B virus 
Short title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection 
Country: Thailand and Lao PDR 
Sponsors: NICHD, IRD 
Study centers: 15 sites in Thailand and 9 sites in Lao PDR 
Study period: 
First enrollment: August 2, 2018 
Planned enrollment duration: 24 months 
Primary endpoint available for all participating infants: 
Fourth quarter 2021  
Planned date of last visit completed: May 1, 2022 
Biological analyses completed: May 1, 2023 
Final report: Fourth quarter 2023 
Clinical Phase: Phase III 
Primary Objective 
To demonstrate that the risk of HBV infection at 6 months of age is lower than 2% in infants who 
receive active immunization but no HBIg, born to HBeAg positive mothers with satisfactory 
virological response on tenofovir disoproxil fumarate (TDF) 300 mg per day from 28 weeks 
gestation to 2 months postpartum. 
Secondary Objectives 
• 
To assess pregnancy outcomes, and infant outcomes until 18 months of age. 
• 
To retrospectively determine the risk of transient infection in infants not chronically infected at 
18 months of age using anti-HBc antibodies. 
• 
To describe infants’ response to HB vaccination in the absence of confounding from HBIg 
administration, assessed by anti-HBs antibody levels at 1, 2, 4, 6, 12 and 18 months. 
• 
To describe the changes in maternal HBV DNA level from initiation of TDF to delivery. 
• 
To compare the risk of infant HBV infection at 6 months of age with that observed in infants 
who received HBIg at birth plus HBV vaccine in one of the 2 arms of a previous study 
conducted in a similar setting in Thailand (iTAP, NCT01745822). 
• 
To assess the risk of transmission in all infants born in the study, including those born to 
women with unsatisfactory virological response to study treatment. 
Design 
Prospective multicenter, international (Thailand and Lao PDR), open-label, single arm clinical trial 
in HBsAg and HBeAg positive pregnant women (from 28 weeks until one year postpartum) and 
their infants (until 18 months of age). 
Planned number of participants 
499 women and their infants. 
Main inclusion/exclusion criteria 
Study Population 
Women aged ≥18 years, positive for HBsAg and HBeAg, and negative for HIV antibodies will be 
proposed to participate in the study. 
Women exclusion criteria 
• 
Receipt of antivirals at any time during the previous 9 months. 
• 
Known liver cirrhosis or evidence of hepatocellular carcinoma. 
• 
Creatinine clearance <50 ml/min, calculated using the Cockcroft-Gault formula. 
• 
Confirmed dipstick proteinuria >1+ (>30 mg/dL) or normoglycemic glycosuria 
Follow up 
Follow-up of women and infants will be carried out on an outpatient basis except for delivery. Study 
visits for mothers will take place at 28, 32, 36 weeks’ gestation, at delivery and 1, 2, 4, 6, and 12 
months postpartum. Infant visits are scheduled at birth, 1, 2, 4, 6, 9, 12, and 18 months. 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 9 of 37 
After the beginning of treatment and at the latest at 36 weeks’ gestation, virological response to 
study treatment will be assessed using HBV DNA load measurement. If the level of HBV DNA load 
has not significantly decreased (at least by 10 fold in IU/mL) and is above 200,000 IU/mL, the site 
study team will contact the participant to reinforce adherence to study treatment and possibly 
recommend HBIg administration to the newborn if available. 
Infants will receive HB vaccine per national guidelines and their HBV infection status will be 
assessed at 6 months of age.  
Maternal study treatment will be discontinued two months after delivery. However, women with 
baseline ALT >60 U/L will be assessed for HBV treatment indications before discontinuation during 
the postpartum period. 
Criteria for evaluation/primary endpoint 
Primary endpoint: infant HBV infection assessed by the detection of HBsAg at six months of age 
confirmed by PCR detection of HBV DNA. 
Study Treatment 
Tenofovir disoproxil fumarate (TDF), one 300 mg tablet once daily from 28 weeks’ gestation 
through two months postpartum. 
Statistical considerations 
The efficacy of maternal antiviral plus infant vaccine will be assessed based on the upper limit of 
the 95% Clopper-Pearson confidence interval (CI) of the observed transmission rate. The efficacy 
of the prevention method will be considered acceptable if the actual risk of transmission is less 
than 2% in infants born to mothers with satisfactory virological response to study treatment, and 
who have received HB vaccine but no HBIg. 
A sample size of 386 evaluable cases is needed to provide 87% power to demonstrate that the 
upper 95% confidence interval limit of the risk of transmission is lower than 2% (i.e. the observed 
risk would be lower than 0.5%). Accounting for 12% unsatisfactory virological response to study 
treatment at 36 weeks’ gestation, and 12% unevaluable cases, 499 women will be enrolled in the 
study. 
In practice, if 4 infections are observed at any time among (386 or less) infants born to mothers 
with satisfactory virological response to study treatment, the new method would be considered 
inferior to infant vaccine + HBIg administration. If this was observed before the final analysis, a 
review by the Data and Safety Monitoring Board would be organized for recommendations, 
including possible termination of the trial. 
 
 
 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 10 of 37 
4. 
ackground information
B
 
4.1 
Background 
Hepatitis B virus (HBV) infection is the 10th leading cause of death worldwide (1), and hepatocellular 
carcinoma (HCC), a major complication of this infection, is the 3rd leading cause of cancer death 
worldwide (2). Pregnant women with chronic HBV infection, as defined by persistence of hepatitis B 
surface antigen (HBsAg), may have a 30%-40% risk of transmitting HBV to their infants in the absence 
of any preventative intervention (3–5). Among HBV infected infants, 65-90% will develop the chronic 
form of the disease (6–9) and will be at risk of developing cirrhosis and hepatocellular carcinoma 
(HCC) during adulthood (10,11).  
HB immunization is highly efficacious in preventing mother-to-child transmission. Wherever universal 
immunization programs have been implemented, the prevalence of HBsAg in the population has 
subsequently decreased. Most Asian countries have implemented HBV immunization programs, and 
coverage has greatly improved within the last 10-15 years (12) but millions of women infected prior to 
the implementation of immunization programs remain at risk of transmission. Pregnant women with 
HBeAg, a marker of high viral replication, retain a significant risk of transmitting HBV even when 
vaccine and HBIg are provided (13,14). Thus, even programs achieving 100% immunoprophylaxis 
coverage will not be sufficient to achieve HBV eradication. 
Efficacy of HB vaccine 
Active immunization with HB vaccine is the cornerstone of preventing HBV infection. Several studies 
have documented that immunization starting with the birth dose can prevent perinatal transmission, 
including when the mother is HBeAg positive (15). It was estimated that HBV immunization already 
prevented 210 million new hepatitis B chronic infections by 2015 and will have averted 1.1 million 
deaths by 2030 (16). The World Health Organisation (WHO) currently recommends HB vaccination of 
infants regardless of maternal HBV infection status (“universal”), starting at birth, and followed by two 
injections during the first 6 months of life (17). The timing of vaccination is crucial. Indeed studies have 
shown that the administration of vaccine cannot cure an infection that is already established (18).  
Efficacy of HBIg combined with HB vaccine birth dose 
For infants born to HBV infected mothers, the additional administration of HBIg immediately after birth 
is recommended although this strategy does not prevent all infant infections from mothers with high 
viremia: in all recent studies where HBIg was administered in addition to vaccine, transmissions. 
mainly in utero, were reported (in randomized studies: 8% (13), 7% (14), and 2% in our recent iTAP 
study conducted in Thailand (19,20); and up to 11% in a retrospective study in Taiwan (21).  
Challenges of universal HBIg provision across diverse clinical settings 
Although global coverage with the three doses of hepatitis B vaccine in infancy reached 84% in 2015, 
coverage with the initial birth dose vaccination is still low at 39% (22), although it seems crucial to 
prevent perinatal transmission. The concomitant administration of HBIg for neonates born to mothers 
with high viremia is even more challenging (23) and the 2015 WHO Guidelines noted that HBIg “may 
not be feasible in most settings” (17). Provision of HBIg to infants born to HBV-infected mothers may 
not be easy, particularly from a country wide programmatic point of view. A major barrier is the lack of 
widespread 24/7 availability of HBIg at all maternity units, in relation with several factors: maintenance 
of refrigerated HBIg stocks, short shelf life, cost considerations, and access to a reliable source of 
HBIg production from immunized donors. As for all human derived products, there is a theoretical risk 
of transmission of known or unknown pathogens, although no studies have found any evidence of 
such transmission. Also, this prevention strategy relies on a single administration of HBIg as soon as 
possible after birth, heavily dependent on the organization of the maternity team, with no forgiveness 
if it is not administered within a certain window period. Moreover, delivering vaccine and HBIg is even 
more complicated when pregnant women deliver at home, often at significant distance from health 
facilities. While the vaccine can be transported at room temperature, HBIg requires cold chain. For 
most infants born to women with HBV infection worldwide, the concomitant administration of HBIg will 
remain probably out of reach for a long time. In Thailand, HBIg administration is recommended to the 
extent it is available. Practically, HBIg is not available in most hospitals in Thailand (in the iTAP trial, 
the study coordination directly provided HBIg to sites as HBIg was not available at all sites). In Lao 
PDR, HBIg is not provided and HBIg is not registered with Health authorities.  
Efficacy of maternal antiviral prophylaxis for HBV transmission 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 11 of 37 
The rationale for providing antiviral therapy to highly viremic HBV-infected pregnant women during the 
last trimester is that the decrease of HBV viremia will provide pre-exposure prophylaxis (i.e. fetal drug 
exposure through drug crossing the placenta), preventing in utero and intrapartum transmission. The 
effect of tenofovir disoproxil fumarate (TDF) during pregnancy on the risk of infant HBV infection has 
recently been evaluated in two different randomized clinical trials, one published (14) and one just 
completed by our research group (24). 
In an open-label randomized study conducted by Pan et al. in China, pregnant women with chronic 
HBV infection and high HB viral load received TDF starting from 30-32 weeks pregnancy until one 
month postpartum, or the standard of care (control group). All infants received HBIg and a first dose 
of HB vaccine at birth, a second dose of HBIg and vaccine at 2 months of age, and a third dose of 
vaccine at 24 weeks. There were no HBV infections at 6 months of age in infants born to 92 women 
who received TDF versus 6 among 88 infants born to women who received the standard of care 
(p=0.01).  
Between 2013 and 2016, PHPT conducted the iTAP study, a multicenter, double-blind, clinical trial in 
Thailand. HBeAg positive pregnant women with alanine aminotransferase (ALT) ≤60 IU/L were 
randomized to TDF or placebo from 28 weeks gestation to 2 months postpartum. Infants received 
HBIg at birth, and HB vaccine at birth, 1, 2, 4 and 6 months. The primary endpoint was HBsAg positivity 
confirmed by HBV-DNA at 6 months. The sample size was 328 women to ensure 90% power to detect 
a ≥9% difference in infant HBV infections (based on the assumption that the rate of infection in infants 
will be 3% in the TDF arm and 12% in the placebo arm). 331 women (168 TDF, 163 placebo) were 
enrolled. Median age was 26 years, gestational age 28.3 weeks, and HBV DNA 8.0 log10 IU/mL.  Of 
322 (97%) on-study deliveries, there were 319 singleton, 2 twin pairs and one stillborn (TDF); 21 (7%) 
(8 TDF, 13 placebo) were preterm. Median time of HBIg and vaccine administration was 1.3 and 1.2 
hours after birth, respectively. In primary analysis, 0/147 (0%, 95% CI 0.0-2.5%) infants were infected 
in TDF versus 3/147 (2.0%, 95%CI 0.4-5.8%, 2 of 3 in utero) in placebo (p=0.12). Adverse events did 
not differ by arm, including maternal ALT ≥300 IU/mL following treatment discontinuation (p=0.29). 
The study was designed to also determine the timing of infant infection, if any, using infant peripheral 
blood (as opposed to cord blood) for HBV DNA testing at birth (19,20). A pharmacokinetic substudy of 
tenofovir was performed among the women randomized to receive TDF. Approximately 10% of the 
plasma samples collected during the follow-up were found to have undetectable tenofovir 
concentrations. The pharmacokinetics of tenofovir in women enrolled in iTAP were in the range 
expected for pregnant and postpartum women receiving TDF alone.  
Previous studies have reported higher rates of transmission, up to 12%, when infants born to mother 
with high viremia received vaccine and HBIg, without maternal antiviral treatment. Medical practices, 
such as amniocenteses and Cesarean sections, vary across settings and countries, which may 
account for differences. The unexpectedly low rate of infant HBV infection in the placebo arm of iTAP 
(HBIg + Vaccine) was consistent with a protective, though incomplete, effect of vaccine and HBIg, 
compared to 11% (11 of 101) at 9 months in infants born HBeAg positive women in an open label 
study in Thailand which compared two less intensive vaccine schedules with no HBIg (15). Importantly, 
in our iTAP study, it was emphasized to the investigators and study personnel that HBIg and vaccine 
must be administered as soon as possible after birth. This was carefully monitored and any departure 
from this recommendation prompted immediate review of the case and a corrective action. Indeed, 
the median time from birth to first vaccination was 1.2 hours (interquartile range: 0.7, 2.2) and only 4% 
of infants had their vaccine administered more than 4 hours after birth. 
Among the HBV infected infants in the placebo arm (HBIg + Vaccine) of our iTAP study: 
- 
Two infants were in utero infected (high HBV DNA loads detected since birth), consistent with the 
hypothesis that HBIg at birth cannot prevent prior in utero infection. 
- 
One infant, born by C-section, tested negative for HBsAg and HBV DNA until 4 months of age but 
was found infected at 6 months.  Sequence analysis showed that the virus was almost identical to 
the mother’s virus (one different nucleotide out of 801 bases in the pol region) ruling out a 
transmission from a third person. Anti-HBs antibody levels decreased after HBIg was administered 
at birth but there was no increase following vaccination, consistent with the clearance of HBIg and 
the absence of a successful response to vaccination. 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
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In addition, in another non-randomized study of telbivudine, another potent drug that inhibits HBV 
replication, versus standard of care, no infants born to mothers who received telbivudine were HBV 
infected (13). 
Safety of maternal antiviral prophylaxis for HBV transmission 
In these studies, there were no safety concerns with regard to maternal antiviral prophylaxis, neither 
for the mothers nor the infants. Some increases of ALT without clinical manifestations were observed. 
In our iTAP study, 9 (6%) women experienced an ALT ≥300 IU/mL following study treatment 
discontinuation in the TDF arm versus 5 (3%) in the placebo arm (p=0.29). The proportions of maternal 
and infant adverse events, pregnancy outcomes and congenital abnormalities were not significantly 
different between arms. Similarly, a recent meta-analysis by the American Association for the Study 
of Liver Diseases (AASLD) concluded that the use of TDF during pregnancy appears well tolerated 
(25).  
4.2 
Study Rationale  
Rationale for not using infant HBIg born to mothers receiving antiviral prophylaxis 
Mother-to-child HBV transmission can occur in utero, intrapartum or in the post-natal period before HB 
vaccine is effective. If viral particles are transmitted to the infants during the intrapartum/early post-
natal period, these viral particles can be neutralized by anti-HBs antibodies elicited by immediate 
vaccination at birth and/or HBIg.  However, vaccination and HBIg at birth cannot prevent infections 
already established in utero.  In two previous PMTCT of HBV trials (13,14) and the recent iTAP study, 
no infants were infected when mothers received either TDF or telbivudine during pregnancy, 
suggesting that a short–course of antiviral treatment during the last trimester and during the early 
postpartum period can prevent in utero transmission, intrapartum and early post-natal transmissions. 
These data support the rationale that the pre-exposure prophylaxis effect of the antiviral transferred to 
the fetus in utero, and the significant reduction in viral load is sufficient to eliminate the risk of infection 
before the vaccine elicits an antibody response (i.e. during the 1st month of life). Thus, in the presence 
of maternal antiviral prophylaxis, it is conceivable to remove HBIg when newborns are vaccinated 
immediately after birth. The study aims to show that substituting maternal antiviral treatment for infant 
HBIg can be favorably considered in settings where HBIg plus vaccine has been used as well as in 
settings where only vaccine is used.  
Post-exposure prophylaxis studies conducted in chimpanzees and humans have provided evidence 
that HB vaccine can prevent infection when administered at the same time or shortly after exposure 
to HBV:  
• 
In a study investigating the post-exposure effect of vaccination, a first dose of HB vaccine was 
administered 4, 8, 48, or 72 hours after HBV was inoculated intravenously to 4 chimpanzees (26). 
A second and a third vaccine doses were administered 2 and 6 weeks after the first dose. Only 
chimpanzees that received vaccination within 48 hours after HBV exposure (3 of 4 vaccinated) 
were protected against HBV infection. 
• 
A subsequent set of experiments assessed the protective effect of post-exposure prophylaxis of 
HB vaccine and/or HBIg. Chimpanzees received immunoprophylaxis (HBIg only or HBIg plus 
vaccine) simultaneously, 4 hours or 4 weeks after intravenous inoculation of HBV (27). There were 
no infections when HBIg was administered simultaneously with HBV inoculum, and when HBIg in 
combination with HB vaccine were administered 4 hours after HBV inoculation. The chimpanzee 
receiving only HBIg 4 hours after HBV inoculation was infected. Based on these results the authors 
proposed that “HBIg may be omitted in the post-exposure situation and be replaced by vaccination 
only”. It was hypothesized that post-exposure hepatitis B vaccination could be effective due to the 
long incubation period of HBV infection, in the same way as rabies vaccine administered after 
exposure to the virus. 
• 
In a placebo controlled, randomized, double blind study of the efficacy of HB vaccine conducted 
among 1,083 homosexual men at high risk of HBV infection in the United States, clinical hepatitis 
B and subclinical infections occurred less frequently in vaccine than in placebo recipients (1.4-
3.4% vs. 18-27%, P <0.0001). Importantly, a significant reduction of HBV incidence was observed 
within 75 days of randomization, suggesting that HB vaccination remains efficacious even after 
exposure (28). 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 13 of 37 
Efficacy of maternal antiviral and HB vaccine on mother-to-child transmission of HBV 
• 
In a study analyzing the early viral kinetics of 
HBV DNA in HBeAg positive patients with 
chronic hepatitis receiving 12 weeks of either 
telbivudine, TDF, or both, the mean (SD) 
reduction in HBV DNA levels in 14 patients on 
TDF was -4.2 (0.7 log10 copies/mL). Each 
antiviral produced a rapid drop in viral load 
within the first 2 weeks of treatment (29) (Figure 
1). 
• 
In our perinatal study, iTAP, 161 women started 
TDF at 28 weeks GA with a median HBV DNA 
load of 8.0 log10 IU/mL. At delivery, median HBV 
DNA load decreased to 3.9 log10 IU/mL, i.e. 
median decrease of 4.00 (IQR 3.16-4.59) log10 
IU/mL. This decrease is consistent with that 
observed by Leung et al. and that reported in 
the Pan’s study: VL reduction from 8.2 to 4.7 
log10 IU/mL over a mean of 8.57 weeks of TDF therapy before delivery (14). 
In two previous randomized clinical trials, no infections occurred when women received TDF during 
pregnancy and the newborn received HBIg plus HB vaccine. It is hypothesized that the HB viral load 
reduction at the time of delivery will ensure a low viral exposure at the time of delivery and HB vaccine 
given immediately at birth will provide an efficacious post-exposure prophylaxis, even in the absence 
of HBIg. A meta-analysis showed that there was no additional benefit of HBIg when mothers were 
HBeAg negative, i.e. with relatively low viral loads (30). Thus, HB vaccine alone may prevent HBV 
infection if HBeAg positive women receive potent antiviral treatment during pregnancy and achieve a 
level of HBV DNA similar to that observed in HBeAg negative women. 
5. Study specific objectives 
5.1 
Study objectives 
Primary objective 
To demonstrate that the risk of HBV infection at 6 months of age is lower than 2% in infants who 
receive active immunization but no HBIg, born to HBeAg positive mothers with satisfactory virological 
response on tenofovir disoproxil fumarate (TDF) 300 mg per day from 28 weeks gestation to 2 months 
postpartum.  
Secondary Objectives 
• To assess pregnancy outcomes and infant outcomes until 18 months of age. 
• To retrospectively determine the risk of transient infection in infants at 18 months of age using anti-
HBc antibodies. 
• To describe infants’ response to HB vaccination in the absence of confounding from HBIg 
administration assessed by anti-HBs antibodies levels at 1, 2, 4, 6, 12 and 18 months. 
• To describe the changes in HBV DNA level from initiation of TDF to delivery. 
• To compare the risk of infant HBV infection at 6 months of age with that observed in infants who 
received HBIg at birth plus HBV vaccine in one of the 2 arms of a previous study conducted in a 
similar setting in Thailand (iTAP, NCT01745822). 
• To assess the risk of transmission in all infants born in the study, including those born to women 
with unsatisfactory virological response to study treatment. 
Figure 1: Mean HBV DNA decline over time by treatment group 
(intent-to-treat population). Error bars are standard deviations. 
From Leung et al. Infect. Dis Ther (2014) 3:191-202. 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 14 of 37 
5.2 
Study Design 
This study is a multicenter, prospective, open-label, single arm clinical study enrolling HBV chronically 
infected pregnant women at 28 weeks gestation. Four hundred and ninety-nine (499) women and their 
infants will be enrolled.  
Rationale for important characteristics of the design 
Choice of the population. We will select women with HBsAg and HBeAg positive tests. Young pregnant 
women with HBeAg positive are most likely to have high viremia (median 8 log10 IU/mL in iTAP). The 
HBeAg test will be used as opposed to HBV DNA load to select pregnant women the most at risk of 
transmission of HBV to their baby because HBeAg transferred during pregnancy to the infant may play 
a role facilitating immune tolerance and infection, for consistency with our previous study and because 
HBeAg tests (Elisa or rapid tests) are widely available, as opposed to HBV DNA measurements, 
making the study results more generalizable in the future. To characterize the study population, HBV 
DNA load at enrollment will be retrospectively measured. 
Gestational age at treatment initiation. The treatment will start at 28 weeks gestational age based on 
the obstetrician judgment guided by the review of the date of last menstruation period, physical exam 
and sonogram. Tenofovir disoproxil fumarate was  started between 30 and 32 weeks’ gestation in the 
study by Pan (14) and at 28 weeks +/- 10 days in the iTAP study (24). There were no infant infections 
in the treated arms of these studies despite slight differences in gestational ages at initiation of 
treatment. 
Evaluation of the response to study treatment at 36 weeks’ gestation. In the iTAP study, 12% of women 
in the TDF arm had HBV DNA at delivery above 200,000 IU/mL, which identifies women at risk of 
transmission (31). A possible lack of adherence to TDF during pregnancy raises the concern of a 
subsequent risk of transmission in the absence of HBIg. HBV DNA load will be measured after 
treatment initiation and at the latest at 36 weeks’ gestation to check that HBV DNA load has decreased 
on study treatment. If the level of HBV DNA load indicates an unsatisfactory response to study 
treatment, whatever the cause (such as adherence or absorption issues), the site study team will 
contact the participant to reinforce adherence to study treatment and possibly recommend HBIg 
administration to the future infant if available.  
Duration of maternal study treatment. There were variations in postpartum duration of treatment in 
previous studies and TDF was not discontinued as planned during the postpartum period in several 
studies. In this study, TDF will be discontinued at 2 months postpartum for all women with baseline 
ALT ≤60 U/L. For women with ALT >60 U/L, indications for lifelong antiviral treatment will be assessed 
before postpartum discontinuation of antiviral treatment. TDF is available in Thailand and Lao PDR for 
treatment of HBV. 
Breastfeeding. Mothers will receive study treatment for 2 months postpartum and breastfeed, as 
recommended by WHO (based on studies finding similar rates of HBV infection in breastfed compared 
to bottle fed children). The oral prodrug TDF was developed because of the poor bioavailability of oral 
tenofovir. It is absorbed and converted into the active form, tenofovir, which circulates in the 
bloodstream. The tenofovir form is excreted in the breast milk and is poorly absorbed by the infant. It 
was estimated that the infant receives 0.03% of the proposed dose for neonates through breast milk 
(32).  
Diagnosis of HBV infection in infants. The endpoint for this study will be HBV infection at 6 months of 
age ascertained by HBsAg and confirmed by PCR detection of plasma HBV DNA. Neither the time of 
contamination nor the time to detection of HBsAg in the fetus/infant serum is known: infant peripheral 
blood will be drawn for HBsAg test at 1, 2, 4, 6, 9, 12, 18 months (before vaccine administration if at 
the same date) and, if HBsAg positive, HBV DNA PCR will be performed retrospectively at other time 
points to determine the timing of infection and chronicity (late infections during infancy are more likely 
to resolve than if occurring soon after birth).  
Evaluation of anti-HBc antibodies at 18 months of age. Antibodies directed against HB core (anti-HBc 
antibodies) are produced during infection and persist after resolution for at least one year (33). They 
are used as markers of resolved/prior infection. All infants negative for HBsAg at 18 months of age will 
be tested for anti-HBc antibodies  and, if positive, previous samples will be tested by PCR for HBV 
DNA to determine whether they experienced a resolved transient HBV infection (i.e. such children 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 15 of 37 
would have been infected but cleared HBV) or have occult HBV infection. Such occult HBV infections 
may reactivate following the administration of immunosuppressive drugs, for example in the context 
of chemotherapy for cancer (34). 
 
 
* HB vaccine schedule in Thailand: at birth, 1, 2, 4, and 6 months  
  HB vaccine schedule in Lao PDR: at birth, at 6, 10, and 14 weeks 
Figure 2: Study design  
Women will be followed until 12 months post-partum and children until 18 months of age.  
6. Study sites and duration of the study 
6.1 
Study sites 
The list of participating sites is provided in the table below (following the 27 February 2019 and 15 
January 2020 amendments, some sites that originally planned to participate did not implement the 
study and others were added).  
Site co-investigators are responsible for the medical management of the patients, the implementation 
of the study interventions according to the protocol and the completion of the Case Report Forms 
(CRFs). At each site, the study teams consist of obstetricians, pediatricians, nurses, laboratory 
technicians, pharmacists and counselors. Each site is regularly monitored by a PHPT clinical research 
assistant to ensure that study procedures are implemented according to the protocol and regulations.  
All study co-investigators and study nurses will be trained before the beginning and during the study 
on the specific aspects of the study and hepatitis B management and treatment.  
 
 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 16 of 37 
Table 1: List of 21 study sites and planned number of participants at each site 
 
Thailand sites 
Province 
Estimated number of 
patients to be enrolled 
Health Promotion Center Region 1 
Chiang Mai 
15 
Lamphun Hospital 
Lamphun 
5 
Chiangrai Prachanukroh Hospital 
Chiang Rai 
30 
Chiang Kham Hospital 
Phayao 
30 
Prapokklao Hospital 
Chantaburi 
5 
Banglamung Hospital 
Chonburi 
5 
Chonburi Hospital 
Chonburi 
6 
Nakornping Hospital 
Chiang Mai 
2 
Nopparat Rajathanee Hospital 
Bangkok 
6 
Samutsakhon Hospital 
Samutsakhon 
20 
Samutprakarn Hospital 
Samutprakarn 
20 
Lampang Hospital 
Lampang 
20 
Lao PDR sites 
 
 
Mother and child hospital 
Vientiane Capital 
70 
Setthathirath Hospital 
Vientiane Capital 
45 
Mahosot Hospital 
Vientiane Capital 
65 
Champasak Province Hospital 
Champasak 
40 
Savannakhet Province Hospital 
Savannakhet 
30 
Luang Prabang Provincial Hospital 
Luang Prabang 
15 
Xayaboury Province Hospital 
Xayaboury 
20 
103 Hospital 
Vientiane Capital 
35 
Vientiane Provincial Hospital 
Vientiane Province 
15 
Total 
 
499 
 
6.2 
Duration of the study 
First enrollment: August 2, 2018 
Planned enrollment duration: 24 months 
Primary endpoint available for all participating infants: Fourth quarter 2021  
Planned date of last visit completed: May 1, 2022 
Biological analyses completed: May 1, 2023 
Final report: Fourth quarter 2023 
 
7. Workplan  
7.1 
Study population 
The population enrolled in the study will be composed of pregnant women meeting all eligibility criteria, 
and none of the exclusion criteria, and their infants.  
7.1.1 Eligibility 
• 
Pregnancy 
• 
Age ≥18 years 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 17 of 37 
• 
Negative HIV antibody test during current pregnancy 
• 
Positive HBsAg test during current pregnancy  
• 
Positive HBeAg using a rapid test during current pregnancy  
• 
Absence of clinical symptoms of liver disease 
7.1.2 Inclusion criteria 
Women: 
• 
Meet all eligibility criteria at time of enrollment  
• 
Gestational age of 28 weeks (+/- 7 days) based on the obstetrician judgment guided by the 
review of the date of last menstruation period. 
• 
Willing and able to provide written informed consent 
• 
Agreeing to bring her infants(s) at the planned study visits at one of the study site until the last 
visit (18 months after birth) and to inform the site investigators if plans to move to another place 
and not be able to return to the clinic 
• 
Understand the need for adequate infant immunization for her infant(s) and accept that blood 
draws will be performed to determine the infant HBV infection status. 
 
Infants: 
• 
All infants born alive to participating mothers can be enrolled in the study.  
7.1.3 Exclusion criteria 
• 
Receipt of anti-HBV antivirals at any time during the last 9 months  
• 
Known liver cirrhosis or evidence of hepatocellular carcinoma 
• 
Creatinine clearance <50 ml/min, calculated using the Cockcroft-Gault formula 
• 
Confirmed dipstick proteinuria >1+ (>30 mg/dL) or normoglycemic glycosuria 
• 
Evidence of pre-existing fetal anomalies incompatible with life 
• 
Any concomitant condition or treatment that, in the view of the clinical site investigator, would 
contraindicate participation or compromise adherence to treatment and satisfactory follow up 
in the study. 
7.1.4 Discontinuation criteria 
Women enrolled in the study are free to withdraw their or their infants’ participation in the study at any 
time without jeopardizing their access to standard medical care or possible participation in future 
research studies. 
A study site co-investigator may decide to end a subject’s participation in the study if, in his/her own 
judgment, such participation would be detrimental to the mother or the infant’s health or well-being. 
However, all efforts should be made to inform the study team and discuss options prior such a decision.  
The reason for participant discontinuation or withdrawal from the study will be recorded on the “End of 
Study Form for Women/Child” Case Report Form (CRF). 
If a participant fails to return to the clinic for a study visit, the site personnel will attempt to contact the 
mother and reschedule the missed visit and ascertain whether the participant wishes to continue 
participating in the study. 
Should a participant continue to be unreachable, she will be considered to have withdrawn from the 
study with a primary reason of lost to follow-up. 
 
7.2 
Implementation, data collection, and monitoring procedures 
7.2.1 Follow-up and study procedures 
1. Women/mothers 
The study visits and procedures for women are summarized in Table 2 below.  
Eligibility and pre-enrolment tests should be performed prior to enrolment. After enrolment at 28 
weeks, maternal visits will be at 32, 36 weeks’ gestation, delivery and at 1,2,4,6 and 12 months post-
partum.  

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Table 2. Schedule of visit and study procedures/assessments for mothers 
 
1 APRI score will be calculated at 4 months postpartum using the formula (AST/ULN) x 100) / platelet count 
(109/L) and FIB-4 = (age (yr) x AST (IU/L)) / (platelet count (109/L) x [ALT (IU/L)1/2]). 
2Creatinine clearance will be calculated using the Cockcroft-Gault formula.  
3To be measured real-time 
4To assess adherence in relation to virological response. 
* Enrollment can be completed only after transmission to the study coordination center of all relevant 
information and approval. 
All efforts should be made to strictly follow the maternal and infant visit schedule but occasional 
departures of no more than one week will be considered acceptable. 
Women with ALT ≤60 U/L at enrollment will discontinue treatment two months after delivery. Those 
with ALT >60 U/L will be assessed during the postpartum period for potential long-term treatment 
indications before discontinuation of study treatment to prevent flares. 
With participant’s authorization, the study team will record contact information including mobile phone 
number and address (this information will not be entered in study databases) to be used for contact if 
needed (e.g. does not show up at a visit).  
After the beginning of treatment and at the latest at 36 weeks’ gestation, virological response to study 
treatment will be assessed using HBV DNA load measurement (the date of this assessment should 
be determined taking into account the risk of premature delivery). If the level of HBV DNA load has 
not significantly decreased (at least by 10 fold in IU/mL) and is above 200,000 IU/mL, the site study 
team will contact the participant to reinforce adherence to study treatment. 
Expected newborn close contacts. The site study team will explain to the pregnant women that HBV 
can be transmitted to their infant by close contact with another person infected with HBV and will 
recommend that they refer any persons who will be in close contact with the infant during at least the 
first month of infant life for counseling and HBsAg testing. If they agree, the close contacts will be 
informed of HBV routes of transmission, provided counseling and proposed HBsAg testing.  
Pregnant Women / Mothers   
Antepartum 
Postpartum 
 
Study treatment 
 
Pre-
enroll 
ment 
Enroll 
ment * 
28 w. 
32 w. 
36 w. 
Delivery 
1 
2 
4 
6 
12 
months after delivery 
Information about the study, 
consent process 
X 
X 
 
 
 
 
 
 
 
 
Counseling, Medical exam 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
Documented telephone contact 
with the participant  
 
 
 
 
 
 
 
 
X 
 
Study treatment dispensation 
and/or adherence assessment 
(self-report and pill counts), return 
of unused study treatment 
 
X 
X 
X 
X 
X 
X 
 
 
 
Record results of previous 
HBsAg, HBeAg, HIV and HCV 
serology and sonogram results  
 
X 
 
 
 
 
 
 
 
 
ALT (SGPT), AST (SGOT)1 
 
X  
 
 
X 
 
X 
X 
 
 
Complete Blood Count  
 
X 
 
 
X 
 
 
X 
 
 
Serum creatinine2 
 
X 
X 
 
 
 
X 
 
 
 
Dipstick glycosuria and 
proteinuria 
 
X 
 
 
 
 
X 
 
 
 
HBeAg 
 
 
 
 
 
 
 
 
 
X 
HBV DNA load 
 
X 
 
X3 
X 
 
 
 
 
 
Tenofovir plasma level4 
(retrospective) 
 
 
 
X 
X 
 
 
 
 
 
Plasma storage 
 
X 
X 
X 
X 
X 
X 
X 
 
X 
Cell pellets storage 
 
X 
 
 
 
 
 
 
 
 
Total volume blood (mL) 
 
16 
10 
6 
11 
4 13 
10 
 
8 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 19 of 37 
Management of toxicities will be discussed and reviewed with the site study teams during on-site 
trainings organized prior to starting the study, and described in detail in the Manual of Onsite 
Operations. The PHPT coordination center can be reached by fax and e-mail and, if needed, by phone 
(24/7). At each visit, the study nurse in charge will record the history and the results of the physical 
exam, record and grade adverse experiences. Women will be asked at all visits to report any 
concomitant treatments (including use of herbal medicines) or medical interventions. Grade 3 and 4 
abnormalities as defined by the NIAID Division of AIDS in the Table for Grading the Severity of Adult 
and Pediatric Adverse Events, Corrected Version 2.1, July, 2017 will be reported immediately to the 
PHPT Study Coordination Center. Any serious adverse event, as defined by ICH Good Clinical 
Practice (GCP) (35), whether or not considered to be related to the study treatment, will be reported 
within 3 business days to the Study Coordination Center and to national health authorities.  
Women with baseline ALT >60 U/L wishing to discontinue the study treatment before 2 months 
postpartum will be referred to a specialist for hepatitis B infection management.  
In case of planned early withdrawal from the study, the investigator will ask for her authorization to 
perform a last blood draw from her and her infant for safety evaluations and for documentation of the 
infant’s HBV status (see Tables 2 and 3). 
 
All women enrolled in the study will be retrospectively assessed for SARS-CoV-2 antibodies at two 
time points, at entry in the study, and at the 2 months postpartum visit or before if no sample has been 
collected at this visit. (2 December 2020 Amendment) 
2. Infants  
Each infant will have 8 study visits from birth to 18 months of age. The study procedures for the infants 
are summarized in Table 3, below. Infant peripheral blood will be drawn for HBsAg test at 1, 2, 4, 6, 9, 
12, 18 months (before vaccine administration if at the same date). All infants will receive HB vaccine 
according to national guidelines. In Thailand infants will receive vaccine immediately after birth, then 
at 1, 2, 4, and 6 months. In Lao PDR infants will receive vaccine immediately after birth, then at 6, 10, 
and 14 weeks).  
Following the assessment of maternal virological response to study treatment, HBIg administration to 
the newborn may be considered if the level of maternal HBV DNA load had not significantly decreased 
and was above 200,000 IU/mL.  
Table 3. Schedule of visits and study procedures/assessments for infants 
Infant assessments 
Birth 
1 
month 
2 
months 
4 
months 
6 
months 
9 
months 
12 
months 
18 
months 
Counseling and 
physical examination  
X 
X 
X 
X 
X 
X 
X 
X 
Record date, time of 
HBV immunization 
X 
X 
X 
X 
X 
 
 
 
HBsAg  
X2 
X1 
X1 
X1 
X1 
X 
X 
X 
HBV DNA PCR  
X2 
X2 
X2 
X2 
X2 
X 
X2 
X2 
Anti-HBs antibodies 
X 
X 
X 
X 
X 
X 
X 
X 
Anti-HBc Antibodies 
 
 
 
 
 
 
 
X 
Plasma storage 
(including cord blood) 
X 
X 
X 
X 
X 
X 
X 
X 
Cell pellets storage 
X 
 
 
 
 
 
 
 
Total volume (mL) 
4 
5 
5 
5 
5 
5 
5 
5 
1 Blood must be drawn before injection of HB vaccine 
2 If HBsAg positive at 6 months 
 
If anti-HBs < 10 IU/L (and HBsAg/HBV DNA negative) at 6, 12 and 18 months of age, the pediatrician 
in charge will consider revaccination. 
7.2.2 Laboratory assessments 
7.2.2.1  Sites Assessments  
Maternal ALT (SGPT), AST (SGOT), complete blood count, creatinine, and dipstick glycosuria and 
proteinuria will be tested at each site laboratory using the same procedures as for routine testing. The 
PHPT laboratory staff will regularly monitor the quality control of the site laboratories. 

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7.2.2.2  Centralized assessments  
The PHPT laboratory (ISO 15189 and 15190 accredited) is responsible for the centralized laboratory 
exams, virological testing, and samples repository. The blood samples will be stored at the central 
laboratory for retrospective assessments as needed. It is located in Chiang Mai, under the Faculty of 
Associated Medical Sciences, Chiang Mai University. 
PHPT laboratory will test HBsAg in infant using the Monolisa HBsAg Ultra kit and measure plasma 
HBV DNA load using the real-time Abbott m2000 system (External quality assurance from Quality 
Control for Molecular Diagnostics, UK). 
HBeAg, anti-HBs antibodies, anti-HBc antibodies and tenofovir plasma level will also be centralized at 
PHPT laboratory.  
For monitoring of virological response in women followed in Lao PDR, HBV DNA concentrations will 
be measured at Center of Infectiology Lao Christophe Mérieux.  
All laboratory procedures will be described in the Manual of Operations. 
7.2.3 Data collection 
Study data, including data related to adverse events, will be collected at sites by the site investigators 
or designees. As soon as possible after each visit, the data Manager will run programs to detect data 
issues that require verification (e.g. inconsistent, missing, unusual or unexpected data) according to 
specific standard operating procedures.  
The following data will be collected for each adverse event: participant identification (including initials, 
date of birth, gender, weight and height), Adverse Event (AE) Lowest Level Term (LLT) based on the 
international terminology dictionary MedDRA, onset and stop dates, severity, outcome date, 
assessment of causality with study treatment; date of study treatment first dose and last dose; action 
taken with study drugs. 
Queries will be issued to clarify issues, and confirm or obtain correct information. All data changes will 
be tracked and documented in compliance with Good Clinical Practice. Study database are backed 
up daily. 
7.2.4 Reporting  
Regular study reporting to Ethics Committees 
The PHPT data management team will submit every 6 months to Ethics Committees a study progress 
report that includes: 
- 
Accrual by site 
- 
Participants’ characteristics at baseline and follow up study visits 
- 
Participants’ follow-up status 
- 
Listing of Serious Adverse Events (SAEs).  
Serious Adverse Events reporting 
The site investigator or designee will contact the PHPT safety monitors/research nurses or CRA within 
24 hours as soon as he/she is aware that a participant is experiencing a SAE.  
The PHPT safety monitors/research nurses will assist the site personnel to prepare an SAE report. All 
information recorded in the SAE report will be checked for consistency with the participant’s study 
records. The Principal Investigator (PI) or a designee physician will then review and sign the SAE 
report and forward it to the site investigator for validation and signature. The PHPT team will then 
forward the report to the Ethics Committees, within 3 business days. Further reports will be issued as 
needed and submitted to Ethics Committees until resolution or stable state. 
7.2.5 Study implementation onsite monitoring  
Monitoring visits to the study sites will be conducted regularly by PHPT clinical research assistants to 
review compliance with the protocol, Good Clinical Practice and regulatory requirements. During the 
first few months of enrollment, the monitoring visits will take place every 2-3 weeks based on the 
recruitment status of each study site. All activities during visits will be documented and significant 
issues will be immediately reported to the PHPT Study Monitoring Director.  
During these visits, study records will be checked against source documents that site investigators will 
make available to PHPT team. These documents include but are not limited to informed consent forms, 

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records related to primary endpoints and safety, regulatory aspects, adverse events, queries, 
laboratory values. In particular, CRAs will ensure that all events to be reported have been declared to 
PHPT. 
Additional activities include assessing site capacity, appropriate storage and accountability of study 
drugs, review of screening/recruitment/retention targets, and assessment of the need of additional 
staff training.  
7.3 
Study drugs 
Tenofovir disoproxil fumarate (TDF) 300 mg tablets. The study site pharmacists will be responsible for 
study drug storage, dispensation and accountability. 
7.4 
Biohazard Containment 
As the transmission of blood-borne pathogens (including HBV) can occur through contact with 
contaminated needles, blood, and blood products, appropriate precautions will be used by all 
personnel when drawing of blood and shipping and handling of all specimens for this study, as 
currently recommended by the US Centers for Disease Control and Prevention. All infectious 
specimens will be transported using requirements for shipping infectious substances. 
7.5 
Statistical considerations   
7.5.1 Justifications for the design 
Ideally, a design to demonstrate that HBIg can be omitted if mothers receive antiviral (TDF) prophylaxis 
would be to assess whether this approach is non-inferior to the administration of HBIg in these 
mothers. As the expected transmission is close to zero, the maximum acceptable difference between 
the rates of infections resulting from each intervention would be very small. Thus, the sample size 
needed for such a design would be large (over one thousand), delaying the answer to the research 
question, limiting drastically the feasibility and the possibility to fund such a study. For example, 
assuming the actual transmission probability in both arms is 0.5% and a non-inferior transmission 
probability in the TDF-alone arm is 2% (i.e. a non-inferiority margin of 1.5%), a sample size of 1344 
participants would be required to have 90% power using a 2.5% significance level allowing for 12% 
loss to follow-up. 
Several studies have shown that, even if infants received HBIg at birth, infections occurred if mothers 
were not given antiviral prophylaxis: reported rates of infection were up to 12%. The lowest percentage 
of infection ever reported in infants receiving vaccine and HBIg was 2%, in the placebo arm of iTAP. 
Thus, a new strategy reducing the risk of infection below 2% in women with high viremia would be 
considered as an improvement. Of note, a 2% transmission has also been considered by the WHO as 
the maximum transmission rate from infected mothers to declare that a member state has virtually 
eliminated perinatal transmission of HIV. In the case of HBV, only HBV infected women with high 
viremia are at significant risk of transmission. 
7.5.2 Endpoints 
Primary endpoint 
For this study, infant HBV infection is defined as a positive HBsAg test confirmed by HBV DNA 
detection by PCR at 6 months of age. 
 
Secondary endpoints 
- 
Occurrence of maternal and infant serious adverse events (ICH SAEs) including DAIDS grade 4 
signs and symptoms (36), regardless of their relatedness to the study treatment 
- 
Occurrence of pregnancy outcomes: full term or preterm live births, stillbirths, spontaneous 
abortions, induced abortions 
- 
Detectable anti-HBc antibodies in children at 18 months of age  
- 
Levels of anti-HBs antibodies in infants at 1, 2, 4, 6, 12 and 18 months 
- 
HBV DNA levels in women at treatment initiation and time of delivery. 

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- 
HBV infection status of all infants, including those born to women with unsatisfactory virological 
response to study treatment  
7.5.3 Sample size 
The primary objective is to demonstrate that virtually no HBV infection is observed at 6 months of age 
in infants born to HBeAg positive mothers who receive antiviral prophylaxis from 28 weeks gestation 
to 2 months postpartum with a satisfactory virological response to treatment. Infants with no infection 
detected by 6 months of age but found later infected would be considered as experiencing vaccine 
failure, whatever the cause, and the study team will make all possible efforts to determine the cause 
of failure. 
Thus, for the primary efficacy analysis, the precision of the estimated probability of HBV infection at 6 
months of age in infants born to mothers given TDF is crucial.  
A significant improvement over the standard HBIg + vaccine strategy would be that adding an antiviral 
strategy would result to less than 2% transmission. If the true infection rate using the new strategy was 
0.5%, a sample size of at least 386 evaluable infants would be needed to demonstrate with at least 
87% power that the infection rate using the new strategy is smaller than 2% (see table below).  
Table 4. Power to detect a transmission rate significantly lower than 2% with a sample size of 386 
evaluable cases according to the actual infection rate (based on the binomial distribution and an exact 
test with a one-sided significance level of 0.05).  
Actual transmission rate 
0.3% 
0.4% 
0.5% 
0.6% 
0.7% 
1% 
Power 
97% 
93% 
87% 
80% 
71% 
46% 
Table 5. Precision on transmission rate at 6 months (90% Clopper Pearson exact confidence interval) 
Sample size 
Observed number of transmissions 
%Transmission 
90% CI 
CI width 
300 
0 
0% 
0%,1% 
1% 
 
2 
0.67% 
0.1%,2.1% 
2% 
 
6 
2% 
0.9%,3.9% 
3% 
386 
0 
0% 
0%,0.8% 
0.8% 
 
2 
0.52% 
0.1%,1.6% 
1.5% 
 
4 
1% 
0.3%,2.3% 
2% 
 
6 
1.6% 
0.7%,3.1% 
2.4% 
450 
0 
0% 
0%,0.7% 
0.7% 
 
2 
0.44% 
0.1%,1.4% 
1.3% 
 
6 
1.3% 
0.6%,2.6% 
2% 
 
Taking into account 12% non-evaluable cases (including mothers lost to follow up before delivery, 
stillbirths and infants not assessed for HBV infection at 6 months), as observed in iTAP, a total of 439 
pregnant women need to be enrolled to obtain enough evaluable infants. 
Infants born to mothers with unsatisfactory virological response at 36 weeks gestation will not be 
included in the primary efficacy analysis. Assuming that 12% of women will have an unsatisfactory 
virological response at 36 weeks gestation, a total of 499 pregnant women will be enrolled. 
7.5.4 Analyses for the primary objective 
The proportion of infants with HBV infection at 6 months of age will be estimated, and the exact 90% 
CI around this estimate will be calculated based on the Clopper-Pearson method. If the upper bound 
of the 90% CI is greater than 2% at any time during the study, a DSMB meeting will be convened (See 
section 7.6 Data and Safety Monitoring Board). The strategy implemented in this study will be 
considered efficacious if the upper bound of the 90% CI remains lower than 2% throughout the study, 
i.e. until the primary endpoint for the last evaluable infant is available. 
The primary analysis will be conducted as a complete case analysis including infants whose 6 month 
endpoint is available, regardless of the duration of study treatment the mothers actually received as 
long as at least one dose was taken. Pregnancies resulting in multiple births (e.g. twins) will be counted 
as one mother-infant(s) pair, and will be counted as HBV-infected if at least one infant was infected. 

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Three sensitivity analyses will be conducted: 1) considering infants from multiple pregnancies 
separately, 2) imputing the last available HBV infection status for infants without 6 month status data, 
and 3) considering infants with missing data as HBV-infected. 
7.5.5 Analyses for the secondary objectives/endpoints 
7.5.5.1 Pregnancy/infant outcomes 
To assess pregnancy outcomes and infant outcomes until 18 months of age. 
The proportion of women with any serious adverse events (ICH SAEs), including DAIDS grade 4 signs 
and symptoms, from enrollment until study exit will be estimated, and the corresponding 95% CI will 
be calculated. Time to first SAE will be estimated and plotted using the Kaplan-Meier method. The 
occurrence of SAEs and time to first SAE in infants will be analyzed in a similar way. 
7.5.5.2 Occurrence of pregnancy outcomes: full term or preterm live births, stillbirths, 
spontaneous abortions, induced abortions 
Proportions of women with full term live births, preterm live births, stillbirths, spontaneous abortions 
and induced abortions, along with their 95% CI, will be provided. 
7.5.5.3  Assessment of anti-HBc antibodies in infants at 18 months of age 
Retrospective assessment of markers of prior infection (anti-HBc antibodies) in infants at 18 months 
of age. 
The proportion of children with detectable anti-HBc antibodies at 18 months of age will be estimated, 
and the corresponding 95% CI will be calculated. 
7.5.5.4 Infant levels of anti-HBs antibodies 
To describe, in the absence of confounding from HBIg administration, the infant levels of anti-HBs 
antibodies at 1, 2, 4, 6, 12 and 18 months in response to HB vaccination. 
Anti-HBs antibody geometric mean concentrations in infants at 1, 2, 4, 6, 12 and 18 months, along 
with their 95% CI, will be tabulated and presented graphically. Proportions of children with anti-HBs 
antibody concentrations >10 mIU/mL at each of these time points, along with their 95% CI, will be 
provided. 
7.5.5.5 Maternal HBV DNA changes  
To describe the changes in HBV DNA level from initiation of TDF to delivery. 
Median (interquartile) change in HBV DNA levels between treatment initiation and delivery will be 
calculated. The proportion of women with HBV DNA levels >200,000 IU/mL at 36 weeks of gestation 
will be estimated, and the corresponding 95% CI will be calculated. 
7.5.5.6 HBV infection status in all infants 
To assess the HBV infection status in all infants, including those born to women with unsatisfactory 
virological response to study treatment  
7.6 
Data and Safety Monitoring Board 
A Data and Safety Monitoring Board will be appointed to help ensure the safety and interests of the 
participants; monitor how well the study is being conducted in accordance with the study protocol, and, 
when needed, suggest changes; assess interim results or external results to determine whether the 
assumptions (accrual rate, event rate, dropout rate) used to determine the size/length of the study are 
realistic; monitor efficacy results and suggest whether the study should be modified or terminated; and 
respond to specific concerns of the study investigators.  
The Data and Safety Monitoring Board (DSMB) will be composed of at least 1 hepatologist/ 
gastroenterologist with a special interest for hepatitis B, 1 pediatrician, 1 obstetrician, 1 infectious 
diseases specialist, and 1 statistician /epidemiologist, at least 3 of them from South East Asia.  
The study will be presented in detail to the DSMB during a protocol initiation review before the study 
opens. A detailed study monitoring plan, outlining reports on study conduct, will be drafted and 
presented at this review meeting.  
The study will be monitored by the DSMB at least annually. The first DSMB review will be held one 
year after the first enrollment or earlier when at least 100 pregnant women have been enrolled. This 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
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meeting will allow for the review of the conduct of the study and Adverse Events. Additional DSMB 
reviews could be triggered if deemed necessary by the Principal Investigator. 
In addition, if the number of infant HBV infections reaches 4 at any time, a DSMB meeting will be 
convened to discuss possible study modifications.  
The Study Statisticians, under the supervision of Camlin Tierney, Senior Statistician at the Harvard 
T.H Chan School of Public Health, Boston MA will prepare the DSMB reports, review data on an interim 
basis, as well as review the regular progress reports prepared at the Study Coordination Center in 
Thailand.  
In case of premature discontinuation of the clinical trial for any reasons, further management of 
patients will be organized taking into account DSMB and health authorities advice. 
8. Ethical considerations 
8.1 
Potential Risks to Participants 
We hypothesize that the risk of HBV mother-to-child transmission in this study will be lower than 2% 
(i.e. the upper limit of the 95% confidence interval of the observed rate is less than 2%) because the 
mothers will receive tenofovir disoproxil fumarate during the last trimester of pregnancy and for two 
months following delivery and the infants will receive vaccine, starting with the birth dose. No 
transmission at all was observed in our previous study, iTAP (19,20), in the arm where women received 
TDF, as well as two other clinical trials evaluating the efficacy of antiviral for PMTCT (37,38). Two 
percent was the rate observed in the placebo arm of iTAP, the lowest rate ever reported where infants 
received HBIg and vaccine (and mothers with high viremia received no antivirals). In the proposed 
study, if more than 3 infections are observed, a DSMB meeting will be immediately convened to review 
the data and discuss possible adaptations to the intervention or stop the study. If this occurs, 
enrollment would be halted, all newborns from mothers already enrolled would receive immune 
globulin until a final decision is made. Any amendment will be submitted to the ethics committee prior 
to implementation.   
In terms of study treatment safety, the risks for the mother and the fetus associated with the use of 
TDF during pregnancy have been studied in HIV and HIV infected pregnant women and their infants. 
A systematic review concluded in 2013 that available safety data were generally reassuring for 
pregnancy outcomes and for lack of congenital or other severe anomalies in exposed infants (19,20). 
8.1.1 Maternal risks associated with the use of tenofovir disoproxil fumarate (TDF) during 
pregnancy 
TDF is a nucleotide analogue which inhibits both HIV and HBV replication through inhibition of their 
reverse transcriptase. TDF is indicated for HIV treatment and HBV treatment, and is part of a WHO 
recommended drug combination to be started in HIV infected pregnant women after 14 weeks’ 
gestation and continued through the breastfeeding period to prevent mother to child HIV transmission. 
In participants with chronic hepatitis B who participated in controlled clinical trials Gilead 0102 and 
0103, more participants treated with tenofovir during the 48-week double-blind period experienced 
nausea (9% versus 3% with adefovir). Other treatment-emergent adverse reactions reported in >5% 
of participants treated with tenofovir included: abdominal pain, diarrhea, headache, dizziness, fatigue, 
nasopharyngitis, back pain and skin rash. No significant change in the tolerability profile (nature or 
severity of adverse reactions) was observed in participants continuing treatment with tenofovir for up 
to 144 weeks in these studies. Flares have been also observed within the first 4–8 weeks of treatment, 
accompanied by decreases in HBV DNA levels. No participant had evidence of decompensation. ALT 
flares typically resolved within 4 to 8 weeks without changes in therapy (39). 
During the course of HBV infection, acute exacerbations of liver damage or hepatic flares can occur 
spontaneously, be induced by IFN-a therapy or the discontinuation of treatment with nucleos(t)ide 
analogues. Flares are also observed during induced immune suppression, favoring viral replication. 
They are most often preceded by high levels of HBV replication and by progressive accumulation of 
HBV antigens.  
Data from iTAP, our previous randomized, placebo-controlled double blind, clinical trial (24) conducted 
from 2013 to 2016 in a population of pregnant women infected with HBV and their infants confirmed 

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Page 25 of 37 
that there were no significant differences in terms of tolerance and safety among patients assigned to 
placebo or TDF (19,20).  
Three-hundred and thirty-one women (168 TDF, 163 placebo) were enrolled. Median age was 26 
years, gestational age 28.3 weeks, and HBV DNA 8.0 log10 IU/mL. Of 322 (97%) on-study deliveries, 
there were 319 singleton, 2 twin pairs and one stillborn (TDF arm); 21 (7%) (8 TDF, 13 placebo) were 
preterm. Median time of HBIg and vaccine administration was 1.3 and 1.2 hours after birth, 
respectively. Forty-one versus 44 women in TDF and placebo, respectively, experienced a grade 3/4 
adverse event or ICH SAE. Fifty-five (17%) women had an ALT increase (31 TDF, 24 placebo). 
Fourteen women (9 TDF, 5 placebo) reached the secondary endpoint of acute exacerbation or flare 
(ALT >300 U/L) following planned discontinuation of study treatment. ALT >60 U/L at scheduled visits 
occurred in 157 women (73 TDF, 84 placebo). Monitoring re-tests were systematically conducted. 
Forty-three versus 38 mother-infant(s) pairs in TDF and placebo, respectively, experienced a grade 
3/4 adverse event or ICH SAE. Forty-one (13%) mother infant(s) pairs had jaundice/hyperbilirubinemia 
(24 TDF, 17 placebo). Infant growth was similar by randomized arm. The vast majority of infants 
received HBIg at birth and HB vaccines at birth and during infancy as required per protocol. 
As in the iTAP study, women will be informed of possible ALT elevations. In case of liver enzyme 
elevation detected after discontinuation of study treatment, additional tests will be performed for case 
management and documentation. Expert advice will be sought to consider re-introduction of antiviral 
therapy in case of significant ALT elevations. Women with high ALT at baseline (> 60 U/L) will be 
evaluated for chronic HBV treatment indication after delivery and before discontinuation of treatment.  
8.1.2 Infant risks associated with the lack of HBIg administration 
In two previous randomized clinical trials, no infections occurred when women received TDF during 
pregnancy and the newborn received HBIg plus HB vaccine. It is hypothesized that the HB viral load 
reduction at the time of delivery will ensure a low viral exposure at the time of delivery and HB vaccine 
given immediately at birth will provide an efficacious post-exposure prophylaxis, even in the absence 
of HBIg. A meta-analysis showed that there was no additional benefit of HBIg when mothers were 
HBeAg negative, i.e. with relatively low viral loads. Thus, HB vaccine alone may prevent HBV infection 
if HBeAg positive women receive potent antiviral treatment during pregnancy and achieve a level of 
HBV DNA similar to that observed in HBeAg negative women, i.e. with low viremia as in women who 
receive antivirals. Moreover, although HBIg is recommended by the Royal College of Pediatricians, 
this intervention is not provided for free in the context of the Universal Health Coverage program and 
most children born to HBV infected mothers do not receive HBIg at birth. Some obstetricians propose 
the parents to purchase the HBIg at a non-hospital pharmacy at their own expense (US$30 to US$130, 
depending on manufacturer). In the proposed study all women will receive antiviral until 2 months 
postpartum, which will reduce the infant exposure to HBV to levels that are not associated with 
perinatal transmission if the child is vaccinated. In addition, the potential close contacts of the infant 
will be screened for HBV infection and educated about the risk of transmission to the newborn in the 
first few weeks of life.  
8.1.3 Infant risks associated with in utero exposure to tenofovir 
Tenofovir is classified in category B of the US FDA. The data collected in the Antiretroviral in 
Pregnancy Registry (issued date: June 2017) (40) show that there have been no increase in birth 
defects in 3229 women exposed during the first trimester and 1480 women during the second and 
third trimester.   
To our knowledge, no cases of mitochondrial toxicity in children exposed to tenofovir in utero have 
been reported to date. In iTAP study, a check list of signs and conditions suggesting possible 
mitochondrial dysfunction was completed at the 6 month visit. Data were available for 290 of 294 
(99%) infants. One infant (placebo arm) had nystagmus (grade 1, mild). One infant (TDF arm) had 
persistent anemia and neutropenia reported as a grade 1/2 (mild/moderate) adverse event.  
8.2 
Adequacy of Protection Against Risks 
8.2.1  Recruitment and informed consent 
At the clinical sites of the study all co-investigators will receive training on Good Clinical Practice (GCP) 
and Human Subject Protection prior to the implementation of the study. As for our previous studies, a 

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Page 26 of 37 
specific training for co-investigators, nurses and counselors will be conducted prior to the 
implementation of the study. Training will address the specific aspects of the study, the GCP 
requirements, and procedures for protection of human participants in clinical research. 
All pregnant women are screened for HBV infection during pregnancy. In this study, women with 
positive HBsAg and HBeAg tests will receive counseling and comprehensive information about HBV 
infection, the risk of transmission to their infants and the details of the study. They will then be proposed 
participation in the study. If available, the infant’s father will be informed and asked for consent. 
Mothers will be enrolled in the study if they consent and meet the selection criteria. If a woman would 
like her infant receive HBIg, she will not be enrolled in the study. 
The consent form will be drafted in English, translated into Thai, discussed, and reviewed by the PHPT 
Community Advisory Board until the final version translated into Thai and back translated into English 
to ensure the accuracy of translation. The same process will be followed for Lao translation. The 
language will be as practical and non-technical as possible to ensure that it is understandable to all 
study participants. The final consent forms will be submitted to the relevant Ethics Committees. At 
each site, the co-investigator will thoroughly discuss with each woman and the infant’s father if 
available the information included in the consent. The consent form will describe the purpose of the 
study, the procedures to be followed and the potential risks and benefits of participation. The consent 
document will specify the woman's freedom to withdraw her participation or the participation of her 
baby at any time without compromising access to future medical care. Written informed consent from 
the father will also be obtained if possible, for the participation of the infant. 
The consent form will include the names and contact details of the site co-investigator and an 
independent physician, whom the study participant may contact with any questions. A copy of the 
consent document will be given to the participant. In addition, study participants may contact the 
Clinical Trial Unit, 24 hours a day by phone. The original consent forms will be kept in a locked cabinet 
at the site. If new information relevant to the participant's consent or her willingness to continue 
participation in the study becomes available, the participants and potential participants will be 
informed. Any changes to the consent document will be submitted to the relevant ethics committees. 
8.2.2 Protection against risk 
8.2.2.1 Institutional Review Board/ Ethics Committees 
Prior to the initiation of the study in a country, the protocol and patient consent documents will be 
submitted for review and approval to ethics committees at national level, and local level if available. 
Subsequent modifications will be submitted for approval before implementation. 
8.2.2.2 Expedited Adverse Experience Reporting 
All clinical adverse events and abnormal laboratory values will be recorded and graded. For severe 
toxicity and serious adverse events, as defined by ICH GCP (35), possibly related to study drugs, a 
report will be sent to the relevant Ministry of Public Health, within 3 business days of awareness. If a 
participant dies, events prior to and at the time of death will be transcribed from hospital records, and 
possible cause(s) of death will be investigated. Management of toxicities and dose modifications for 
patients will be managed with experts’ advice as needed. 
8.2.2.3 Confidentiality 
Every effort will be made to maintain the confidentiality of the study participants and this will be 
stressed during Human Subjects Protection training session of study personnel at all sites. To 
minimize this risk, study participants will not be identified by name on any study documents but by 
patient identification number. All evaluation forms, laboratory specimens, reports and other records 
will be identified only by the patient identification number to maintain participant confidentiality. All 
records will be kept in a locked file cabinet in the clinical research unit. All computer entry and 
networking programs will be processed with patient identification number only. Clinical information will 
not be released without the written permission of the patient except when necessary for monitoring by 
PHPT Study Coordination Center or the sponsors. 
8.2.2.4 Compensation 
Immediate necessary care is available free of charge to mothers and her infant in the case of medical 
problems related to participation in this study. However, the study is not responsible for treatments 
unrelated to the study and no financial compensation will be provided. 

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Page 27 of 37 
8.2.2.5 Other related ethical aspects 
The subject information sheet is written in Thai or Lao language, and physician or hospital’s names, 
contact address and telephone number will be specified at each site. 
8.3 
Potential Benefits of the Proposed Research to the Participants and Others 
8.3.1 Mothers 
In this study, co-investigators and their teams will closely monitor mothers and infants. The co-
investigators will have received specific training on the specific aspects of HBV infection prevention 
and management and information about tenofovir disoproxil fumarate use during pregnancy for the 
conduct of the study. As in our previous iTAP study, they will have easy access to national and 
international experts who are knowledgeable in the management and treatment of HBV disease for 
any specific questions related to case management.  
8.3.2 Expected infant close contacts 
The expected close contacts of the infant will be proposed counseling about HBV transmission and 
HBsAg test. This will not be mandatory for participation in the study but highly recommended. Indeed 
referring a relative for HBV testing will require that the woman discloses her HBV status, which may 
be not always desirable. HBV discrimination and stigma is uncommon in Thailand and Laos. If relatives 
are diagnosed with HBV infection, they will be referred to a gastroenterologist for further follow up and 
evaluations. 
8.3.3 Infants 
All infants will receive follow up assessments until 18 months after birth, including diagnosis of HBV 
status and, if infected, the site pediatrician will provide appropriate counseling and follow up. 
The infants will not be exposed to the theoretical risk associated with the use of human derived 
products, though, to date, the process of HBIg production is considered safe, and no studies have 
found evidence of transmission of pathogens with HBIg derived from human donor blood. 
8.4 
Importance of the knowledge to be gained  
Despite the use of vaccine and in some cases the addition of HBIg, the risk of perinatal transmission 
of HBV persists in the study population, most often infected with HBV genotype C (85% in Thailand or 
Laos), which has a high viral replication rate. Several studies have documented that the use of vaccine, 
with or without HBIg, cannot prevent all transmissions. However, clinical studies have shown that no 
perinatal transmissions occurred when antivirals were prescribed to the mother at the end of 
pregnancy and during the early postpartum period. Antivirals can decrease viral replication to levels 
similar to that found in women who do not usually transmit the virus if the infant receives vaccine.  
It is unlikely that the use of HBIg is useful when mothers have low viral loads, as shown by a systematic 
review and meta-analysis of the comparative efficacy of vaccine alone or vaccine + HBIg in infants 
born to mothers with a positive HBsAg test but HBeAg negative test (associated with low viral loads), 
concluding that “vaccine alone seems to be equally effective to the combination of HBIG and hepatitis 
B vaccine for neonates of HBsAg+/HBeAg 2 mothers in preventing infection” (30). 
Moreover, the provision of HBIg to infants born to HBV-infected mothers can be challenging from a 
programmatic point of view, a major issue is the lack of widespread availability of HBIg 24/24 7/7 at all 
maternity units, due to multiple factors: need for a cold chain and the maintenance of a refrigerated 
stock of HBIg, short shelf life, cost considerations, and reliance for HBIg production on the availability 
of human plasma from immunized donors not infected by any other pathogens. Also, this prevention 
strategy relies on a single administration of HBIg as soon as possible after birth, heavily dependent 
on the organization of the maternity team, with no forgiveness if it is not administered. In several small 
hospitals in Thailand, it is known that HBIg are usually not available.  
The proposed study has been designed to provide clear data on the efficacy of an intervention to 
decrease HBV perinatal transmission in this population. If such an intervention were proved to be safe 
and efficacious, recommending and implementing this approach would have a significant public health 
impact. 
 

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Page 28 of 37 
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Appendix 1: Cockcroft-Gault formula for women 
 
(140-age [in years]) x weight [in kg] x0.85 
 (72 x creatinine [in mg/dL]) 
 
Calculation on line at: http://nephron.com/cgi-bin/CGSI.cgi 
 
 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 32 of 37 
Appendix 2: Amendment dated 19 July 2019 
1. In the original protocol it was originally planned to measure the maternal serum concentration of 
phosphorus and calcium at the visits scheduled at enrollment, 32 weeks of pregnancy, and 2 
months postpartum.  
However, current guidelines for the use of tenofovir disoproxil fumarate (TDF) do not recommend 
systematic measurement of these electrolytes. The TDF/Viread Package Insert of TDF states only 
that "Routine monitoring of estimated creatinine clearance, serum phosphorus, urine glucose, and 
urine protein should be performed in patients with mild renal impairment".  The new version of 
the protocol does not require the measurement of phosphorus and calcium because women with 
renal impairment of any severity cannot be enrolled in the study (normal creatinine clearance, no 
confirmed normoglycemic glycosuria, no confirmed proteinuria).  
Table 2 has been modified accordingly. 
 
2. The list of “Exempted Congenital Anomalies/Birth Defects (Listed by Body Site)” has been added 
as an Appendix. These anomalies do not need to be immediately reported to the Ethics 
Committees but will continue to be recorded in the case report forms. 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 33 of 37 
Appendix 3: Exempted Congenital Anomalies/Birth Defects (19 July 2019 Amendment) 
3.1. Listed by Body Site 
Abdomen/Groin/Pelvis 
Diastasis recti 
Hernia, inguinal or umbilical without mention of 
obstruction or gangrene 
Hip click, with no follow-up or therapy 
Umbilical artery, single 
Umbilical cord atrophy 
Urachus, patent 
 
Chest/Thorax 
Breast hypertrophy 
Inverted nipples 
Nipples, anomalies of 
Rib, cervical 
 
Face/Mouth 
Brushfield Spots 
Duct, lacrimal, stenosis, stricture, or obstruction 
of  
Epicanthal folds 
Epstein's Pearls 
Esotropia 
Exotropia 
Gum cysts - includes epulis, ranula, mucocele 
Macrocheilia (large lips) 
Microcheilia (small lips) 
Nose, congenital deviation of septum of 
Nose, flat bridge of 
Nystagmus 
Palate, high-arched 
Palsy, facial 
Protruding tongue 
Sclera, blue 
Teeth, natal 
Tongue tie 
 
Foot/Toe 
Foot, rocker-bottom 
Tibia, torsion of 
Toes, long 
Toes, overlapping 
Toes, webbing 
 
Hand/Finger 
Clinodactyly of fifth finger 
Fingers, long 
Metatarsus varus or adductus 
Polydactyly, postaxial 
Simian crease 
 
Head/Neck 
Dolichocephaly 
Ear, malformations of external ear 
Ear, preauricular sinus, cyst, or pit of 
Fontanelle, large or small 
Occiput, flat or prominent 
Scaphocephaly, no mention of craniosynostosis 
Neck, webbing or redundant skin folds of 
Neck, short 
 
Skin 
Albinism 
Birthmark, NOS 
Dimple, sacral, pilonidal 
Lanugo, persistent or excessive 
Mongolian spots 
Neonatal acne 
Neoplasm, benign 
Nevus, flammaeus 
Skin tags on hands or feet 
 
Urogenital Rectal 
Anal fissure 
Anus, skin tags of 
Clitoromegaly, enlarged clitoris, hypertrophy 
Hydrocele 
Hymen, imperforate 
Phimosis 
Redundant foreskin 
Scrotum, hypoplastic due to cryptorchidism 
Testes, torsion of, or torsion of spermatic cord 
Testes, retractile 
Testicle, undescended (unilateral, bilateral or 
NOS) 
Vagina, embryonal cyst of 
Vagina, tag of

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 34 of 37 
3.2. Listed Alphabetically 
 
Albinism 
Anal fissure 
Anus, skin tags of 
Birthmark, NOS 
Breast hypertrophy 
Brushfield Spots 
Clinodactyly of fifth finger 
Clitoromegaly, enlarged clitoris, hypertrophy 
Diastasis recti 
Dimple, sacral, pilonidal 
Dolichocephaly 
Duct, lacrimal, stenosis, stricture, or obstruction 
of 
Ear, malformations of external ear 
Ear, preauricular sinus, cyst, or pit of 
Epicanthal folds 
Epstein's Pearls 
Esotropia 
Exotropia 
Fingers, long 
Fontanelle, large or small 
Foot, rocker-bottom 
Gum cysts - includes epulis, ranula, mucocele 
Hernia, inguinal or umbilical without mention of 
obstruction or gangrene 
Hip click, with no follow-up or therapy 
Hydrocele 
Hymen, imperforate 
Inverted nipples 
Lanugo, persistent or excessive 
Macrocheilia (large lips) 
Metatarsus varus or adductus 
Microcheilia (small lips) 
Mongolian spots 
Neck, short 
Neck, webbing or redundant skin folds of 
Neonatal acne 
Neoplasm, benign 
Nevus, flammaeus 
Nipples, anomalies of 
Nose, congenital deviation of septum of 
Nose, flat bridge of 
Nystagmus 
Occiput, flat or prominent 
Palate, high-arched 
Palsy, facial 
Phimosis 
Polydactyly, postaxial 
Protruding tongue 
Redundant foreskin 
Rib, cervical 
Scaphocephaly, 
no 
mention 
of 
craniosynostosis 
Sclera, blue 
Scrotum, hypoplastic due to cryptorchidism 
Simian crease 
Skin tags on hands or feet 
Teeth, natal 
Testes, retractile 
Testes, torsion of, or torsion of spermatic cord 
Testicle, undescended (unilateral, bilateral or 
NOS) 
Tibia, torsion of 
Toes, long 
Toes, overlapping 
Toes, webbing 
Tongue tie 
Umbilical artery, single 
Umbilical cord atrophy 
Urachus, patent 
Vagina, embryonal cyst of 
Vagina, tag of 

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Appendix 4: 15 January 2020 Amendment (stamped by the Ethics Committee)  
 
 
 
 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
Page 36 of 37 
 
 
 
 

Study Title: Antiviral prophylaxis and infant vaccination to prevent perinatal hepatitis B infection, version 1.4 dated 2 December 2020 
 
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Appendix 5: 2 December 2020 Amendment (approved by the Ethics Committee)