Phase Ib Placebo-Controlled Study of the Infectivity, Safety and Immunogenicity of a Single Dose of a Recombinant Live-Attenuated Respiratory Syncytial Virus Vaccine, LID/ΔM2-2/1030s, Lot RSV#010A, Delivered as Nose Drops to RSV-Seronegative Infants and Children 6 to 24 Months of Age
Phase: PHASE1
Conditions: RSV Infection
Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)

 
1 
Phase Ib Placebo-Controlled Study of the Infectivity, Safety and Immunogenicity of a 
Single Dose of a Recombinant Live-attenuated Respiratory Syncytial Virus Vaccine, 
LID/ΔM2-2/1030s, Lot RSV#010A, Delivered as Nose Drops to 
RSV-Seronegative Infants and Children 6 to 24 Months of Age 
 
Sponsored by:  
National Institute of Allergy and Infectious Diseases (NIAID) 
 
Center for Immunization Research (CIR) Protocol Number: CIR 335 
WIRB-Copernicus Group IRB (WCG IRB) Protocol Number: 20200975 
FDA Investigational New Drug application (IND) Number: 16990 
Project Assurance: FWA #00000287 
 
IND Sponsor:  
Office of Clinical Research Policy and Regulatory Operations (OCRPRO) 
Division of Clinical Research (DCR) 
National Institute of Allergy and Infectious Diseases (NIAID) 
National Institutes of Health (NIH) 
5601 Fishers Lane 
Room 4B11, MSC 9820 
Bethesda, MD 20892 
 
 
Respiratory Syncytial Virus (RSV) LID/ΔM2-2/1030s 
Provided by: 
Laboratory of Infectious Diseases (LID), NIAID, NIH 
 
Medical Monitor:  
Shirley Jankelevich, MD 
 
 
Principal Investigator: 
Ruth Karron, MD 
 
Version 6.0 
February 21, 2023 
 
 

 
2 
STUDY STAFF ROSTER 
 
PRINCIPAL INVESTIGATOR 
Ruth A. Karron, MD 
CIR 
Johns Hopkins Bloomberg School of Public Health (JHSPH) 
624 N. Broadway, Room 217 
Baltimore, MD 21205 
Phone: 410-614-0319 
Administrative Coordinator: 410-955-1624  
Email: rkarron@jhu.edu 
 
CLINICAL INVESTIGATORS  
Mary T. Caserta, MD 
Professor of Pediatrics, Division of Pediatric 
Infectious Diseases 
Director, Pediatric Infectious Diseases 
Fellowship 
University of Rochester Medical Center 
601 Elmwood Ave., Box 690 
Rochester, NY 14642 
Phone: 585-275-5944  
Fax: 585-273-1104 
Email: mary_caserta@urmc.rochester.edu 
 
Jennifer Johnson, PNP 
University of Rochester Medical Center  
601 Elmwood Ave Box 690  
Rochester, NY 14642  
Phone: 585-276-8398 
Fax: 585-276-1077 
Email: 
Jennifer_Johnson1@URMC.Rochester.edu 
 
Jennifer Nayak, MD 
Associate Professor of Pediatrics and 
Microbiology & Immunology 
University of Rochester Medical Center 
601 Elmwood Ave Box 690 
Rochester, NY 14642 
Phone: (585) 275-9477 
Fax: (585) 273-1104 
Email: Jennifer_Nayak@URMC.Rochester.edu 
 
 
 
 
 
Natasha Halasa, MD, MPH 
Professor of Pediatrics 
Pediatric Infectious Diseases 
Vanderbilt University Medical Center 
1161 21st Ave South 
D7232 MCN 
Nashville, TN 37232 
Phone: 615-322-3346 
Fax: 615-343-7659 
Email: Natasha.halasa@vumc.org 
 
 
Samantha Economos MSN, CPNP-PC 
Vanderbilt University Medical Center 
Department of Infectious Diseases 
Pediatric Nurse Practitioner 
1161 21st Ave South D-7240 MCN 
Nashville, TN 37232 
Phone: 615-322-6988 
Fax:  615-343-7659 
Email: samantha.a.economos@vumc.org 
 

 
3 
 
Kawsar Talaat, MD 
CIR, JHSPH 
624 N. Broadway, Room 249 
Baltimore, MD 21205 
Phone: 410-502-9627 
Email: ktalaat1@jhu.edu 
 
 
Kristi Herbert, CRNP-P 
 
CIR, JHSPH 
624 N. Broadway, Room 205 
Baltimore, MD 21205 
Phone: 410-955-4362  
Email: kherber1@jhu.edu 
 
Elizabeth Schappell, RN, MSN, CCRP 
CIR, JHSPH 
624 N. Broadway, Room 205 
Baltimore, MD 21205 
Phone: 410-614-9114  
Email: eschappe@jhu.edu 
 
Jocelyn San Mateo, CRNP-F, CCRP 
CIR, JHSPH 
624 N. Broadway, Room 201 
Baltimore, MD 21205 
Phone: 410-614-4306 
Email: jsanmat1@jhu.edu  
Beulah Sabundayo, PharmD, MPH 
CIR, JHSPH 
624 N. Broadway, Room 200 
Baltimore, MD 21205 
Phone: 410-502-7451 
Email: bsabund1@jhu.edu 
 
 
Suzanne Woods, CRNP-P, CCRP 
CIR, JHSPH 
624 N. Broadway, Room 212 
Baltimore, MD 21205 
Phone: 410-614-1880  
Cell: 443-813-0697 
Email: swoods12@jhu.edu 
 
SCIENTIFIC INVESTIGATORS  
 
Ursula Buchholz, PhD 
LID, NIAID, NIH 
Building 50, Room 6503 
50 South Drive, MSC 8007 
Bethesda, MD 20892 
Phone: 301-594-1533 
Email: ubuchholz@niaid.nih.gov 
 
STUDY STATISTICIAN  
Sally Hunsberger, PhD 
Biostatistics Research Branch, NIAID, NIH  
5601 Fishers Lane, Room 4D13 MSC 9820,  
Bethesda, MD 20852 
Phone: 240-669-5257 
Email: sally.hunsberger@nih.gov 
 
 
 
 

 
4 
Table of Contents 
STUDY STAFF ROSTER .............................................................................................................. 2 
Table of Contents ............................................................................................................................ 4 
List of Figures ................................................................................................................................. 8 
List of Tables .................................................................................................................................. 8 
1 
BACKGROUND ................................................................................................................. 10 
1.1 
Epidemiology, Disease Burden, and the Need for a Vaccine ........................................ 10 
1.2 
Prior Research ................................................................................................................ 12 
1.2.1 Experimental Vaccines Against RSV: M2-2 Deletion Mutants ................................ 12 
1.2.2 Preclinical Studies ..................................................................................................... 13 
1.2.3 Previous Clinical Experience .................................................................................... 14 
1.3 
Clinical Development Plan ............................................................................................. 15 
2 
OBJECTIVES ...................................................................................................................... 17 
2.1 
Primary Objectives ......................................................................................................... 17 
2.2 
Secondary Objectives ..................................................................................................... 17 
2.3 
Exploratory Objectives ................................................................................................... 17 
3 
STUDY DESIGN................................................................................................................. 18 
4 
STUDY POPULATION ...................................................................................................... 19 
4.1 
Recruitment Process ....................................................................................................... 19 
4.2 
Study Visits .................................................................................................................... 20 
4.3 
Consenting Process ........................................................................................................ 20 
4.4 
Screening Visit ............................................................................................................... 21 
4.5 
Randomization ............................................................................................................... 21 
4.6 
Inoculation (Day 0) ........................................................................................................ 22 
4.7 
Study Phases ................................................................................................................... 23 
4.7.1 Acute Phase: In-person Study Visit Days ................................................................. 24 
4.7.2 Acute Phase: Non-Visit Study Day Contacts ............................................................ 25 
4.7.3 Study Day 29 Visit .................................................................................................... 26 
4.7.4 Post-Acute Phase ....................................................................................................... 26 
4.7.5 Study Day 56 Visit .................................................................................................... 26 
4.7.6 Period After Day 56 through Start of RSV Surveillance Phase ................................ 27 
4.7.7 RSV Surveillance ...................................................................................................... 27 
4.8 
Illness Visit ..................................................................................................................... 28 
4.9 
Early Discontinuation Study Visit .................................................................................. 29 
4.10 
Participant Retention ...................................................................................................... 30 
4.11 
Participant Withdrawal or Termination from the Study .................................................. 30 
4.12 
Specimen Collection ....................................................................................................... 30 
4.12.1 Virus Detection .......................................................................................................... 30 
4.12.2 Immunologic Assays ................................................................................................. 31 
4.12.3 Specimen Preparation, Testing, Storage, and Shipping ............................................ 31 
4.12.4 Research Laboratories ............................................................................................... 31 
4.12.5 Plan for Use and Storage of Biological Samples ...................................................... 31 

 
5 
4.12.6 Biohazard Containment ............................................................................................. 32 
5 
Inclusion/Exclusion Criteria ................................................................................................ 32 
5.1 
Inclusion Criteria ............................................................................................................ 32 
5.2 
Exclusion Criteria ........................................................................................................... 32 
5.3 
Co-Enrollment Considerations ........................................................................................ 34 
5.4 
Re-Enrollment Considerations ........................................................................................ 34 
6 
STUDY PRODUCT ............................................................................................................ 34 
6.1 
Study Product Regimens ................................................................................................. 34 
6.2 
Study Product Formulation ............................................................................................ 35 
6.2.1 RSV LID/ΔM2-2/1030s ............................................................................................ 35 
6.2.2 Diluent for RSV LID/ΔM2-2/1030s .......................................................................... 35 
6.2.3 Placebo for RSV LID/ΔM2-2/1030s ......................................................................... 35 
6.3 
Study Product Storage .................................................................................................... 35 
6.4 
Study Product Preparation .............................................................................................. 35 
6.4.1 Diluent ....................................................................................................................... 36 
6.4.2 Placebo ...................................................................................................................... 36 
6.4.3 Live RSV LID/ΔM2-2/1030s .................................................................................... 36 
6.5 
Study Product Inoculation Procedure ............................................................................. 36 
6.6 
Study Product Acquisition ............................................................................................. 36 
6.7 
Study Product Accountability ........................................................................................ 37 
6.8 
Disposition of Used/Unused Study Product ................................................................... 37 
6.9 
Final Disposition of Study Products .............................................................................. 37 
6.10 
Concomitant Medications ............................................................................................... 37 
7 
SAFETY ASSESSMENT, MONITORING, AND REPORTING ...................................... 38 
7.1 
Safety-Related Roles and Responsibilities ...................................................................... 38 
7.1.1 Principal Investigator ................................................................................................ 38 
7.1.2 Safety Review and Communications Plan (SRCP) ................................................... 38 
7.1.3 Sponsor Medical Monitor .......................................................................................... 38 
7.1.4 Data and Safety Monitoring Board ........................................................................... 38 
7.1.5 Sponsor Reporting ..................................................................................................... 38 
7.2 
Safety-Related Recording on CRFs ............................................................................... 39 
7.3 
Serious Adverse Event Reporting .................................................................................. 41 
7.4 
Reporting of Unanticipated Problems to OCRPRO ....................................................... 41 
8 
PARTICIPANT MANAGEMENT ...................................................................................... 42 
8.1 
Management of Adverse Events .................................................................................... 42 
8.1.1 Solicited Adverse Events ........................................................................................... 43 
8.1.2 Serious Adverse Events ............................................................................................. 44 
8.1.3 Unexpected Adverse Event ....................................................................................... 44 
8.2 
Grading the Severity of Adverse Events ........................................................................ 44 
8.2.1 AE Grading ................................................................................................................ 44 
8.2.2 Fever Grading ............................................................................................................ 45 
8.3 
Pausing and Stopping Rules ........................................................................................... 45 
9 
STATISTICAL CONSIDERATIONS................................................................................. 46 

 
6 
9.1 
General Design Issues .................................................................................................... 46 
9.1.1 General Design .......................................................................................................... 46 
9.1.2 Description of the Statistical Methods to be Employed ............................................ 46 
9.2 
Outcome Measures ......................................................................................................... 46 
9.2.1 Primary Outcome Measures ...................................................................................... 46 
9.2.2 Secondary Outcome measures ................................................................................... 47 
9.2.3 Exploratory Outcome Measures ................................................................................ 48 
9.3 
Sample Size and Accrual ................................................................................................ 49 
9.3.1 Sample Size and Randomization ............................................................................... 49 
9.4 
Monitoring ...................................................................................................................... 50 
9.4.1 Site Monitoring Plan ................................................................................................. 50 
9.4.2 Monitoring by the NIAID Intramural Data and Safety Monitoring Board ............... 51 
9.5 
Analyses ......................................................................................................................... 52 
9.5.1 Assessment of Primary Objectives ............................................................................ 52 
9.5.2 Assessment of Secondary Objectives ........................................................................ 53 
10 
DATA HANDLING AND RECORD KEEPING ................................................................ 53 
10.1 
Data Management and Coordination .............................................................................. 53 
10.2 
Essential and Source Documents and Access to Source Data ....................................... 53 
10.3 
Investigator’s Brochure .................................................................................................. 54 
10.4 
Quality Control and Quality Assurance ......................................................................... 54 
11 
CLINICAL SITE MONITORING ....................................................................................... 54 
12 
HUMAN SUBJECTS PROTECTIONS .............................................................................. 55 
12.1 
Institutional Review Board/Ethics Committee Review and Approval ........................... 55 
12.2 
Vulnerable Participants .................................................................................................. 55 
12.3 
Informed Consent ........................................................................................................... 55 
12.4 
Potential Benefits ........................................................................................................... 56 
12.5 
Potential Risks ................................................................................................................ 56 
12.5.1 Venipuncture ............................................................................................................. 56 
12.5.2 Nasal Swab ................................................................................................................ 56 
12.5.3 Topical Anesthetic Cream ......................................................................................... 56 
12.5.4 Receipt of Study Product ........................................................................................... 56 
12.6 
Reimbursement/Compensation ...................................................................................... 56 
12.6.1 Study Compensation: Acute Phase and Surveillance ................................................ 56 
12.7 
Privacy and Confidentiality ............................................................................................ 57 
12.8 
Management of Incidental Findings ............................................................................... 57 
13 
ADMINISTRATIVE PROCEDURES ................................................................................ 57 
13.1 
Regulatory Oversight ..................................................................................................... 57 
13.2 
Protocol Registration ...................................................................................................... 57 
13.3 
Study Implementation .................................................................................................... 57 
13.4 
Protocol Deviation Reporting ......................................................................................... 58 
13.5 
ClinicalTrials.gov ........................................................................................................... 58 
14 
PUBLICATIONS ................................................................................................................. 58 
15 
ABBREVIATIONS ............................................................................................................. 59 

 
7 
16 
REFERENCES .................................................................................................................... 61 
Appendix I: Tables Referenced in the Background Section ......................................................... 64 
Appendix II: Schedule of Events: RSV Seasonal Surveillance .................................................... 66 
Appendix III: Definitions of Solicited Adverse Events ................................................................ 67 
Appendix IV: RSV SEASONALITY IN BALTIMORE, MD; Nashville, TN; ........................... 68 
and Rochester, NY ........................................................................................................................ 68 
 
 
 

 
8 
List of Figures 
 
Figure 1: Investigational Product Label Sample ........................................................................... 35 
Figure 2: RSV Seasonality in Baltimore, MD (top), Nashville, TN (middle), and Rochester, NY 
(bottom) .........................................................................................................................68 
 
 
 
 
List of Tables 
 
Table 1: Inoculation Schedule .........................................................................................................9 
Table 2: Temperature Sensitivity of LID/ΔM2-2/1030s (Experimental Lot), RSV ΔNS2 Δ1313 
I1314L, and Additional Controls ..................................................................................14 
Table 3: Screening Visit Procedures ..............................................................................................21 
Table 4: Enrollment Visit Procedures ............................................................................................23 
Table 5: Group 1: Acute Phase In-Person Visit Procedures ..........................................................24 
Table 6: Groups 1 and 2: Day-28 In-Person Visit Procedures .......................................................25 
Table 7: Groups 1 and 2: Acute Phase Non-Visit Contact Procedures ..........................................26 
Table 8: Groups 1 and 2: Day 29 Non-Visit Procedures ...............................................................26 
Table 9: Groups 1 and 2: Day 56 Visit Procedures .......................................................................27 
Table 10: Groups 1 and 2: RSV Season Surveillance Procedures .................................................28 
Table 11: Groups 1 and 2: Post-RSV Seasonal Surveillance Study Visit Procedures ...................28 
Table 12: Illness Visit Timeframe .................................................................................................29 
Table 13: Illness Visit Procedures .................................................................................................29 
Table 14: Early Discontinuation Procedures .................................................................................29 
Table 15: AE CRF Recording Requirements .................................................................................40 
Table 16: Grading for Adverse Events ..........................................................................................44 
Table 17: Grading for Fever ..........................................................................................................45 
Table 18: Pausing and Stopping Rules ..........................................................................................45 
Table 19: Probability of Observing a 90% Confidence Interval Half Width Less than a Specified 
Amount with Various True AE Rates ...........................................................................49 
Table 20: Detectable Differences with 80% Power for Various True Differences .......................50 
Table 21: Schedule of Events: Group 1: RSV-Seronegative Participants; Intensive ....................64 
Table 22: Schedule of Events: Group 2: RSV-Seronegative Participants; Less Intensive ............65 
Table 23: Schedule of Events: RSV Seasonal Surveillance ..........................................................66 
Table 24: Definitions of Solicited Adverse Events ........................................................................67 
 
 
 
 
 
 

 
9 
Phase Ib Placebo-Controlled Study of the Infectivity, Safety and Immunogenicity of a 
Single Dose of a Recombinant Live-attenuated Respiratory Syncytial Virus Vaccine, LID/ΔM2-
2/1030s, Lot RSV#010A, Delivered as Nose Drops to RSV-Seronegative Infants and Children 6 to 
24 Months of Age 
 
SHORT TITLE 
LID/ΔM2-2/1030s 
PURPOSE 
Assessment of safety, infectivity and immunogenicity of the respiratory 
syncytial virus (RSV) vaccine candidate LID/ΔM2-2/1030s in RSV-
seronegative infants and children ≥ 6 months to < 25 months of age 
DESIGN 
A double blind, randomized, placebo-controlled study design will be used to 
evaluate the safety and immunogenicity of the study product in RSV-
seronegative participants.  
STUDY POPULATION Groups 1 and 2: Healthy RSV-seronegative* infants and children ≥ 6 months to 
< 25 months of age 
 
*RSV-seronegative: RSV serum neutralizing antibody titer < 1:40; determined 
≤ 42 days prior to inoculation  
SAMPLE SIZE 
Group 1: Approximately 21 RSV-seronegative infants and children 
 
Group 2: Approximately 60 RSV-seronegative infants and children  
 
It is expected that up to 150 children will need to be screened to accrue 81 
RSV-seronegative participants. 
STUDY PRODUCT 
Single dose of intranasal RSV LID/ΔM2-2/1030s vaccine or placebo 
Table 1: Inoculation Schedule 
 
 
 
 
 
 
 
 
* plaque-forming units (PFU) 
 
** to be accrued in parallel.  
 
Group 1 (intensive) and Group 2 (less intensive) will differ only in the frequency of study visits and 
nasal swab collections. Group 1 will have a study visit with nasal swabs obtained on study days 
5,7,10, and 12 +/- 1 day and whenever solicited adverse events (febrile or respiratory illnesses) are 
reported between days 0 and 28. Group 2 will only have nasal swabs collected in the event of febrile 
or respiratory illnesses on study days 0 – 28. Both groups will have serum specimens obtained on 
days 0, 28, and 56, and post-surveillance.   
STUDY DURATION 
Participants will receive study product outside of the RSV season, and will remain on the study until 
they complete the post–RSV season visit.  
 
Group # 
N 
Study Product 
Dose 
1** 
14 
RSV LID/ΔM2-2/1030s  
105.0 PFU* 
7 
Placebo 
0 
2** 
40 
RSV LID/ΔM2-2/1030s 
105.0 PFU* 
20 
Placebo 
0 

 
10 
1 
BACKGROUND 
 
1.1 Epidemiology, Disease Burden, and the Need for a Vaccine  
 
In the United States (US), respiratory syncytial virus (RSV) is responsible for 75,000 to 125,000 
hospitalizations of infants yearly (1). Globally, RSV was estimated to have caused at least 33 
million cases of acute lower respiratory infection (ALRI) in children under 5 years old, resulting in 
an estimated 3.2 million RSV lower respiratory infection (LRI) hospitalizations and approximately 
59,600 RSV-attributable deaths (2015 estimates) (2, 3). In temperate climates, annual RSV 
epidemics typically occured in late winter and early spring prior to the SARS-CoV-2 pandemic, and 
nearly all children were infected within the first 2 years of life. Beginning in 2020, the timing of 
circulation of RSV in the US became unpredictable and variable across the country.   
 
RSV illness can range from mild upper respiratory tract illness (URI), including rhinitis, 
pharyngitis, and coryza, to severe LRI, including bronchiolitis and pneumonia. Beyond the acute 
burden of disease caused by RSV, severe RSV disease in infancy may predispose to reactive airway 
disease during childhood (4, 5). 
 
RSV is an enveloped ribonucleic acid (RNA) virus that is a member of the Pneumoviridae family, 
genus Orthopneumovirus (6). RSV has a single negative-sense strand RNA genome of 15.2 
kilobases encoding 10 messenger ribonucleic acids (mRNAs). Each mRNA encodes a single 
protein, with the exception of the M2 mRNA, which contains 2 overlapping open reading frames 
(ORFs). The 11 RSV proteins are the viral RNA-binding nucleoprotein N, the phosphoprotein P, 
the large polymerase protein L, the attachment glycoprotein G, the fusion glycoprotein F, the small 
hydrophobic surface glycoprotein SH, the internal matrix protein M, the 2 nonstructural proteins 
NS1 and NS2, and the M2-1 and M2-2 proteins encoded by the M2 mRNA. The gene order is: 3’-
NS1-NS2-N-P-M-SH-G-F-M2-L-5’. RSV transcription and genome replication take place 
exclusively in the cytoplasm, and virions form by budding from the apical plasma membrane of 
respiratory epithelial cells.  
 
Currently, no licensed vaccine against RSV is available, although there is broad consensus that such 
a vaccine is urgently needed and should be a global health priority. Although passive 
immunoprophylaxis with the monoclonal RSV-neutralizing antibody palivizumab (Synagis®; 
MedImmune) is available for high-risk infants, this approach is not feasible for general use. A 
formalin-inactivated vaccine against RSV was evaluated clinically in the 1960s and did not confer 
protection; instead, disease enhancement occurred at a high rate following natural infection of 
vaccinees with wild-type (wt) RSV (7). Studies in experimental animals established that disease 
enhancement was specific to non-replicating RSV vaccines and not seen with infectious RSV or 
replicating vaccine vectors (8, 9).  
 
Following the failure of the formalin-inactivated RSV vaccine, RSV vaccine development at the 
Laboratory of Infectious Diseases (LID) of the National Institute of Allergy and Infectious Diseases 
(NIAID) has focused largely on live-attenuated approaches (10). Throughout a period of over 30 
years, a number of live-attenuated investigational RSV vaccines have been evaluated in RSV-naïve 
infants and children, and enhanced disease following wt RSV infection of vaccinees has not been 
observed (11). Apart from the absence of enhanced disease, live-attenuated RSV vaccines have a 
number of known advantages over non-replicating RSV vaccines. They can be administered 
intranasally (i.n.), induce protective mucosal immunity in the respiratory tract (as well as systemic 
immunity), infect in the presence of maternally-derived RSV serum antibody, and have been well 
tolerated and immunogenic when administered to infants as young as 4 weeks of age (12).  
 

 
11 
Human RSV has a single serotype with 2 antigenic subgroups, A and B. The 2 subgroups exhibit a 
3- to 4-fold reciprocal difference in neutralization by polyclonal convalescent serum. Analysis of 
glycoprotein-specific responses in infants by enzyme-linked immunosorbent assay (ELISA) with 
purified F and G glycoproteins showed that the fusion proteins (F proteins) were 50% related 
antigenically, and the G proteins were 7% related (13). Consistent with this level of antigenic 
relatedness, F protein expressed by a recombinant vaccinia virus was equally protective in cotton 
rats against challenge with either subgroup A or B, whereas the G protein was 13-fold less effective 
against the heterologous subgroup (14). Thus, the F protein is responsible for most of the observed 
cross-subgroup neutralization and protection, and a subgroup A vaccine virus is likely to induce a 
broad immune response against wt RSV of either subgroup. Antibodies to the F protein are one of 
the endpoints evaluated in this study. 
 
The RSV vaccine to be evaluated in this study was derived using a recombinant deoxyribonucleic 
acid (rDNA)–based technique called reverse genetics (15). The technique of reverse genetics has 
been used to produce a number of licensed vaccines; among them is FluMist® (MedImmune). This 
technique allows de novo recovery of infectious virus entirely from complementary DNA (cDNA) 
in a qualified cell substrate under defined conditions. Reverse genetics provides a means to 
introduce predetermined mutations into the RSV genome via the cDNA intermediate. Derivation of 
vaccine virus from cDNA minimizes the risk of contamination with adventitious agents and helps 
to keep the passage history brief and well documented. Once recovered, the vaccine virus is 
propagated in the same manner as a biologically derived virus. As a result of repeated passage and 
amplification, the drug substance (clinical trial material [CTM]) does not contain any rDNA.  
 
This vaccine is a derivative of strain A2, subgroup A, attenuated by deletion of the M2-2 ORF, and 
by the "1030s" amino acid substitution in the L protein which induces temperature sensitivity. The 
RSV M2-2 protein is a small protein (90 amino acids in RSV strain A2) encoded by the second, 
downstream ORF in the M2 mRNA, which slightly overlaps the 5'-proximal, upstream M2-1 ORF 
(16). cDNA-derived RSV mutants in which the M2-2 ORF has been silenced or deleted grow more 
slowly in vitro than wt RSV (17, 18). Deletion of M2-2 results in increased accumulation of 
intracellular viral mRNA and decreased accumulation of genome and antigenome. This finding 
suggests that, during infection by wt RSV, M2-2 plays a role in shifting the balance of RNA 
synthesis from transcription to RNA replication (17). The increase in mRNA accumulation in cells 
infected with an M2-2 deleted RSV (ΔM2-2) was accompanied by an increase in the expression of 
RSV proteins, including expression of the F and G glycoproteins, suggesting that M2-2 deletion 
mutants might be more immunogenic than wt RSV. M2-2 deletion mutants are highly attenuated in 
non-human primates but do replicate to detectable titers (19). In previous pediatric Phase 1 studies, 
RSV M2-2 deletion mutants were attenuated, but highly immunogenic in infants and children, and 
refractory to genetic or phenotypic reversion (20-22).  
 
Vaccine Description  
RSV LID/ΔM2-2/1030s is a recombinant RSV that contains a deletion of the M2-2 ORF, combined 
with the "1030s" mutation in the L protein. Deletion of M2-2 is attenuating and thought to increase 
immunogenicity; “1030s” confers a temperature sensitivity phenotype and is further attenuating 
(21, 23).  
 
Genetic stability of live-attenuated RNA viruses is a concern in clinical vaccine development. The 
deletion of an entire ORF, here M2-2, is refractory to genetic or phenotypic reversion. The "1030s" 
mutation [1313C (TCA)/1321K (AAA); (23)] of the L protein is a genetically stabilized version of 
the original "1030" mutation (12, 24, 25). This stabilized version remained stable under temperature 
stress conditions (23), and stability was substantially increased compared to previous non-stabilized 
versions in clinical studies (21, 26).  

 
12 
 
To generate an RSV antigenomic cDNA with an M2-2 deletion, a cDNA fragment of 241 nt length 
was removed from a wt RSV antigenomic cDNA, and 3 potential translation initiation codons were 
silenced by site directed mutagenesis. In addition, the LID/ΔM2-2/1030s full length plasmid 
contains a deletion of 112 nucleotides from the downstream nontranslated region of the SH gene, 
and 5 translationally silent nucleotide changes in the downstream end of the SH ORF. These 
changes in the SH noncoding region stabilize RSV full-length cDNA plasmids during propagation 
in bacteria, and were deemed to be phenotypically inconsequential based on in-vitro and in-vivo 
studies. The "1030s" mutation was added by site directed mutagenesis of the full-length plasmid. 
The resulting plasmid was used to recover this recombinant RSV vaccine candidate from cDNA.  
  
Seed virus was transferred to Charles River Laboratories (CRL; Malvern, PA) for manufacture of 
the Final Drug Product under cGMP (current Good Manufacturing Practice). The seed virus passed 
pre-production final container testing (Sterility, Mycoplasma, Bacteriostasis/Fungistasis, and testing 
for porcine circovirus types 1 and 2) and was accepted for manufacturing. For the production of the 
Final Drug Product at CRL, the 143rd passage of Vero cells (MF 11702; Lot #426068-2) was grown 
in OptiPRO™ serum-free medium. On day 3 post-infection, OptiPRO™ medium was removed, and 
replaced by Dulbecco’s modified Eagle medium (DMEM). Antibiotics were not used in any stage 
of cell passage, virus growth, or vaccine development. The virus-containing supernatant was 
harvested on Day 6 post-infection and clarified by centrifugation. Intact cells were removed by 
filtration.  
 
Clarified supernatant in 1X SPG (sucrose, 0.218 M; KH2PO4, 0.0038 M; K2HPO4, 0.0072 M; L-
Glutamic Acid, 0.0054 M) was dispensed in 0.6 mL aliquots into labeled 2.0 mL cryogenic vials. 
Vials are snap-frozen and stored at -80ºC ± 15ºC. The Final Drug Product is a concentrated 
suspension of live recombinant LID/ΔM2-2/1030s Vero Grown Virus Vaccine (Lot RSV 010A) in 
DMEM without phenol red with 1X SPG (sucrose, 0.218 M; KH2PO4, 0.0038 M; K2HPO4, 0.0072 
M; L-Glutamic Acid, 0.0054 M). The Final Drug Product has a potency of 6.0 log10 plaque-forming 
units (PFU)/mL and is diluted to dose on site.  
 
The Final Drug Product, LID/ΔM2-2/1030s, Lot RSV # 010A, passed all in-vitro and in-vivo 
testing required for viral vaccines (Detection of Inapparent Viruses in a Viral Vaccine Product, in-
vitro Tuberculosis Testing, PCR-based Reverse Transcriptase Testing, Porcine Circovirus Testing, 
Sterility, Mycoplasma, Bacteriostasis/Fungistasis, Residual DNA testing, DNA Sizing, Endotoxin, 
General Safety, Determination of the Sucrose Level, pH Determination, Intact Cell Assay, 
Potency/Infectivity, Identity, Purity, Toxicology and Pharmacology testing). Sequence analysis 
confirmed that the working seed virus and Final Drug Product, RSV Lot #010A, were of identical 
sequence. LID/ΔM2-2/1030s, Lot RSV #010A, was released by CRL for use as an investigational 
vaccine. 
 
1.2 Prior Research 
  
1.2.1 Experimental Vaccines Against RSV: M2-2 Deletion Mutants  
  
Efforts have been directed toward the development of a live-attenuated RSV vaccine because of the 
advantages of live-attenuated vaccines over inactivated or subunit vaccines. These advantages 
include the ability to (i) induce the full spectrum of protective immune responses including serum 
and local antibodies as well as CD4+ and CD8+ T cells and innate immunity; (ii) infect and 
replicate in the presence of maternal antibody, permitting immunization of young infants; and (iii) 
produce an acute, self-limited, attenuated infection that is well tolerated and readily eliminated from 

 
13 
the respiratory tract. Another important advantage is the absence of vaccine-related enhanced 
disease, as has been confirmed in clinical studies (11).  
 
A number of RSV vaccine candidates with M2-2 deletion have recently been evaluated. The first 
vaccine candidate evaluated in humans, designated RSV MEDI ΔM2-2, was sequentially evaluated 
in adults, RSV-seropositive children, and RSV-seronegative infants and children (20). RSV MEDI 
ΔM2-2 was highly restricted in replication; no shedding was observed in RSV-seropositive 
children, and minimal shedding was detected in RSV-seronegative children, in whom the mean 
peak titer of virus shed was 101.5 PFU/mL. Rhinorrhea occurred more frequently in recipients of 
RSV MEDI ΔM2-2 (85%) than placebo (44%), although this difference was not significant. Despite 
its restriction in replication, RSV MEDI ΔM2-2 was highly immunogenic. When we compared 
vaccine virus replication and antibody responses in RSV-seronegative children who received RSV 
MEDI ΔM2-2 to those achieved with rA2cp248/404/1030ΔSH, a live-attenuated RSV vaccine 
candidate that was well tolerated and immunogenic in pediatric Phase I studies, we found that RSV 
MEDI ΔM2-2 vaccine virus shedding was significantly more restricted, yet the post-vaccination 
RSV-neutralizing serum antibody titers achieved (geometric mean titer [GMT] = 1:97) were 
significantly greater. Surveillance during the subsequent RSV season showed that several RSV 
seronegative RSV MEDI ΔM2-2 recipients had substantial antibody rises without reported illness, 
suggesting that the vaccine was protective yet primed for anamnestic responses to RSV. The M2-2 
deletion was stable in all shed vaccine virus samples that were tested (20).  
 
The closely related RSV LID ΔM2-2 candidate vaccine was evaluated in RSV-seronegative 
children [IMPAACT 2000/CIR 291, ClinicalTrials.gov identifier NCT02237209, NCT02040831; 
(21, 22)], 20 of whom received vaccine and 9 of whom received placebo. RSV LID ΔM2-2 was 
found to be highly infectious; 95% of vaccinees shed vaccine virus, with a mean peak titer of 103.4 
PFU/mL by immunoplaque assay and a mean peak titer of 105.9 log10 copies/mL by quantitative 
real-time polymerase chain reaction (qRT-PCR). The level of replication of RSV LID ΔM2-2 in 
seronegative children was greater than expected based on previous study of RSV MEDI ΔM2-2. 
Respiratory or febrile illnesses occurred frequently in both recipients of RSV LID ΔM2-2 (95%) 
and placebo (78%). One vaccinee experienced a mild LRI (rhonchi) accompanied by shedding of 
vaccine virus and rhinovirus. It was not possible to determine whether the vaccine virus played a 
causal role in this participant's LRI, since an additional respiratory pathogen was also present. 
However, based upon the overall high level of vaccine virus replication, a decision was made to 
stop accrual to the study at 29 rather the targeted 51 participants.  
Because of the unique properties of the M2-2 deletion mutation, which increases antigen production 
and seems to increase the inherent immunogenicity per infectious unit of virus, a decision was 
made to introduce additional attenuating mutations into the LID ΔM2-2 backbone to create vaccine 
candidates that would be more restricted in replication than LID ΔM2-2. The vaccine for the current 
protocol, LID/ΔM2-2/1030s, is closely related to LID ΔM2-2. It contains 2 attenuating elements, 
namely the M2-2 deletion, and the further attenuating "1030s" mutation, a genetically stabilized 
version of a temperature sensitivity mutation [Y1321K (AAA) in conjunction with the stabilizing 
mutation S1313 (TCA) in the L protein (21)]. As described below, LID/ΔM2-2/1030s appears to be 
a promising vaccine candidate based on evaluation in a small number of RSV-seronegative children 
(21). The purpose of this study is to further evaluate the safety and immunogenicity of LID/ΔM2-
2/1030s in RSV-seronegative children.  
1.2.2 Preclinical Studies  
RSV with M2-2 deletion has been extensively studied in vitro and in vivo (17-19, 27).  The results 
indicate that RSV ΔM2-2 is attenuated in small animal models and in non-human primates. RSV 

 
14 
ΔM2-2 was also found to be immunogenic in these animal models. In mice and in 2 nonhuman 
primate models, namely in rhesus macaques and African green monkeys (AGMs), LID/ΔM2-
2/1030s was confirmed to be further attenuated than RSV LID/ΔM2-2. Additional information 
about the preclinical evaluation of LID/ΔM2-2/1030s can be found in the Investigator’s Brochure 
(IB).  
 Evaluation of Temperature Sensitivity of LID/ΔM2-2/1030s 
 
In an in-vitro temperature sensitivity assay in Vero cells, LID/ΔM2-2/1030s exhibited a shut off 
temperature for plaque formation of 40°C, while LID ΔM2-2 and wt RSV have a shutoff 
temperature above 40°C. The shut-off temperature is defined as the lowest restrictive temperature at 
which the reduction in plaque number compared to that at the permissive temperature of 32ºC is 
100-fold or greater than that observed for wt RSV at the 2 temperatures (28). Starting at 38°C, 
LID/ΔM2-2/1030s exhibited a small-plaque phenotype. RSV ∆NS2 ∆1313 I1314L, a virus with a 
known shutoff temperature in Vero cells of 39°C, was included in these assays as a control (Table 
2). This moderate level of temperature sensitivity is likely to somewhat restrict replication of 
LID/ΔM2-2/1030s in the lower respiratory tract, contributing to safety. 
 
Table 2: Temperature Sensitivity of LID/ΔM2-2/1030s (Experimental Lot), RSV 
ΔNS2 Δ1313 I1314L, and Additional Controls  
 
Virus titer (log10 PFU per mL) at indicated temperature (°C) a 
Virus 
32 
35 
36 
37 
38 
39 
40 
TSHb  
TSP c 
LID/DM2-2/1030s 
7.1 
7.1 
7.1 
7.0 
6.5* 
5.4 
< 1 
40 
38   
RSV cp DSH  DM2-2 
6.9 
6.8 
6.9 
6.8 
6.7 
6.5 
6.3* 
> 40 
40   
RSV DSH  DM2-2 
6.8* 
6.8 
6.9 
6.8 
6.7 
6.7 
6.4 
> 40 
32 
RSV ΔNS2 Δ1313 
I1314L 
7.3 
7.2 
7.3 
7.1* 
6.3 
3.3 
< 1 
39 
37 
LID DM2-2 
7.3* 
7.4 
7.4 
7.4 
7.4 
7.3 
6.9 
> 40 
32 
wt RSV 
7.7 
7.7 
7.7 
7.7 
7.6 
7.6 
7.3 
> 40 
> 40 
a   The ts phenotype for each virus was evaluated by plaque assay on Vero cells at the indicated temperatures.  For 
viruses with ts phenotype, titers at shut-off temperatures are marked (bold, underlined). See footnote b for the 
definition of shut-off temperature. 
b Shut off temperature (TSH, bold, underlined) is defined as the lowest restrictive temperature at which the reduction in 
plaque number compared to that at the permissive temperature of 32ºC is 100-fold or greater than that observed for 
wt RSV at the 2 temperatures (28). The ts phenotype is defined as having a shut off temperature of 40º C or less. 
c TSP, Small plaque temperature is defined as the lowest restrictive temperature at which the small-plaque phenotype 
is observed. Titers at lowest restrictive temperature are marked with an asterisk. 
 
1.2.3 Previous Clinical Experience  
  
The live-attenuated recombinant LID/ΔM2-2/1030s vaccine virus was previously evaluated in 32 
RSV-seronegative children (21 vaccinees and 11 placebo recipients; NCT02952339 and 
NCT02794870). The vaccine was highly infectious in RSV-seronegative children: Eighteen of the 
20 vaccinees (90%) were infected with vaccine virus (i.e. shed vaccine virus and/or had a ≥4-fold 
rise in serum RSV antibodies). Vaccine virus was detected by immunoplaque assay and/or RT-
qPCR for 17 of the 20 vaccinees (85%) [90% CI: (78%, 99.7%)] and in none of the placebo 
recipients. The mean peak titer of vaccine virus detected by immunoplaque assay was 2.8 log10 
PFU/mL [compared to 3.4 log10 PFU/mL for LID/ΔM2-2 (22)]; 85% of vaccinees had RSV 
neutralizing antibody responses detectable on day 56 after immunization (29).Vaccine virus was 
detected for a median duration of 10 days (IQR 9-12) by immunoplaque assay and 12 days (IQR 
10-14) by RT-qPCR. Daily viral shedding was highest on study days 7 to 10. 
 

 
15 
As is commonly observed in our vaccine trials in young RSV-seronegative children, respiratory and 
febrile illnesses occurred frequently in both vaccinees and placebo recipients.  During the 28 days 
post-inoculation, respiratory and/or febrile illnesses occurred in 60% [90% CI: (39%, 78%)] of 
vaccinees and 27% [90% CI: (8%, 56%)] of placebo recipients. These differences in rates of illness 
were not statistically significant. Among the 12 vaccinees with illness, multiplex reverse 
transcription polymerase chain reaction (RT-PCR) testing (FastTrack Diagnostics, Luxembourg) of 
NW detected vaccine alone in 3, vaccine plus ≥1 other adventitious agent in 4, and no vaccine but 
≥1 other agent in 5. Among the 3 placebo recipients with illness, rhinovirus was detected in one 
and no agent in 2. Grade 3 fever occurred in 2 participants, one vaccinee and one placebo recipient. 
The vaccinee with grade 3 fever (104°F, Day 3) and respiratory symptoms (Days 5-22), did not 
have detectable vaccine virus shedding or a serum RSV antibody response (thus no evidence of 
infection by vaccine virus) but did have 4 other viruses detected in NW collected between Days 5-
22. All other events in both groups were grade 2 or lower in severity. One vaccinee had a grade 2 
LRI on day 21 after inoculation, characterized by wheezing, cough, and URI symptoms. This 
vaccinee had vaccine virus detectable in NW only on day 9. At the time of his LRI, vaccine virus 
was no longer detected in the NW, but rhinovirus was present. No SAEs were observed during the 
postvaccination follow-up period (21). 
 
Based on the results from this small Phase 1 study, RSV LID/ΔM2-2/1030s was selected for further 
evaluation.  
 
1.3 Clinical Development Plan 
 
In the small Phase 1 study in RSV seronegative infants and children described above (21), the 
investigational RSV vaccine RSV LID/ΔM2-2/1030s showed promising levels of infectivity, 
immunogenicity, and safety. Under the present protocol, RSV LID/ΔM2-2/1030s will be further 
evaluated in additional cohorts of RSV-seronegative infants and children.  
 
The main purposes of this study are (i) to collect additional data on vaccine infectivity, including 
magnitude and kinetics of vaccine virus shedding (Group 1), and (ii) to further evaluate in a larger 
Phase 1 study whether this vaccine is well tolerated and immunogenic in RSV-seronegative infants 
and children (Groups 1 and 2). The vaccine virus shedding results from Group 1 will provide 
additional insights on magnitude and kinetics of vaccine replication. Both Groups 1 and 2 will 
include follow-up for medically-attended RSV during the RSV surveillance season. Based on the 
results from this safety and immunogenicity study, evaluation of RSV LID/ΔM2-2/1030s may 
proceed to larger studies with efficacy endpoints.  
 
In preparation for these larger studies, Groups 1 and 2 will include a blood draw on days 28 and 56 
after study product administration to evaluate the timing of the maximum serum antibody response 
following vaccination. The nasal swab sampling performed in Group 1 will allow further 
exploration of the replication characteristics of RSV LID/ΔM2-2/1030s, and will add to the data 
collected in the previous Phase 1 study described in section 1.2.3 (21).  Information generated from 
this study will provide the basis for larger studies focusing exclusively on safety and efficacy 
endpoints. 
 
The primary immunogenicity endpoint to be evaluated is the proportion of vaccines with a ≥4-fold 
rise in RSV  neutralizing antibody titers on Day 56 (the time point used in previous studies to 
evaluate the immune response to live-attenuated vaccines). The induction of neutralizing antibodies 
56 days after immunization is a well-established and important surrogate marker of effective 
immunity to RSV disease. Antibodies to the F protein are also associated with cross-subgroup 

 
16 
neutralization and protection (14). These assays will be performed at the Johns Hopkins University 
(JHU) CIR laboratory. Antibody detection assays may also be performed at the LID.  
 
 

 
17 
2 
OBJECTIVES 
2.1 Primary Objectives 
 
Safety: Groups 1 and 2 (combined): 
1. To assess the frequency and severity of study product–related solicited and unsolicited AEs 
from day 0 through the 28th day following inoculation 
2. To assess the frequency and severity of study product–related SAEs from day 0 through the 56th 
day following inoculation  
 
Immunogenicity: Groups 1 and 2 (combined):  
1. To evaluate the percentage of vaccinees with a ≥4-fold rise in RSV-neutralizing serum 
antibodies at day 56 after inoculation 
   
Infectivity: Group 1  
1. To determine the peak titer of vaccine virus shed by each participant in Group 1 
2. To determine the proportion of vaccinees infected with vaccine virus in Group 1 [defined as 
shedding vaccine virus, detected by RT-qPCR, and/or ≥4-fold rise in RSV-specific serum 
antibodies, detected by ELISA against the RSV F protein and/or an RSV plaque reduction 
neutralization test (RSV-PRNT)] 
 
2.2 Secondary Objectives 
 
1. Groups 1 and 2 (combined): Safety - To characterize the frequency and severity of symptomatic 
medically attended respiratory and febrile illness in vaccine and placebo recipients who 
experience natural infection with wt RSV during the subsequent RSV season(s) in Groups 1 
and 2 
 
2. Groups 1 and 2 (combined): Immunogenicity - To evaluate the percentage of vaccines with a 
≥4-fold rise in serum RSV F immunoglobulin G (IgG) antibodies at day 56 after inoculation  
 
2.3 
Exploratory Objectives 
 
1. Groups 1 and 2 (combined): Safety - To evaluate the association of vaccine virus shedding with 
adverse events: To assess the incidence and magnitude of vaccine virus shedding in samples 
collected at Illness Visits associated with solicited AEs on Study Days 0 through 28 and with 
serious AEs from Study Day 0 through Day 56  
2. Groups 1 and 2 (combined): Immunogenicity – timing of maximum response: To estimate and 
compare serum RSV F IgG and serum RSV-neutralizing antibody responses at the Day 28 and 
56 Visits in vaccine recipients 
3. Groups 1 and 2 (combined): Immunogenicity - magnitude of anamnestic response: To estimate 
and compare in vaccine recipients to placebo recipients the titers of serum RSV F IgG and 
serum RSV-neutralizing antibodies in participants infected with wt RSV during the RSV season  
4. Groups 1 and 2 (combined): Immunogenicity – durability of vaccine-induced RSV antibodies: 
to estimate and compare the magnitude of RSV serum antibody titers in samples collected at 
the Day 56 and Post-RSV Season Visits among vaccine recipients who do not have evidence of 
RSV infection during RSV season 
5. Group 1: The genetic stability of vaccine isolates will be evaluated by sequence analysis.  
 
Study samples may be used in comparative assays with samples from other RSV vaccine studies 
initiated by the LID, NIAID, NIH. 

 
18 
3 
STUDY DESIGN 
 
The study will be performed in RSV-seronegative children, and will be double-blind, randomized, 
and placebo-controlled. Groups 1 and 2 will be accrued in parallel. Group 1 (Intensive) and Group 
2 (Less Intensive) will differ only in the frequency of study visits and nasal swab collections during 
the acute phase (days 0-28 after study product administration). Participants in Groups 1 and 2 will 
be block-randomized in groups of 3 at a ratio of 2:1 to receive a single intranasal dose of 105 PFU 
of vaccine or placebo, respectively. Evaluations in Group 1 will include nasal swabs during the 
predicted time of peak vaccine shedding. Infectivity endpoints will be evaluated only for Group 1. 
For evaluation of safety and immunogenicity endpoints, results from Groups 1 and 2 will be 
combined. All sites will follow relevant CDC and institutional guidance regarding in-person visits 
and use of personal protective equipment to ensure protection of subjects, families, and staff in the 
context of the SARS-CoV-2 pandemic. 
 
For the purpose of this study, RSV-seronegative is defined as having a serum neutralizing antibody 
titer of < 1:40. This definition has been used in previous evaluations of live- attenuated RSV 
vaccines (11, 12, 20-22). In these and other previous studies, live-attenuated RSV vaccines were 
highly restricted in replication and poorly immunogenic in children with titers ≥ 1:40 but were far 
less restricted in replication and highly immunogenic in children with titers <1:40. These data 
suggest that this neutralizing antibody cutoff can distinguish effectively between RSV-experienced 
and RSV-naïve children. 
 
At Vanderbilt University Medical Center (VUMC), participants will be screened and enrolled under 
this protocol. If eligible, participants will be randomized and will receive study product. At the 
University of Rochester Medical Center and the CIR, a separate screening protocol may be used to 
determine eligibility. Enrollment will occur at the time of inoculation with study product, Day 0. At 
all sites, inoculation with study product will avoid the time during which wt RSV circulates in the 
community, through ongoing local and national (CDC NREVSS) surveillance, and communication 
with study sites.  Participants will remain on the study until they complete the post–RSV season 
visit. 
 
The first 28 days after inoculation is considered the acute phase of the study and the participants’ 
parents/guardians will be contacted daily. These contacts will consist either of an in-person 
evaluation of interim medical history, clinical assessment, and nasal  swab, or an interim medical 
history conducted by a mutually agreed upon communication method. Children will not be enrolled 
in this study while a Stay at Home Order is in place. However, in the event that a Stay at Home 
Order is initiated within the first 28 days following inoculation, or if a child develops a respiratory 
illness, parents may be asked to obtain the nasal swabs, and clinical assessments may be completed 
via remote or in-person research visits. During remote research visits parents will also be asked to 
measure the child’s temperature, heart rate and respiratory rate. Parents will be informed of these 
possibilities prior to enrollment, and will be trained in the methods used to collect an anterior nasal 
swab specimen. During the Acute Phase, the participants will be evaluated for adverse events (AEs) 
or serious adverse events (SAEs).  
 
Group 1 will have intensive follow-up with nasal swabs obtained on study days 5, 7, 10, and 12 and 
whenever febrile or respiratory illnesses or otitis media (solicited AEs) are reported. Group 2 will 
have a less intensive follow-up with nasal swabs only in the event of solicited AEs during the acute 
phase of the study. Participants who have a solicited AE will have a nasal swab obtained and a 
remote or in person clinical assessment. The nasal swab will be tested for RSV, and for other 
respiratory pathogens that are considered adventitious agents. During the Post-Acute Phase, study 
days 29 – 56, participants’ parents/guardians will be instructed to contact the study staff if any 

 
19 
SAEs occur. Groups 1 and 2 will have a scheduled follow-up visit on the 28th and 56th day after 
inoculation. The schedules of evaluations during the Acute Phase and Post-Acute Phase are shown 
in Appendix I, Table 21 and Table 22. 
 
The study has a third phase that assesses the incidence and severity of illness suggestive of RSV 
occurring during the RSV season following inoculation. During the RSV Season Surveillance 
Period, beginning on the date of seasonal enrollment pause and ending on March 31, study staff 
will make weekly contact with the participants’ parents/guardians to identify medically attended 
episodes of fever, URI, LRI, or otitis media. Participants who have such an episode will have an in-
person evaluation of interim medical history, clinical assessment, and nasal swab to evaluate for 
RSV and other respiratory pathogens that are considered adventitious agents (Appendix II). As 
noted above, if a Stay at Home Order is initiated during the RSV Surveillance Period, parents may 
be asked to obtain nasal swabs and clinical assessments may be completed via remote or in-person 
research visits. 
 
Participants in both groups will have a post-RSV season visit to collect blood to assess the 
durability of the vaccine response and to assess the immune response to naturally occurring wt RSV 
infection. Some participants may have an overlap between the initial phases and the RSV 
surveillance phase of the study, depending upon the date of inoculation. 
 
4 
STUDY POPULATION 
 
Approximately 21 RSV-seronegative infants and children ≥ 6 months to < 25 months of age will be 
accrued in Group 1; 14 will receive a single dose of 105.0 PFU of vaccine and 7 will receive a single 
dose of placebo. 45-60 RSV-seronegative infants and children ≥ 6 months to < 25 months of age 
will be accrued in Group 2 and will receive a single dose of either 105.0 PFU of vaccine or placebo 
in a 2:1 ratio. These numbers were chosen based upon experience with phase I evaluation of other 
live-attenuated respiratory virus candidate vaccines (11, 12, 20-22) and statistical considerations 
(Section 9.1). 
 
4.1 Recruitment Process 
 
Research staff will recruit participants from pediatric practices and clinics in the surrounding area. 
At the CIR and the University of Rochester, an IRB-approved screening protocol may be used for 
this study. At VUMC, children will be screened under this protocol. Upon referral by the 
participants’ primary care provider or the provider’s staff, staff will contact parents/guardians in 
person or remotely as appropriate, via telephone, email, or text message, send them IRB-approved 
informational brochures, and obtain contact information. Study staff will follow up with interested 
parents/guardians to elaborate upon the details and requirements of the screening and study process. 
 
Research staff may also recruit potential participants from local pediatric practices and clinics 
through mail, email, or electronic medical record messaging (e.g. MyChart), and via mail to 
households in local zip codes containing age- appropriate children. In addition, research staff may 
recruit participants through group gatherings such as health fairs and by social media posting IRB-
approved recruitment materials. 
 
If parents/guardians are interested in having their child participate and the child meets the minimum 
inclusion and exclusion criteria, then the study staff will schedule a screening visit to determine the 
child’s eligibility.  
 
 

 
20 
4.2 
Study Visits 
An overview of the study visits, evaluation schedule, and specimen collection is provided in 
Appendix I and Appendix II. This section contains additional information on visit-specific study 
procedures. 
 
Study visits, except inoculation, may be performed at one of the clinical sites or at a mutually 
agreed-upon location. Inoculation must be performed at one of the clinical sites. As noted above, 
sites will follow relevant CDC and institutional guidance regarding in-person visits and use of 
personal protective equipment.  Unless otherwise specified, visits may be split, with required 
procedures performed on more than one day within the allowable visit window. All clinical tasks 
will be performed by a medical professional. The physical examination will include temperature, 
heart rate, respiratory rate, assessment of ears, eyes, nose, and throat (EENT), lungs, heart, and 
skin, as well as abdominal, musculoskeletal, and, as appropriate, neurological exams. A focused 
clinical assessment will include temperature, heart rate, respiratory rate, EENT, lung, heart and 
lymph nodes assessment.  As previously stated, for visits following the inoculation visit, a parent 
may be asked to obtain the nasal swabs and clinical assessment may be done via a remote or in-
person research visit if a Stay at Home order is initiated or if a child is ill.  
 
All specimens will be obtained, processed, stored and transported per the Manual of Procedures 
(MOP). 
 
In addition to the protocol-specified procedures listed in this section, study staff may complete 
other tasks consistent with standard operating procedures (SOPs), including but not limited to 
collecting, reviewing, and updating demographic and locator information; reviewing elements of 
informed consent; scheduling telephone (or text/email) contacts and visits; providing instructions 
for contacting study staff between visits; providing visit reminders; and following up on missed 
visits. All visit procedures will be documented in accordance with the MOP. Refer to Section 10 for 
more information on documentation requirements and completion of case report forms (CRFs). 
 
The study’s medical professional will inform parent/guardian of any significant abnormal physical 
findings and, after obtaining parental release of information, will make appropriate referrals back to 
the child’s primary caregiver, if necessary. 
 
4.3 
Consenting Process 
 
At the CIR and the University of Rochester, the screening process may be completed under a 
separate screening protocol and consent. At VUMC, screening will be performed under this 
protocol. The parent/guardian must complete the informed consent process and sign the informed 
consent document (ICD) before screening or study procedures are performed. The consenting 
process for the study may take place during the screening visit or may be conducted at a separate 
visit. During the consenting process, the child’s parent will review the ICD, be encouraged to ask 
questions, and complete a comprehension assessment to evaluate consent understanding. Study staff 
will use incorrect answers from the comprehension assessment to identify areas of the ICD that 
need further review with the parent/guardian. This will help ensure that the parent/guardian has 
sufficient understanding of the process before the ICD is signed. Parent/guardian will be provided 
with a  copy of the ICD. 
 
During the consenting process, the parent will be given the opportunity to provide permission for 
use of their child’s picture in advertisement flyers, articles, or presentations. In addition, the parent 
will be given the opportunity to provide permission for storing their child’s specimens for future 
respiratory virus vaccine studies and for research purposes. 

 
21 
A parent/guardian will complete a Health Insurance Portability and Accountability Act (HIPAA) 
medical record release to allow study staff to review medical history and immunization records, and 
to allow review of AEs during the study. The portions of the medical record that are pertinent to the 
study will be maintained in the study chart.  
 
4.4 
Screening Visit 
 
The screening process will include reviewing the medical record, obtaining a medical history from 
parent/guardian, and conducting a physical examination. The physical examination will occur on 
the day of screening or the day of inoculation. The medical record review should include review of 
history related to the study eligibility criteria, the immunization record, and growth chart data. The 
medical history from the parent should include demographics, prior diagnoses, current medications, 
signs and symptoms, developmental status, age of household members, day care attendance, and 
use of medications prior to inoculation. 
 
The screening visit will include obtaining a serum sample to test for the presence of RSV 
antibodies. Approximately 3-5 mL of blood is sufficient quantity for the screening and pre-
inoculation assays. The procedure will be performed and documented per the MOP. As in previous 
phase I trials of other live-attenuated RSV vaccines (11, 12, 20-22), hematologic and metabolic 
screening laboratory tests will not be performed on the participant.  Such tests are not routinely 
performed as part of well- child care, given that the risk of undiagnosed hepatic, metabolic, and 
renal diseases is much lower in children than in adults (29). 
 
The screening serum sample must be obtained no more than 42 days prior to inoculation. Study 
staff should consider potential randomization and inoculation dates when scheduling the participant 
screening visits. 
 
Table 3: Screening Visit Procedures 
Screening Visit Procedures 
Administrative Tasks 
• Conduct consenting process 
• Confirm parent/guardian’s informed consent comprehension 
• Obtain release of medical records as required per HIPAA 
• Obtain available medical records 
• Assess eligibility 
Clinical Tasks 
• Obtain, review, and document medical history 
• Perform physical examination or defer until study day 0 
• Address any concerns 
• Document findings 
• Obtain and review participant’s immunization record 
• Review participant’s medical records to determine age-appropriate 
developmental assessment, and participant’s weight and length 
Laboratory Tasks       Blood 
Collect blood for: 
• Screening1 and pre-inoculation1 sample for RSV serum antibody testing 
Follow-up Preparation 
• Schedule enrollment visit if eligible  
1. Obtained no more than 42 days prior to inoculation 
 
4.5  Randomization 
Randomization numbers will be assigned by Research Electronic Data Capture (REDCap) and will 
be forwarded to the Data and Safety Monitoring Board (DSMB) Executive Secretary. A copy of the 
randomization code will be retained by the unblinded dispenser.  

 
22 
 
Randomization will be implemented using the Randomization Module within Vanderbilt’s 
REDCap database. The investigational pharmacy at each of the 3 institutions will distribute the 
assigned study vaccine. Without the PI's written request to unblind, the randomization code will not 
be released to the clinical staff until the acute monitoring phase is complete for each subject within 
the randomization group. Pediatric subjects will be block-randomized in groups of 3 (2 vaccinees 
and 1 placebo recipient per block); this allows for maintenance of the blind during each subject’s 
acute monitoring phase but also provides early information regarding safety, which is appropriate 
and common practice for phase 1 respiratory virus vaccine studies (11, 12, 20-22). Detailed 
procedures for randomization and unblinding will be placed in the MOP.  
 
Unblinded study personnel will label the vaccine syringes and complete the appropriate parts of the 
vaccine administration record (VAR). After the participant has been inoculated, the vaccine 
administrator and verifier will initial the label and place the label in the subject’s study chart after 
inoculation. The inoculation time will be documented on the VAR and a copy will be sent to the 
pharmacy. All syringes will be appropriately disposed of by the study staff. 
 
4.6 
Inoculation (Day 0) 
 
Inoculation with study product will avoid the time during which wt RSV circulates in the 
community, through ongoing local and national (CDC NREVSS) surveillance,  and communication 
with study sites.  Study product administration occurs on study day 0, and must be completed at a 
clinic or medical office site or pediatric practice where emergency supplies are available in case of 
an adverse event (e.g. allergic reaction). Prior to inoculation, an authorized prescriber will provide a 
request for study product to the unblinded dispenser. The request must include the information 
outlined in the MOP. 
 
Informed consent will be obtained from the parent/guardian of each child who participates in this 
study prior to the performance of any study procedures or inoculation. At the VUMC, study-
specific informed consent will be obtained prior to screening, whereas at Johns Hopkins CIR and 
the University of Rochester, screening may be performed under a separate protocol and study-
specific consent will be obtained prior to inoculation. The child’s parent/guardian will be 
encouraged to ask questions and complete a comprehension assessment to evaluate understanding 
of the study. Study staff will use incorrect answers from the comprehension assessment to identify 
those areas of the ICD that need further review with the parent/guardian. This will help ensure that 
the parent/guardian has sufficient understanding of the study process before the ICD is signed. 
 
If the participant is noted to have any of the following on the study visit day, inoculation must be 
deferred: 
• fever (temporal or rectal temperature of ≥ 100.4°F), or 
• URI or LRI symptoms or signs (including but not limited to rhinorrhea, cough, or pharyngitis), 
or 
• nasal congestion significant enough to interfere with successful inoculation, or 
• otitis media, or 
 
If the 42-day window from screening to inoculation is exceeded, then the infant or child must be 
rescreened, and an additional blood draw is needed.  
 
 

 
23 
Table 4: Enrollment Visit Procedures 
Enrollment Visit Procedures (Day 0)* 
Administrative Tasks 
• Confirm study ICD is completed and signed and dated by both 
parent/guardian and study staff who completed the consenting 
process 
• Complete eligibility determination and confirmation 
• Complete paper-based eligibility checklist 
• Obtain release of medical records as required per HIPAA 
Clinical Tasks 
• Obtain interim history from parent/guardian 
• Complete physical exam if deferred at screening, OR 
Focused physical exam if physical completed at screening 
• Address any concerns 
• Document findings 
• Confirm eligibility 
Laboratory Tasks 
Blood 
 
If insufficient volume obtained at screening, collect blood for: 
• Pre-inoculation RSV antibody titer 
Study Product Administration 
• Administer study product and maintain participant in a supine 
position for 1 minute 
• Observe for approximately 30 minutes after inoculation to evaluate 
for immediate hypersensitivity reactions 
Follow-up Preparation 
• Confirm contact method 
• Complete teaching 
• Schedule next visit 
*No more than 42 days from screening  
 
Following the inoculation day visit, the parent/guardian will record the infant/child’s temperatures 
and signs of illness on the temperature card and provide these to study personnel during a remote or 
in-person research visit or non-visit day contact. New rectal thermometers will be given, and 
temporal artery thermometers will be provided to parent/guardian for use during the study. For 
temperature measurements, parent/guardian will be instructed to use the study-provided temporal 
artery thermometer to screen for elevated temporal artery temperatures. This device is used to 
minimize the number of rectal temperature measurements and has been shown to be an effective 
screening tool for rectal fever (30). The parent/guardian will measure temporal artery temperatures 
following the manufacturer’s directions. If any temporal artery temperature is ≥ 100.0°F, 
parent/guardian will be asked to measure a rectal temperature within 20 minutes (30). For study-
specific management and grading of temperatures, see Section 8.2.2, Table 17. 
4.7 Study Phases 
 
The Acute Phase begins with inoculation and ends at midnight on the 28th day after inoculation. 
During the Acute Phase of the study, a study healthcare professional will be available by telephone 
24 hours a day for consultation with parent/guardian regarding any illnesses that may occur. 
 
Study personnel will have daily contact with participants during the first 28 days after inoculation. 
This 28-day period is consistent with the duration of shedding of live- attenuated respiratory virus 
vaccines in RSV-seronegative participants (11, 12, 20-22). 
 
On non-visit days, study staff will contact the parent/guardian and will record the parent/guardian-
provided temperatures and signs of illness. Participants with illness may have additional remote or 
in-person research visits to assess the illness (Section 4.8). 
 
Timing and amounts of study compensation will vary according to site and are included in the site-
specific consent forms. 

 
24 
   
4.7.1 Acute Phase: In-person Study Visit Days 
4.7.1.1 Group 1: Study Days 1-27  
 
An in-person study visit and clinical assessment performed by a healthcare professional will be 
completed during visits on days 5, 7, 10, and 12 after inoculation, with a visit window of ± 1 day. If 
an in-person visit is moved by ± 1 day, then the non-visit day contact will be completed in place of 
the original interim visit date. All sites will follow relevant CDC and institutional guidance 
regarding in-person visits and use of personal protective equipment.  If a Stay at Home Order is 
initiated following inoculation, or if the child has a respiratory or febrile illness, the parent may be 
asked to obtain the nasal swab and the clinical assessment may be done via a remote or in-person 
research visit.  Transport of specimens from the home to the research laboratory will be arranged as 
needed.    
 
 
Table 5: Group 1: Acute Phase In-Person Visit Procedures  
Days 5, 7, 10 and 12 In-person Visit Procedures (each visit ± 1 days) (Group 1) 
Clinical Tasks 
• Obtain and document from parent/guardian the participant’s 
previous days’ interim history including: 
• 
medications and/or immunizations 
• 
signs and symptoms of illness 
• 
highest temperature reading, indicate temperature 
method 
• Perform focused clinical assessment 
• Address any concerns 
• Review safety data 
• Document findings 
Laboratory 
Tasks 
Nasal Swab 
Collect nasal swab  for*: 
• RSV viral detection and quantification 
Follow-up Preparation 
• Schedule non-visit day contact and follow-up, in-person visits 
 
*During the Acute Phase study visit, if the participant is diagnosed with or suspected of having 
URI, LRI, otitis media or fever (as defined in Appendix III), testing of the nasal swab specimen for 
adventitious agents will be performed as described in the MOP. Additional remote or in-person 
research visits with nasal swabbing will be scheduled if the participant experiences febrile or 
respiratory illnesses before Day 5 or after Day 12  
4.7.1.2 Group 2: Study Days 1-27 
 
A study visit is conducted if the participant is diagnosed with or has a parental report of having 
symptoms of URI, LRI, otitis media or fever (as defined in Appendix III) and testing of the nasal 
swab specimen for adventitious agents will be performed as described in the MOP.  Parents will be 
provided with the necessary materials and will receive video instruction on collection of anterior 
nasal swab specimens to use if a remote visit is scheduled.  Transport of specimens from the home 
to the research laboratory will be arranged as needed.    
 
 

 
25 
4.7.1.3 Groups 1 and 2: Study Day 28 
 
Table 6: Groups 1 and 2: Day-28 In-Person Visit Procedures  
Day 28 In-person Visit Procedures (each visit ± 1 days)  
Clinical Tasks 
• Obtain and document from parent/guardian the participant’s 
previous days’ interim history including: 
• 
medications and/or immunizations 
• 
signs and symptoms of illness 
• 
highest temperature reading, indicate temperature 
method 
• Perform focused clinical assessment*  
• Address any concerns 
• Review safety data 
• Document findings 
Laboratory 
Tasks 
Nasal Swab* 
 
Collect nasal swab* for: 
• RSV viral detection and adventitious agents 
Blood 
Collect blood for: 
Serum antibodies to RSV 
Follow-up Preparation 
• Schedule day 56 follow-up, in-person visit 
 
*A clinical assessment is performed and nasal swab specimen is obtained only if the participant 
has febrile or respiratory illness or otitis media. Timing of visit and collection are outlined in 
Table 12 and Table 13.  
 
4.7.2 Acute Phase: Non-Visit Study Day Contacts 
4.7.2.1 Group 1 
 
In the 28 days following inoculation, contact with parents/guardians will be made on days that an 
in-person visit is not completed: days 1, 2, 3, 4, 6, 8, 9, 11, 13-27 (each visit ± 1 day). On non-visit 
days, study staff will contact the parent/guardian and will record the parent/guardian-provided 
temperatures and signs of illness. Participants with illness may have additional remote or in-person 
research visits to assess the severity of the illness and obtain a nasal swab for testing for 
adventitious agents. The families may be asked to obtain the nasal swabs for testing for adventitious 
agents if a remote visit is completed (Section 4.8).  If a Stay at Home Order is initiated, the parent 
may be asked to obtain nasal swabs for routine study visits or illness visits, and clinical assessments 
may be completed via remote research visits. During remote research visits parents will also be 
asked to measure the child’s temperature, heart rate and respiratory rate. 
 
4.7.2.2 Group 2 
 
In the 28 days following inoculation, parental contact will be made on days that an in-person visit is 
not completed: days 1-27. On non-visit days, study staff will contact the parent/guardian and will 
record the parent/guardian-provided temperatures and signs of illness. For participants with febrile 
or respiratory illnesses or otitis media, a remote or in-person research illness visit will be scheduled 
to assess the severity of the illness and obtain a nasal swab for testing for adventitious agents. The 
families may be asked to obtain the nasal swabs for testing for adventitious agents if a remote visit 
is completed (Section 4.8). During remote research visits parents will also be asked to measure the 
child’s temperature, heart rate and respiratory rate.  
 
 

 
26 
Table 7: Groups 1 and 2: Acute Phase Non-Visit Contact Procedures 
Days 1, 2, 3, 4, 6, 8, 9, 11, 13-27 (Group 1) and Days 1 – 27 (Group 2) 
 Contact Procedures 
Clinical Tasks 
• Obtain and document from parent/guardian the participant’s 
interim history from previous days, including: 
o medications and/or immunizations 
o signs and symptoms of illness 
o highest temperature reading, indicate temperature method 
• Address any concerns 
• Review safety data 
• Document findings 
Follow-up Preparation 
• Schedule an illness appointment if necessary 
 
4.7.3 Study Day 29 Visit 
 
There will be a non-visit contact on Day 29 to obtain interim history through midnight on the 28th 
day following inoculation. If the Day 28 Visit takes place on Day 29, it is not necessary to have an 
additional contact with the family on Day 29. 
 
Table 8: Groups 1 and 2: Day 29 Non-Visit Procedures 
 Day 29 Non-Visit Procedures  
Clinical Tasks 
• Obtain and document from parent/guardian the participant’s 
previous days’ interim history including: 
o 
medications and/or immunizations 
o 
signs and symptoms of illness 
o 
highest temperature reading, indicate temperature method 
• Address any concerns 
• Review safety data 
• Document findings 
Follow-up Preparation 
• Review SAE criteria with participants and how to contact study 
personnel during Post-Acute Phase 
 
4.7.4 Post-Acute Phase 
 
The Post-Acute Phase begins on the 29th day after inoculation and ends on the 56th day after 
inoculation. During the Post-Acute Phase, parent/guardian will be instructed to monitor for and 
contact the study staff if their infant or child has symptoms that are suggestive of a SAE. If the 
parent reports an SAE that may meet the study pause or stop criteria (Section 8.3), then a remote or 
in-person Illness Visit will be scheduled to assess the severity of the illness and obtain a nasal swab 
for testing for adventitious agents. The families may be asked to obtain the nasal swabs for testing 
for adventitious agents if a remote visit is completed (Section 4.8). During remote research visits 
parents will also be asked to measure the child’s temperature, heart rate and respiratory rate.   
 
 
4.7.5 Study Day 56 Visit 
 
The Day 56 Visit should be conducted between 56 and 63 days following inoculation.  
 
Because the Post-Acute Phase ends on the 56th day following inoculation, only events through that 
time should be evaluated as having occurred during the Post-Acute Phase. 
 
 

 
27 
Table 9: Groups 1 and 2: Day 56 Visit Procedures 
 Day 56 Visit (+7 Days) (Groups 1 and 2) 
Administrative Tasks 
• Provide study compensation  
Clinical Tasks 
• Obtain and document from parent/guardian the participant’s interim 
history from midnight of the 28th day through the 56th day following 
inoculation, including: 
o 
visits to medical provider/hospitalizations 
o 
medications and/or immunizations 
o 
signs and symptoms of illness meeting SAE criteria 
• Address any concerns 
• Review safety data 
• Document findings 
Laboratory 
Tasks 
Blood 
 
Collect blood for: 
• Serum antibodies to RSV (if Stay-at-Home orders are in place at a 
given site, sera will be collected as soon as possible thereafter) 
Follow-up Preparation 
Review plans for weekly contact during the RSV Season Surveillance 
Period (Section 4.7.7.1) 
 
4.7.6 Period After Day 56 through Start of RSV Surveillance Phase  
 
During this period, contact with the participant is not required. No clinical data will be recorded on 
CRFs or reported under this protocol. 
 
4.7.7 RSV Surveillance 
4.7.7.1 Weekly Contact for Surveillance During the RSV Season 
Each site will seasonally pause enrollment and start the RSV Surveillance Phase of the study based 
on local and/or national (CDC NREVSS) surveillance for RSV positivity locally in the Baltimore, 
MD; Rochester, NY; and Nashville, TN areas (Appendix IV, Figure 2).  The seasonal enrollment 
pause will be determined at each site individually based on details in the MOP.  The surveillance 
for RSV-associated disease will be conducted between the seasonal pause of enrollment and March 
31st of the year  following receipt of study product. For some RSV- seronegative participants, 
surveillance during the RSV season may overlap with the Acute and/or Post-Acute study phases. In 
this case, all evaluations required for each of the relevant phases of the study will be conducted. 
 
During the RSV season following receipt of study product, participants enrolled in this study will 
be monitored for symptomatic, medically attended, RSV-like illnesses listed below via weekly 
telephone or email communication or an in-person visit. (rhinorrhea and cough need not meet the 
Appendix III criteria if they are documented by the health care provider): 
• 
Medically attended fever 
• 
Medically attended URI 
• 
Medically attended otitis media 
• 
Medically attended LRI 
 
An Illness Visit will be scheduled within 3 days of study staff notification of any of these events (Section 
4.8).  All sites will follow relevant CDC and institutional guidance regarding in-person visits and use of 
personal protective equipment to ensure protection of subjects, families, and staff in the context of the 
SARS-CoV2 pandemic.   If a Stay at Home Order is initiated, the parent may be asked to obtain the nasal 
swab for the RSV Surveillance illness, and the clinical assessment may be completed via a remote or in-
person research visit. 
 

 
28 
 
Table 10: Groups 1 and 2: RSV Season Surveillance Procedures 
RSV Season Surveillance following inoculation 
Clinical Tasks 
• Obtain interim history 
• Review safety data 
• Document findings 
Follow-up Preparation 
• Continue with weekly contacts through March 31 
• Schedule an Illness Visit if warranted 
• Schedule the Post-RSV Season Study Visit to take place (targeted 
April 1 - April 30 with allowable window through September 30th if 
Stay at Home Orders require that this study visit be delayed) 
4.7.7.2 Post-RSV Season Surveillance Study Visit 
 
The Post-RSV Season Surveillance Visit will occur in the calendar year following receipt of study 
product, ideally between April 1st and April 30th with an allowable window through September 
30th if Stay at Home Orders require that this study visit be delayed. 
 
Table 11: Groups 1 and 2: Post-RSV Seasonal Surveillance Study Visit Procedures 
 Post-RSV Season Study Visit  
Administrative Tasks 
• Provide study compensation 
Clinical Tasks 
• Document findings related to study procedures 
Laboratory 
Tasks 
Blood 
 
Collect blood for: 
• Serum antibodies to RSV 
 
 
4.8 Illness Visit 
 
The timeframe after staff notification in which the Illness Visit must occur depends on the study 
phase and the grading of the fever and respiratory symptoms per Section 8.2. If the Illness Visit 
occurs on a day concurrent with an in-person study visit, a single nasal swab collection is required, 
and adventitious agent testing will be requested. All sites will follow relevant CDC and institutional 
guidance regarding in-person visits and use of personal protective equipment to ensure protection of 
subjects, families, and staff in the context of the SARS-CoV-2 pandemic.  For illness visits, the 
parent may be asked to obtain the nasal swab. During remote research visits parents will also be 
asked to measure the child’s temperature, heart rate and respiratory rate. As otitis media and LRI 
cannot be detected by remote study visit, medical records from provider visits will be obtained to 
document these events if a remote visit is completed or an in-person visit cannot be completed in a 
timely fashion.  
 
If the acute or post-acute phases overlap the surveillance period (between the date of seasonal pause 
of enrollment and March 31), then the timelines for the acute and post-acute phases will be used. 
 
 

 
29 
Table 12: Illness Visit Timeframe 
Illness Visit Timeframe 
Phase 
Symptoms 
Grade 
Visit Timeframe 
Acute 
Fever, otitis media or URI 
1 
Within 3 days 
Acute 
Fever, otitis media or URI 
≥ 2 
Within 2 days 
Acute 
LRI 
Any 
Within 1 day; a follow-up visit, 
including nasal swab is required 
one to three days after the initial 
assessment. 
Post-Acute 
SAE that meets study pause or 
stop criteria (Section 8.3) 
≥ 2 
Within 3 days 
RSV Season 
Surveillance 
Medically attended fever, otitis 
media, URI or LRI 
≥ 2 
Within 3 days 
 
Table 13: Illness Visit Procedures 
Illness Visit Procedures 
Administrative Tasks 
• Complete Adventitious Agent Assay Request for rRT-PCR on nasal 
swab for adventitious agents 
• Complete medical record release if needed 
Clinical Tasks 
• Obtain and document from parent/guardian the participant’s interim 
history including: 
o 
medications and/or immunizations 
o 
signs and symptoms of illness 
o 
highest temperature reading, indicate temperature method 
• Perform focused clinical assessment 
• Address any concerns 
• Review safety data 
• Document findings 
Laboratory 
Tasks 
Nasal Swab 
Collect nasal  swab for 
• Viral detection and quantification 
Follow-up Preparation 
• Schedule follow-up as appropriate 
4.9 Early Discontinuation Study Visit 
In the event that a child is unable to continue participation in the study, parent/guardian will be 
encouraged to allow the participant to complete safety monitoring through Day 56. Every effort 
should be made to schedule a final Early Discontinuation Visit. 
 
Table 14: Early Discontinuation Procedures 
 Early Discontinuation 
Administrative Tasks 
• Record data on CRF 
Clinical Tasks 
• Obtain interim history 
• Address any concerns 
• Review safety data 
• Encourage parent/guardian to allow the participant to complete 
safety monitoring through Day 56  
• Document findings 
Laboratory 
Tasks 
Blood 
Collect blood for: 
• Serum antibodies to RSV 
Nasal Swab 
If Early Discontinuation Visit is within 56 days (Appendix I), 
 collect nasal swab for: 
• Viral detection and quantification 

 
30 
4.10  Participant Retention 
 
Study staff will make every effort to retain participants in the study, thereby minimizing potential 
biases associated with loss to follow-up. 
 
4.11 Participant Withdrawal or Termination from the Study 
Participants in this study may voluntarily withdraw from the study at any time. Any participant who 
has received study product will be encouraged to remain in the safety evaluation for the duration of 
the study even if sample collection is refused. 
A participant may withdraw or terminate participation in the study early for any of the following 
reasons: 
• 
Withdrawal of consent – applies to a parent/guardian who verbally or in writing withdraws 
consent for the participant to continue in the study for any reason. 
• 
Noncompliant with protocol – applies to a parent/guardian who does not comply with protocol - 
specific visits or evaluations on a consistent basis, such that adequate follow-up is not possible, 
and the participant’s safety would be compromised by continuing in the study. 
• 
Investigator discretion – participant withdrawal may occur if the investigator believes that it is in 
the best interest of the participant. 
• 
Other – a category used when previous categories do not apply; requires an explanation. 
 
The study may be ended for the following reasons: 
• 
Research is terminated by sponsor or investigator – applies to the situation where the entire 
study is terminated by the sponsor or investigator for any reason. 
• 
The study sponsor, CIR, the institutional review board (IRB), the Office for Human Research 
Protections (OHRP), NIAID, or the US Food and Drug Administration (FDA) may decide to 
end the study. 
For any participant who withdraws or who is terminated from the study prior to completion of 
follow-up, study staff will document the reason for the withdrawal or termination. In the event that 
the circumstances that led to a participant’s withdrawal or termination change, the study staff will 
contact the PI to discuss options for resumption of follow-up. Withdrawn subjects will not be 
replaced. Compensation will be given only for the visits and contacts that are completed.  
 
4.12 Specimen Collection 
Specimens will be collected for this study as indicated in the Schedule of Events. Further 
information on collection of blood and nasal swab specimens will also be provided in the MOP. 
4.12.1 Virus Detection 
Specimens for viral detection, quantification of vaccine virus shedding by rRT-qPCR, and to obtain 
vaccine isolates for analysis of genetic stability will be obtained by nasal swab approximately 4 
times after inoculation in Group 1, as shown in Appendix I. These specimens may also be tested for 
adventitious respiratory viruses and bacteria  if needed. Additional anterior nasal swab specimens 
for detection of RSV and adventitious respiratory viruses by rRT-qPCR will also be obtained from 
participants in Group 1 who meet illness criteria during the Acute phase (Days 0 through Day 28); 
participants in Group 2 will only have  nasal swabs obtained during the Acute Phase if they 
experience febrile or respiratory illnesses. During the RSV Season Surveillance Period (starting 
with the seasonal pause in enrollment through March 31) nasal swabs will be obtained from all 
study participants in Groups 1 and 2 in the event of medically-attended febrile or respiratory 
illnesses. If a participant becomes ill during the Acute or Post-Acute Phase, then additional nasal 
swabs may be obtained to exclude infection with an adventitious virus. Laboratory testing will be 

 
31 
performed by personnel who are not involved with clinical assessment to maintain the blinding 
status. 
4.12.2 Immunologic Assays 
For measurement of RSV serum antibodies, serum specimens will be obtained not more than 42 
days prior to inoculation and on Days 28 and 56 (+7) post-inoculation. In addition, post RSV 
season serum specimens will be collected from all participants. 
These samples will be used to assess antibody responses to vaccine, and to determine whether a 
four-fold or greater rise in antibody titer has occurred following the RSV season, which would 
signify infection with wt RSV. This will allow comparison of the rate and severity of significant 
RSV illness following infection with wt virus, as well as comparison of the antibody responses, in 
vaccine and placebo recipients. Obtaining serum samples for antibody testing on days 28 and 56 will 
allow an assessment of the kinetics of the antibody response, which will be useful in determining the 
optimal time to obtain post-inoculation sera in future studies.   
Specimens will be obtained by venipuncture, finger-stick, or heel-stick. No more than 5 mL of 
blood will be drawn at each blood draw visit. A maximum of 20 mL of blood will be obtained from 
participants for study purposes from screening through the surveillance period.  
4.12.3 Specimen Preparation, Testing, Storage, and Shipping 
All specimens collected for this study will be labeled, transported, processed, tested, stored and/or 
shipped in accordance with SOPs. The frequency of specimen collection and testing will be directed 
by the Schedule of Evaluations (Appendix I and Appendix II). 
4.12.4 Research Laboratories 
Quantitation of the amount of vaccine virus shed, assays to measure immune responses before and 
after inoculation, and assessment of nasal swabs for adventitious viral agents will be performed at 
the CIR.. Specimens may be sent to LID, NIAID for confirmatory testing, for specialized immune 
assays, and for sequence analysis, including deep sequencing, of vaccine isolates.   
4.12.5 Plan for Use and Storage of Biological Samples 
All specimens collected as part of this study may, with the parent/guardian’s permission, be stored 
for future research as part of CIR’s approved biospecimen repository for vaccine research. These 
samples and data may be used for future screening for respiratory virus vaccine studies and to learn 
more about RSV infection and other diseases. The parent/guardian or child will not own the blood 
specimens, nasal fluid, or data after it is given to the study. No financial benefit will be provided to 
the parent/guardian or child from any product or idea created by the investigators using the data or 
materials. These samples will not be sold or used to make commercial products. Genetic tests will 
not be performed on these samples unless separate informed consent is obtained. 
Samples stored in the repository will be labeled with the study identification number of the 
participants that, by themselves, cannot identify study participants but are linkable to the study 
databases generated by the main study. The repository database will contain only the study 
participants’ numbers. A master log linking the study participants’ identification numbers to their 
names is maintained by the study’s clinical staff in a password-protected computer system with 
limited access to authorized research team members and will not be shared with the laboratory. 

 
32 
Study participants, or their parents/guardians, may withdraw consent for future testing of their 
specimens at any time. 
4.12.6 Biohazard Containment 
As the transmission of blood-borne pathogens can occur through contact with contaminated 
needles, blood, and blood products, appropriate blood and secretion precautions will be employed 
by all personnel. The procedures for obtaining, shipping, and handling of all specimens for this 
study will follow the current recommendation of the Centers for Disease Control and Prevention 
(CDC) and the NIH. All infectious specimens will be transported using packaging mandated in 
Title 42 of the Code of Federal Regulations (CFR), Part 72 (42 CFR 72) and in accordance with 
individual carrier guidelines (e.g., Federal Express). 
 
5 
Inclusion/Exclusion Criteria 
 
5.1  Inclusion Criteria 
 
Potential participants must meet all of the following inclusion criteria to be enrolled in this study 
and randomized to receive study product or placebo: 
 
5.1.1.  ³6 months of age and <25 months of age at the time of inoculation 
5.1.2. Screening and pre-inoculation serum specimens for RSV-neutralizing antibody are 
obtained no more than 42 days prior to inoculation 
5.1.3. Seronegative for RSV antibody, defined as serum RSV-neutralizing antibody titer <1:40 
5.1.4. In good health based on review of the medical record, history, and physical examination at 
the time of inoculation 
5.1.5. Received routine immunizations appropriate for age based on the ACIP Recommended 
Immunization Schedule for Children and Adolescents Aged 18 Years or Younger 
5.1.6. Growing normally for age as demonstrated on a WHO growth chart, AND 
5.1.6.1. If < 1 year of age: has a current height and weight above the 5th percentile for age 
5.1.6.2. If ≥ 1 year of age: has a current height and weight above the 3rd percentile for age 
5.1.7. Expected to be available for the duration of the study 
5.1.8. Parent/guardian is willing and able to provide written informed consent 
 
5.2 Exclusion Criteria 
Potential RSV-seronegative participants who meet any of the following criteria will be excluded 
from this study: 
5.2.1. ≤ 6 months of age and > 25 months of age at the time of inoculation 
5.2.2. Born at less than 34 weeks gestation 
5.2.3. Born at less than 37 weeks gestation, and at the date of inoculation less than 1 year of age 
5.2.4. Maternal history of a positive HIV test before or during pregnancy  

 
33 
5.2.5. Evidence of chronic disease 
5.2.6. Known or suspected infection or impairment of immunological functions 
5.2.7. Bone marrow/solid organ transplant recipient 
5.2.8. Major congenital malformations, including congenital cleft palate or cytogenetic 
abnormalities 
5.2.9. Suspected or documented developmental disorder, delay, or other developmental problem 
5.2.10. Cardiac abnormality requiring treatment 
5.2.11. Lung disease or reactive airway disease 
5.2.12. More than one episode of medically diagnosed wheezing in the first year of life 
5.2.13. Wheezing episode or received bronchodilator therapy within the past 12 months 
5.2.14. Wheezing episode or received bronchodilator therapy after the age of 12 months 
5.2.15. Previous receipt of supplemental oxygen therapy in a home setting 
5.2.16. Previous receipt of an investigational RSV vaccine 
5.2.17. Previous receipt or planned administration of anti-RSV antibody product including 
ribavirin, RSV Ig, or RSV mAb 
5.2.18. Previous receipt of immunoglobulin or any antibody products within the past 6 months 
5.2.19. Previous receipt of any blood products within the past 6 months 
5.2.20. Previous anaphylactic reaction 
5.2.21. Previous vaccine-associated adverse reaction that was Grade 3 or above 
5.2.22. Known hypersensitivity to any study product component 
5.2.23. Member of a household that contains an infant who is less than 6 months of age at the date 
of inoculation through the 28th day after inoculation 
5.2.24. Member of a household that, at the date of inoculation through the 28th day after 
inoculation, contains an immunocompromised individual including but not limited to: 
• 
a person who is HIV-infected 
• 
a person who has cancer and has received chemotherapy within the 12 months prior 
to enrollment 
• 
a person living with a solid organ or bone marrow transplant 
5.2.25. Attends a daycare facility that does not separate children by age and contains an infant <6 
months of age at the date of inoculation through the 28th day after inoculation 
5.2.26. Receipt of any of the following prior to enrollment: 
• 
inactivated influenza vaccine within 3 days prior, or  
• 
any other inactivated vaccine or live-attenuated rotavirus vaccine within the 14 days 
prior, or 
• 
any live vaccine, other than rotavirus vaccine, within the 28 days prior, or 
• 
another investigational vaccine or investigational drug within 28 days prior, or 
• 
salicylate (aspirin) or salicylate-containing products within the past 28 days 
5.2.27. Scheduled administration of any of the following after planned inoculation 
• 
inactivated vaccine or live-attenuated rotavirus vaccine within the 14 days after, or 

 
34 
• 
any live vaccine other than rotavirus in the 28 days after, or 
• 
another investigational vaccine or investigational drug in the 56 days after 
5.2.28. Receipt of any of the following medications within 3 days of study enrollment: 
• 
systemic antibacterial, antiviral, antifungal, anti-parasitic, or antituberculous agents, 
whether for treatment or prophylaxis, or 
• 
intranasal medications, or 
• 
other prescription medications except the permitted concomitant medications listed 
below 
5.2.29. Permitted concomitant medications (prescription or non-prescription) include nutritional 
supplements, medications for gastroesophageal reflux, eye drops, and topical medications, 
including (but not limited to) cutaneous (topical) steroids, topical antibiotics, and topical 
antifungal agents. 
5.2.30. Any of the following events at the time of enrollment: 
• 
fever (temporal or rectal temperature of ≥100.4°F), or 
• 
upper respiratory signs or symptoms (rhinorrhea, cough, or pharyngitis) or 
• 
nasal congestion significant enough to interfere with successful inoculation, or 
• 
otitis media 
• 
contact with a person diagnosed with  COVID-19 disease or active SARS-CoV-2 
infection within the preceding 10 days 
Eligible siblings may be enrolled in this study provided that they are enrolled simultaneously. In 
this event, they will be co-randomized to receive the same study product (vaccine or placebo), and 
randomization will be expanded to groups of 6 or 9 as needed. 
  
5.3 
Co-Enrollment Considerations 
Co-enrollment in an investigational vaccine or investigational drug study is not allowed during the 
Acute Phase or Post-Acute Phase of this study. After the Post-Acute Phase, co-enrollment may be 
considered at the discretion of the principal investigator (PI). 
5.4 
Re-Enrollment Considerations 
Participants who receive placebo may re-enroll in the initial study following completion of the RSV 
surveillance period if the study is ongoing at that time and they continue to meet all eligibility 
requirements 
6 
STUDY PRODUCT 
 
The unblinded dispenser should consult the study MOP. Refer to the IB for further information 
about the study product. 
 
• 
Groups 1 and 2: Live Recombinant Respiratory Syncytial Virus RSV LID/ΔM2-2/1030s, 
approximately 105.3 PFU per 1.0 mL vaccine 
• 
Groups 1 and 2: Placebo for the RSV vaccine will be Lactated Ringer’s Solution for Injection, 
USP 1.0 mL 
 
6.1 Study Product Regimens 
 

 
35 
Enrolled study participants will receive a single dose of RSV LID/ΔM2-2/1030s vaccine or 
placebo, administered as nose drops.  
 
6.2 
Study Product Formulation  
 
6.2.1 RSV LID/ΔM2-2/1030s 
 
The LID/ΔM2-2/1030s vaccine is provided in a sterile 2.0-mL cryovial, each containing 0.6 mL of 
vaccine (Lot RSV#010A) with a titer of approximately 105.7 PFU/mL. The vaccine virus 
concentrate is diluted by trained pharmacy personnel to a dose of approximately 105.0 PFU in a 0.5-
mL volume. The vaccine vial is labeled as shown in Figure 1.  
 
Live Recombinant Respiratory Syncytial Virus 
LID DM2-2 1030s 
VERO GROWN VIRUS VACCINE 
Date: 09JUN2015 
Vial#:XXXX 
Lot: RSV #010A  
 
CAUTION:NEW DRUG LIMITED 
 BY FEDERAL (USA) LAW 
TO INVESTIGATIONAL USE 
Store at –80°C ± 15°C 
Charles River Laboratories, Malvern, PA 
 
Figure 1: Investigational Product Label Sample 
 
 
6.2.2 Diluent for RSV LID/ΔM2-2/1030s 
 
The diluent for RSV LID/ΔM2-2/1030s is Lactated Ringer’s Solution for Injection, USP.  
 
6.2.3 Placebo for RSV LID/ΔM2-2/1030s 
 
The placebo for RSV LID/ΔM2-2/1030s is Lactated Ringer’s Solution for Injection, USP. 
 
6.3 
Study Product Storage 
 
Vaccine will be stored in a secure freezer at -80°C ± 15°C. It must remain frozen until the time of 
use. Once the vaccine is thawed, it should never be refrozen for reuse. Vaccine will be prepared 
from new, unopened containers for each use.  
 
Lactated Ringer’s Solution for Injection, USP should be stored at room temperature as 
recommended by the supplier until the day before study product preparation. Vaccine 
diluent/placebo must be transferred to a secure 2°C to 8°C refrigerator at least 24 hours before use.  
 
Procedures for managing the vaccine and diluent/placebo shipment are in the MOP. 
 
6.4 
Study Product Preparation 
 
The diluent for the vaccine, the placebo for the vaccine, and the RSV vaccine must be prepared by 
following the detailed instruction in the MOP. 

 
36 
The unblinded dispenser will prepare the correct dose of study product for each participant in a 
biological safety cabinet (BSC) or compounding aseptic containment isolator (CACI) using aseptic 
technique. If necessary to preserve blinding, all prepared syringes will be as described in the MOP. 
6.4.1 Diluent  
The diluent is Lactated Ringer’s Solution for Injection, USP. 
6.4.2 Placebo 
Placebo is Lactated Ringer’s Solution for Injection, USP.  
Placebo will be drawn up in a sterile syringe to a volume of 0.5 mL and labeled per instructions in 
the MOP. If necessary to preserve blinding, all prepared syringes will be as described in the MOP. 
 
6.4.3 Live RSV LID/ΔM2-2/1030s 
Diluent will be prepared prior to removal of vaccine from the freezer. The MOP will be followed 
for proper handling of the study product.  
Approximately 3 vials per dose of undiluted vaccine will be used to prepare the administration 
dose. When manipulating the undiluted study product, the smallest gauge needle possible will be 
used to avoid loss of study product in the needle and syringe hub. Concentration of the undiluted 
study product is approximately 105.7 PFU per mL. The frozen study product will be thawed and 
diluted with Lactated Ringer’s Solution for Injection, USP to a dose of approximately 105.0 PFU in 
0.5mL prior to administration.  
 
The diluted study product will be drawn up to a volume of 0.5 mL in a sterile syringe and labeled 
per instructions in the MOP. The labeled filled syringes will be transported in a cooler at 2ºC to 8ºC 
with ice or cold packs to the clinical site for administration. Vaccine must be administered within 4 
hours of being removed from the freezer. Placebo must be administered within 4 hours of being 
removed from the refrigerator. 
 
Samples of undiluted (if available) and diluted study product will be aliquoted from the remaining 
vaccine that has been prepared. The samples will be snap-frozen as per the MOP and stored at  
-80°C ± 15°C separate from the concentrated study product. Titration of vaccine will be completed 
to confirm the titer of the vaccine administered to the participants.  
 
The MOP provides detailed instructions on vaccine storage, handling, preparation, labeling and 
transport to the clinic. 
6.5 
Study Product Inoculation Procedure 
All study participants will receive a single dose of study product, administered as nose drops. There 
is no nasal preparation prior to administration. While the participant is supine, a volume of 0.5 mL 
of study product will be delivered as nose drops (approximately 0.25 mL per nostril) using a sterile, 
needle-less, syringe. Participant will remain supine for approximately 60 seconds following 
inoculation. 
6.6 
Study Product Acquisition 
The clinical lot of RSV LID/ΔM2-2/1030s was generated by CRL using the seed virus provided by 
the NIH.  
 
Lactated Ringer’s Solution for Injection, USP will be used as diluent and placebo. 
 

 
37 
Vaccine virus will be stored at a NIAID-designated commercial repository until formally requested 
by the PI/designee. Following institutional biosafety committee (IBC) approval, and prior to IRB 
approval, the PI/designee may request that vials of vaccine be transferred from the Sponsor to the 
research pharmacy at the clinical site for confirmation of the vaccine titer. However, only after 
receipt of IRB approval will vials of vaccine be used for administration to study subjects. Such an 
initial shipment may contain the full number of vials needed for implementation of the protocol, but 
no vaccine will be administered to participants until all necessary approvals have been received. 
Procedures for ordering and shipping of the study product are in the MOP.  
 
6.7 
Study Product Accountability 
 
The unblinded dispenser is responsible for maintaining an accurate inventory and accountability 
record of study-product and Lactated Ringer’s Solution for Injection, USP for this study. A copy of 
the randomization code will be retained by the unblinded dispenser as outlined in the MOP. 
Without written request to unblind, the randomization code may not be released. The unblinded 
dispenser will be responsible for maintaining the blind.  
  
6.8 
Disposition of Used/Unused Study Product 
 
After the unblinded dispenser dilutes the vaccine and draws up the vaccine into a syringe for 
administration, the label will be removed from the vaccine vials used for preparation and placed in 
the accountability log. In this manner, monitoring personnel will be able to verify the accountability 
of all vaccine vials used for the study. If there is any vaccine left after the syringes have been drawn 
up and aliquots have been removed for titering, it will be destroyed by research personnel as per the 
MOP.  
 
6.9 
Final Disposition of Study Products 
After study completion or termination, all unused study product will be disposed of per the 
sponsor’s instructions.  
 
6.10 Concomitant Medications 
Permitted concomitant medications at enrollment (prescription or non-prescription) include 
nutritional supplements, medications for gastroesophageal reflux, gas, eye drops, and topical 
medications, including (but not limited to) cutaneous (topical) steroids, topical antibiotics, and 
topical antifungal agents. 
The use of prophylactic antipyretics, decongestants, or antihistamines is discouraged during the 
Acute Phase: day of inoculation through the 28th day following inoculation. However, use of these 
medications for treatment of symptoms is allowed. 
Due to the potentially confounding effect on study immunogenicity results, the following 
concomitant medications should be avoided after inoculation unless deemed clinically necessary. 
• 
Licensed inactivated vaccine or live-attenuated rotavirus vaccine within 14 days of 
inoculation, with the exception of inactivated influenza vaccine 
• 
Licensed live virus vaccine, other than rotavirus vaccine, within 28 days of inoculation 
• 
Systemic corticosteroids for more than 14 days at a dosage equivalent to prednisone at ≥ 2 
mg/kg or 20 mg daily, or other immune-modifying drugs within 28 days of inoculation 
• 
Immunoglobulins and/or any blood products within 28 days of inoculation 
• 
Investigational drug or investigational vaccine within 56 days of inoculation  

 
38 
7 
SAFETY ASSESSMENT, MONITORING, AND REPORTING 
Participant safety will be carefully assessed, monitored, and reported at multiple levels throughout 
this study. Sections 7.1-7.4 describe safety-related roles, responsibilities, and procedures. The 
safety monitoring roles of the NIAID Intramural DSMB are briefly referenced in Section 7.1.4 and 
described in detail in Section 9.4.2. 
7.1 Safety-Related Roles and Responsibilities 
 
7.1.1 Principal Investigator 
 
Each site PI is responsible for continuous monitoring of  study participants and for alerting the 
protocol team if unexpected concerns arise. Trained study staff will record safety-related data on 
CRFs as indicated in Section 7.2. The PI is also responsible for prompt reporting to the IRBs and 
other applicable review bodies of any unanticipated problems (UPs) involving risks to participants 
or others. 
 
7.1.2 Safety Review and Communications Plan (SRCP) 
 
A Safety Review and Communication Plan (SRCP) was developed for the protocol. The SRCP is 
an internal communications document between the PI and the IND sponsor (OCRPRO) Clinical 
Safety Office, which delineates the safety oversight responsibilities of the PI, the CSO, and other 
stakeholders. The SRCP also includes the overall plan for conducting periodic safety surveillance 
assessments. 
 
7.1.3 Sponsor Medical Monitor 
 
A medical monitor representing the IND sponsor (OCRPRO) has been appointed for oversight of 
safety in this clinical study. The sponsor medical monitor will be responsible for performing safety 
assessments as outlined in a Safety Review and Communications Plan (SRCP). 
 
7.1.4 Data and Safety Monitoring Board 
 
An independent DSMB will monitor participant safety through routine and as-needed reviews of 
study data. Refer to Section 9.4.2 for more information on the composition and role of the DSMB 
in the monitoring of this study. 
 
7.1.5 Sponsor Reporting 
 
A SUSAR is a suspected adverse reaction that is both serious and unexpected, as defined in 21 CFR 
312.32. SUSARs will be reported to the FDA and all participating investigators as IND Safety 
Reports. The Regulatory Sponsor will also submit a brief report of the progress of the investigation 
to the FDA on an annual basis as defined in 21 CFR 312.33. 
 
Following notification from the PI, OCRPRO, as the IND Sponsor, will report all SAEs to the FDA 
within the required timelines. Fatal and life-threatening events will be reported within 7 calendar 
days of the sponsor’s awareness and all other SAEs will be reported within 15 calendar days of the 
sponsor’s awareness. 
 

 
39 
7.2 
Safety-Related Recording on CRFs 
 
AEs that occur during protocol-specified AE reporting periods following inoculation of study 
product should be considered AEs. The current section outlines which events should be collected on 
source documents and which should be recorded on CRFs for inclusion in the database. 
 
AEs may be observed by the study investigator or designee, elicited or volunteered from the 
parent/guardian or participant, or captured on participant’s temperature cards. Assessment of safety 
will include clinical observation and monitoring of laboratory parameters as necessary. Follow-up 
measures such as history, physical examination, and laboratory testing and/or treatment may be 
necessary if a participant experiences an AE. Details of AEs will be properly documented on the 
source documents, recorded on CRFs, and reported to LID investigators and the DSMB in separate 
semi-annual and annual reports. AEs will be provided to the IRB as defined by the IRB policy. 
 
This study has several periods of AE observation that have different AE CRF recording 
requirements. In addition, there may be a period when no AEs are recorded on CRFs if the Day 56 
Visit occurs in advance of the start of the RSV Season Surveillance Period (date of seasonal 
enrollment pause). The AEs (solicited and unsolicited; and SAEs) to be recorded on CRFs and the 
study phase and the calendar dates during which they are to be reported are defined in Table 19. 
 
Concomitant medications and AEs identified in this study will be recorded on CRFs. AEs will be 
recorded as signs, symptoms, laboratory test results, and diagnoses, as shown in Table 15.

 
40 
Table 15: AE CRF Recording Requirements  
Study Phase at the Time 
of Event Onset 
Calendar Date 
AEs to Record on CRFs 
Concomitant Medications to Record on 
CRFs 
 
 
• All SAEs 
• All solicited AEs that meet 
Appendix IV. criteria 
• All unsolicited AEs (Grades 
1 to 4), with the exception 
of the following conditions 
if not treated with 
prescription medication or 
non-prescription 
medications with 
antipyretic properties: 
diaper rashes, teething pain, 
and spitting up 
Record these medications on the CRFs 
regardless of whether the related event 
is recorded on the CRFs: 
 
 
Day 0 through 
midnight of 28th day 
following inoculation 
(Acute Phase) 
 
 
 
ANY 
• All cough and cold remedies 
including decongestants, cough 
suppressants, expectorants 
• All nasal sprays (except saline spray) 
• All antihistamines 
• All antipyretics 
• All prescription medications 
 
 
For SAEs and LRIs: 
• All medications related to the 
recorded event 
From the 29th day after 
inoculation to the 56th 
day after inoculation 
(Post-Acute Phase) 
 
ANY 
• All SAEs 
• All medications related to the 
recorded event 
From Day 56 Visit 
through start of RSV 
Season Surveillance 
Period 
Up to date of 
seasonal pause 
in enrollment in 
year of 
inoculation 
• Grade ≥ 3 AEs or SAEs that 
is deemed related to Pre-
RSV Season Study Visit 
procedures 
• All medications related to the 
recorded event 
 
 
 
RSV Season 
Surveillance Periods 
 
 
Date of seasonal 
pause in 
enrollment to 
March 
31 
• Fevers, LRIs, URIs, and/or 
otitis media that are 
medically attended 
• All SAEs 
Note: These events do not 
need to meet the Appendix 
III criteria 
For SAEs and LRIs (all grades): 
• All medications related to the 
recorded event 
 
Medications related to recorded 
medically attended illness should be 
documented in source notes 
 
 
Post-RSV Season 
April 1 to 
April 30 in the 
year after the 
inoculation 
• Grade ≥ 3 AEs or SAEs that 
are deemed related to Post-
RSV Season Study Visit 
procedures 
• All medications related to the 
recorded event 
 
 
 
 
Throughout study 
 
 
 
 
ANY 
• Unresolved AEs or SAEs 
with onset from Day 0 to 
midnight on the 28th day 
after inoculation 
• Unresolved SAEs with onset 
prior to the 56th day 
following inoculation 
• Unresolved SAEs with onset 
during RSV Surveillance 
Period or related to the Pre- 
or Post-RSV 
Season Study Visit 
• All medications related to the 
recorded event 

 
41 
7.3 
Serious Adverse Event Reporting 
 
SAEs are described in Section 8.1.2. All SAEs will be reviewed by a study physician, recorded as 
specified by the CSO, through REDCap or on the Safety Expedited Report Form (SERF) and 
followed through to resolution. SAEs that have not resolved by the end of the follow-up period are 
followed until final outcome is known. If it is not possible to obtain a final outcome for an SAE 
(e.g., the subject is lost to follow-up), the reason a final outcome could not be obtained will be 
recorded by the investigator on the AE CRF and the SERF. In addition to the SAE Reporting 
Category identified below, other AEs that must be reported in an expedited manner are LRIs as 
defined in Appendix III if they occur during study days 0 to 28. 
 
Deaths and immediately life-threatening SAEs will be reported within 1 business day after the site 
becomes aware of the event. All other SAEs will be reported within 3 business days of site 
awareness. SAEs will be reported either by fax or e-mail to all of the following: 
 
• 
Sponsor: Office of Clinical Research Policy and Regulatory Operations, NIAID, NIH: 
Clinical Safety Office (CSO): Phone: 301-846-5301, Fax: 301-846-6224, 
rchspsafety@mail.nih.gov 
• 
DSMB Executive Secretary: Phone 301-846-5360, Fax: 301-846-6224, 
niaiddsmbia@niaid.nih.gov 
• 
LID, NIAID: Ursula Buchholz, PhD, NIAID/NIH, 301-594-1533, Fax: 301-480-1268, 
Email: ubuchholz@niaid.nih.gov 
 
SAEs will also be reported to WIRB-Copernicus Group (WCG IRB) (contact information below) 
based on its reporting requirements: 
 
• 
WIRB-Copernicus Group, 1019 39th Ave SE, Puyallup, WA 98374, Phone: 1-800-562-
4789 
7.4 
Reporting of Unanticipated Problems to OCRPRO 
An UP is defined as any event, incident, experience, or outcome that is: 
1. Unexpected in terms of nature, severity, or frequency in relation to 
a. The research procedures that are described in the IRB-approved research protocol 
and informed consent or other study documents; and 
b. The characteristics of the participant population being studied; and 
2. Possibly, probably, or definitely related to participation in the research; and 
3. Places participants or others at a greater risk of harm (including physical, 
psychological, economic, or social harm) than was previously known or recognized. 
Per the IND sponsor, an AE with a serious outcome will be considered increased risk. 
 
UPs must be reported to the local IRB per their requirements. Non-Serious AEs that are UPs must 
also be reported to the sponsor CSO. Submit the local IRB UP report form to the CSO at the 
following address no later than 7 calendar days of the PI awareness of the event. 
SPONSOR CLINICAL SAFETY OFFICE CONTACT INFORMATION: 
 
Clinical Safety Office 5705 Industry Lane 
Frederick, MD 21704 
Phone 301-846-5301 
Fax 301-846-6224 
E-mail: rchspsafety@mail.nih.gov 

 
42 
UPs that are not AEs (UPnonAE) are not routinely reported to the CSO. However, an UP nonAE 
that may, in the opinion of the investigator, involve risk to the participant, affect others in the 
research study, or significantly impact the integrity of research data would be considered a non- 
serious UP and would be reported to the CSO. For example, we will report occurrences of breaches 
of confidentiality, accidental destruction of study records, or unaccounted-for study drug. 
 
 
8 
PARTICIPANT MANAGEMENT  
 
8.1 
Management of Adverse Events 
 
An AE is any untoward medical occurrence in a participant administered a pharmaceutical product 
that does not necessarily have a causal relationship with this treatment. An AE can therefore be any 
unfavorable and unintended sign (including an abnormal laboratory finding), symptom, or disease 
temporally associated with the subject’s participation in the research, whether or not related to the 
subject’s participation in the research. This includes exacerbation of pre-existing conditions and 
intercurrent illnesses. 
 
Causality assessment is based on available information at the time of the assessment of the AE. The 
investigator may revise the causality assessment as additional information becomes available. 
 
All AEs identified in this study will be source documented, consistent with the policies and 
procedures referenced in Section 10. Among other details, source documentation will include the 
severity of each event (graded as described in Sections 8.2.1 and 8.2.2 and its relationship to study 
product, assessed by the study clinician according to the following categories and definitions: 
 
Related 
There is a reasonable possibility that the adverse event may be 
related to the study drug. 
 
Not related 
There is not a reasonable possibility that the adverse event 
may be related to the study drug. 
 
There are 2 categories of AEs specific to CIR 335: solicited and unsolicited. Solicited AEs are 
described in Section 8.1.1. Unsolicited AEs are all other AEs. However, for infants and children, 
the following common events will not be recorded as AEs unless a prescribed concomitant 
medication is used to treat them: non-infectious rashes, teething pain, and spitting up. The use of 
medications will only be captured in the event of an AE or pre-existing condition. 
 
Serious Adverse Events (SAEs) are described in Section 8.1.2. 

 
43 
8.1.1 Solicited Adverse Events 
 
Solicited AEs are predefined AEs that can occur after study product administration, may be 
expected to occur if the study product is insufficiently attenuated, and have protocol-specific 
criteria for reporting. 
 
Solicited AEs, whether identified by a parent/guardian or clinician, are only recorded on CRFs if 
they meet the definitions per Appendix III Individual symptoms listed in the “events” column that 
fail to meet the criteria in the “definition” column in Appendix III are recorded in source documents 
but are not recorded on the CRFs. During the Acute Phase of this study, days 0 through 28, solicited 
AEs meeting the criteria for reporting will be recorded on CRFs, assigned a severity grade (Section 
8.2), and assessed for relationship to study product (see Section 8.1). Solicited AEs are defined in 
Appendix III and include the following: 
 
1. Fever 
2. URI 
a. Rhinorrhea, 
b. Pharyngitis, 
c. Cough without LRI, or 
d. Hoarseness 
3. Otitis Media 
4. LRI 
a. Wheezing, 
b. Pneumonia, 
c. Laryngotracheobronchitis (croup), 
d. Rhonchi, or 
e. Rales 
 
Solicited AEs Elicited by History Unconfirmed by Clinical Assessment 
 
With the exception of fever, solicited AEs occurring on the day of the study visit and reported by 
parents/guardians are NOT recorded on CRFs if a clinical assessment done on the day of the 
event(s) does/did not confirm their presence. For example, if a parent/guardian reports rhinorrhea 
on the day of visit, and there is/was no rhinorrhea upon exam, then the participant is considered to 
not have rhinorrhea that day. 
 
If the parent/guardian report of a fever meets the “definition” column criteria in Appendix III on a 
day on which there was a clinical assessment, the fever will be recorded on CRFs regardless of 
whether the clinical assessment confirmed its presence. 
 
Events elicited by parent/guardian history for days on which there was no clinical exam will be: 
 
1) Recorded on the CRFs as AEs if the parent/guardian description meets the “definition” 
column criteria in Appendix III. 
2) Recorded only on the source document, and NOT on the CRF, if the parent/guardian 
description fails to meet the “definition” column criteria in Appendix IV. For example, both 
rhinorrhea and cough must each occur on 2 consecutive days to meet the definition required 
for reporting per Appendix III. 

 
44 
8.1.2 Serious Adverse Events 
 
A SAE is an AE, whether considered related to the study product or not, that meets one or more of 
the following criteria: 
1. Results in death during the period of protocol-defined surveillance. 
2. Is life threatening: defined as an event in which the participant was at immediate risk of 
death at the time of the event; it does not refer to an event that hypothetically might have 
caused death were it more severe. 
3. Requires inpatient hospitalization (or prolongation of existing hospitalization): defined as at 
least an overnight stay in the hospital or emergency ward for treatment that would have been 
inappropriate if administered in the outpatient setting. 
4. Results in a persistent or significant disability/incapacity. 
5. Is a congenital anomaly or birth defect. 
6. Is an important medical event that may not be immediately life threatening or result in death 
or hospitalization but may jeopardize the patient or may require intervention to prevent one 
of the outcomes listed above. 
 
8.1.3 Unexpected Adverse Event 
 
An AE is unexpected if it is not listed in the IB or Package Insert (for marketed products) or is not 
listed at the specificity or severity that has been observed. It is the responsibility of the IND 
Sponsor to make this determination. 
 
8.2 
Grading the Severity of Adverse Events 
 
The Investigator will assess all AEs with respect to Seriousness (criteria listed above), Severity 
(intensity or grade), and Causality (relationship to study agent and relationship to research). All 
AEs and fever will be graded using the protocol-defined grading system outlined below. 
 
8.2.1 AE Grading 
 
Table 16: Grading for Adverse Events 
Severity 
Defined 
Grade 1 Mild 
No medical intervention required; may include over-the-counter 
medications managed by the participant or caregiver for treatment of 
symptoms.  Does not interfere with usual activities, including eating 
and/or  sleeping. 
Grade 2 Moderate Symptoms interfering to some degree with usual activities, including 
eating and/or sleeping. In most cases, symptoms severe enough to 
necessitate a medical care visit would likely meet this criterion; 
however, if medical care is sought and symptoms are assessed as only 
mild, the event may remain Grade 1. If prescription medication is 
used or recommended for symptoms, the event automatically moves 
to at least Grade 2. 
Grade 3 Severe 
Prolonged medical intervention and/or hospitalization required 
Grade 4 Life 
threatening 
Illness requiring hospitalization with intensive care 
Grade 5 Death 
Event resulting in fatal outcome to the participant 

 
45 
8.2.2 Fever Grading 
Table 17: Grading for Fever 
Severity 
Defined 
Grade 1 
≥100.4ºF but ≤101.4ºF 
Grade 2 
≥101.5ºF but ≤102.4ºF 
Grade 3 
≥102.5ºF but ≤104.8ºF 
Grade 4 
≥104.9ºF 
 
8.3 
Pausing and Stopping Rules 
 
If any of the following occur in a participant during the specified period after receiving the study 
product, additional enrollment/inoculations will be temporarily suspended at all sites (Table 18). 
 
Table 18: Pausing and Stopping Rules 
Specified Phase 
Event 
Reporting 
Acute and Post-Acute 
Days 0 through 56 
following inoculation  
An SAE that cannot be 
attributed to an etiology or 
cannot be attributed to a cause 
unrelated to the study product. 
A description of the vaccine-
associated AE(s) or safety 
issue must be reported by 
the PI or study staff, within 
one business day of the PI's 
awareness, to the CSO and 
the DSMB by fax or email. 
The event will be reviewed 
by the DSMB prior to 
resuming enrollment. 
 
 
 
The DSMB and regulatory sponsor will be informed and receive pertinent data of the event by the 
PI. Follow-up visits for participants already inoculated will continue as outlined in Appendix I 
(Table 21 and Table 22). 
 
The DSMB will notify the PI (via the study sponsor) of their recommendations as to whether 
enrollment can resume, or if the study needs to be stopped. The regulatory sponsor (OCRPRO) will 
be informed about this decision. In the event of an SAE, the study may be resumed if it can be 
demonstrated to the DSMB that there is no proven causal relationship with the vaccine. The 
regulatory sponsor (OCRPRO) will determine if the FDA needs to be notified. 
 
Ad hoc DSMB Expert Member review will also be requested by the PI if any of the events listed 
below occur.  The CSO and Study Medical Monitor will also be notified. 
 
• 
>1 Grade 4 fever occurs within 14 days of study product administration, or  
• 
>1 Grade ≥3 solicited AE (excluding rhinorrhea or fever) occurs within 28 days of study 
product administration.  
• 
Any LRI occurs during the acute 28 day follow up period 
In these cases, accrual and study product administration will continue while ad hoc DSMB Expert 
Member review is in progress (See Section 9.4.2, Monitoring by the NIAID Intramural DSMB, for 
details). 

 
46 
9 
STATISTICAL CONSIDERATIONS  
 
9.1 
General Design Issues 
 
9.1.1 General Design 
 
The goal of this phase I, blinded, randomized, placebo-controlled vaccine trial is to assess the 
safety, infectivity, and immunogenicity of the LID/ΔM2-2/1030s vaccine candidate in RSV-
seronegative pediatric participants.  
 
Group 1 (intensive sampling): Twenty-one RSV-seronegative participants will be randomized in a 
2:1 ratio to receive either the candidate vaccine at a dose of 105.0 PFU or placebo to evaluate safety 
and immunogenicity. 
 
Group 2 (less intensive sampling): Sixty RSV-seronegative participants will be randomized in a 2:1 
ratio to receive either the candidate vaccine at a dose of 105.0 PFU or placebo to evaluate safety and 
immunogenicity. 
 
9.1.2 Description of the Statistical Methods to be Employed 
 
This study, like other phase I studies, is exploratory, rather than confirmatory; its purpose is to 
assess frequencies of AEs and patterns of immune responses. Descriptive approaches will be used 
to meet the protocol objectives as stated in Section 2 of this protocol, as well as formal statistical 
tests as outlined in Section 9.5.  
 
9.2 
Outcome Measures 
 
9.2.1 Primary Outcome Measures 
 
Primary Objective: Safety: Groups 1 and 2 (combined):  
1. To assess the frequency and severity of study product–related solicited and unsolicited AEs 
from day 0 through the 28th day following inoculation 
 
Outcome measures: 
Grade 1 or higher solicited AEs as defined in Appendix III from Day 0 through Day 28 
Grade 2 or higher LRIs as defined in Appendix III from Day 0 through Day 28 
 
2. To assess the frequency and severity of study product–related SAEs from day 0 through the 
56th day following inoculation  
 
Outcome measure: 
Serious AEs from Day 0 through Day 56 
 
 

 
47 
Primary Objective: Immunogenicity: Groups 1 and 2 (combined):  
1. To evaluate the percentage of vaccinees with a ≥4-fold rise in RSV-neutralizing serum 
antibodies at day 56 after inoculation  
 
Outcome measure: 
≥4-fold rise in serum RSV-neutralizing antibody titer from pre-study product 
administration (screening) to the Day 56 Visit 
 
Titer is quantified even if <1:40; therefore, a ≥4-fold rise can be determined even for 
lower titers. 
 
Primary Objective: Infectivity: Group 1  
1. To determine the peak titer of vaccine virus shed by each participant in Group 1 
 
Outcome measure: 
Peak titer of vaccine virus shed from Study Day 0-28 
 
2. To determine the proportion of vaccinees infected with vaccine virus in Group 1 [defined as 
shedding vaccine virus, detected by  RT-qPCR, and/or ≥4-fold rise in RSV-specific serum 
antibodies, detected by ELISA against the RSV F protein and/or an RSV-PRNT] 
 
Outcome measure: 
Shedding vaccine virus, detected by RT-qPCR, and/or ≥4-fold rise in RSV-specific 
serum antibodies, detected by ELISA against the RSV F protein and/or an RSV-PRNT] 
 
9.2.2 Secondary Outcome measures 
 
Secondary Objective: Safety: Groups 1 and 2 (combined): - To characterize the frequency and 
severity of symptomatic medically attended respiratory and febrile illness in vaccine and placebo 
recipients who experience natural infection with wt RSV during the subsequent RSV season(s) in 
groups 1 and 2. 
 
Outcome measures: 
 
1. RSV-medically attended acute respiratory illness (MAARI) and maximum grade (if more 
than one illness within a participant) 
2. RSV-medically attended acute lower respiratory illness (MAALRI) and maximum grade 
(if more than one illness within a participant) 
 
Groups 1 and 2 (combined): Immunogenicity - To evaluate the percentage of vaccines with a ≥4-
fold rise in serum RSV F IgG antibodies at day 56 after inoculation  
 
Outcome measures: 
≥4-fold rise in serum RSV F IgG from pre-study product administration (screening) to 
the Day 56 Visit 
 
 

 
48 
9.2.3 Exploratory Outcome Measures 
 
Groups 1 and 2 (combined): Safety - To evaluate the association of vaccine virus shedding with 
adverse events: To assess the incidence and magnitude of vaccine virus shedding in samples 
collected at Illness Visits associated with solicited AEs on Study Days 0 through 28 and with 
serious AEs from Study Day 0 through Day 56  
 
Outcome measures: 
For solicited AEs between Days 0 and 28 (more than one per participant possible). 
Detection and magnitude of vaccine virus shedding detected in Illness Visit specimens as 
determined by:  
1. RT-PCR 
 
Groups 1 and 2 (combined): Immunogenicity – timing of maximum response: To estimate and 
compare serum RSV F IgG and serum RSV-neutralizing antibody responses at the Day 28 and 56 
Visits in vaccine recipients 
 
Outcome measures: 
Titer of serum RSV F IgG at the Day 28 and 56 Visits 
Titer of serum RSV-neutralizing antibodies at the Day 28 and 56 Visits 
 
Groups 1 and 2 (combined): Immunogenicity - magnitude of anamnestic response: To estimate and 
compare in vaccine recipients to placebo recipients the titers of serum RSV F IgG and serum RSV-
neutralizing antibodies in participants infected with wt RSV during the RSV season  
 
Outcome measures: 
In subset of children who had RSV infection documented during the RSV season (via 
viral testing confirming presence of RSV or a further ≥2.5-fold rise in serum RSV-
neutralizing antibody titers from the Day 56 Visit to the Post-RSV Season Visit): 
 
Titer of serum RSV F IgG at the Day 56 and Post-RSV Season Visits  
Titer of serum RSV-neutralizing antibodies at the Day 56 and Post-RSV Season Visits 
 
Groups 1 and 2 (combined): Immunogenicity – durability of vaccine-induced RSV antibodies: to 
estimate and compare the magnitude of RSV serum antibody titers in samples collected at the Day 
56 and Post-RSV Season Visits among vaccine recipients who do not have evidence of RSV 
infection during RSV season 
Outcome measures: 
In subset of children who achieve ≥4-fold rises in serum RSV-neutralizing antibody titers 
between pre-study product administration and the Day 56 Visit and with no evidence of 
RSV infection after Day 56 (no RSV infection identified by viral testing done at the site 
or centrally and <2.5-fold rise in serum RSV-neutralizing antibody titers from the Day 56 
Visit to the Post-RSV Season Visit): 
 
Titer of serum RSV F IgG at Day 56 and Post-RSV Season Visits  
Titer of serum RSV-neutralizing antibodies at Day 56 and Post-RSV Season Visits 
 
Group 1: The genetic stability of vaccine isolates will be evaluated by sequence analysis.  
Study samples may be used in comparative assays with samples from other RSV vaccine studies 
initiated by the LID, NIAID, NIH. 

 
49 
9.3 
Sample Size and Accrual 
 
 
 
9.3.1 Sample Size and Randomization 
 
In Group 1, 21 RSV-seronegative infants and children will be accrued and will be randomized to 
receive either 105.0 PFU of vaccine or placebo at a ratio of 2:1. In Group 2, 60 RSV-seronegative 
infants and children will be accrued and will receive either 105.0 PFU of vaccine or placebo at a ratio 
of 2:1. The results from groups 1 and 2 will be combined for evaluation of safety and 
immunogenicity. The 2:1 randomization ratio will be used to maximize the information obtained 
regarding the response of children to the LID/∆M2-2/1030s vaccine. 
 
 
The following calculations focus on the assessment of the safety of the vaccine and, in particular, 
occurrence of LRI due to vaccine virus from vaccine inoculation through day 56, which occurs very 
infrequently in children who participate in these types of studies but would be considered a sentinel 
safety event if observed in children infected with vaccine virus.   
 
The probability of observing 3 or more LRI events with a sample of 54 (14 vaccinees from Group 1 
and 40 from Group 2) seronegative vaccine recipients is 0.02 if the true LRI rate is 1% and the 
probability is 0.82 if the true rate is 8%. Therefore, if we observe 3 or more LRI events we will 
consider the vaccine safety to be concerning, since there is high probability of having increased the 
rate of LRI over the low background rate. If after 1 season we are only able to accrue 44 vaccine 
recipients (14 in Group 1 and 30 from Group 2), we would still consider 3 more LRI events to be 
troubling: With the smaller sample size, the probability of observing 3 or more events out of 44 is 
0.01 for a true LRI rate of 1% and 0.83 for a true LRI rate of 10%. This means that the true increase 
in LRI rate would need to be slightly higher to have good power to detect an increase if only 44 
vaccine recipients have been accrued. For all sample sizes between 44 and 54, we would also 
consider 3 or more LRIs to be concerning. 
 
We are also interested in estimating AE rates and will calculate 90% confidence intervals (CIs) for 
AEs. Table 19 gives the probability of 90% CI half widths less than a specified amount for sample 
sizes of 54 and 44 vaccines. 
 
Table 19: Probability of Observing a 90% Confidence Interval Half Width Less than a 
Specified Amount with Various True AE Rates 
 
True AE rate 
N=54 
N=44 
Specified half 
width, h 
Probability half 
width will be 
less than h 
Specified half 
width, h 
Probability half 
width will be 
less than h 
0.01 
0.04 
0.92 
0.04 
0.90 
0.05 
0.07 
0.82 
0.06 
0.87 
0.10 
0.08 
0.91 
0.09 
0.85 
 
There will be very little power for between-group (placebo and vaccine) comparisons of AEs. Table 
20 gives the detectable differences with 80% power for both samples sizes of 27 vs 54 and 22 vs 44 
for various true differences. The one-sided Fishers exact test is used. The alpha level of the test that 
was targeted is one sided 0.05 to see if the AE rate has been increased in the vaccine group.  
 

 
50 
Table 20: Detectable Differences with 80% Power for Various True Differences 
 
True Response 
Proportion in the Placebo 
Group 
True Response proportion in 
vaccine group (difference) 
N= 54 vs 27  
N= 44 vs 22 
0.01 
0.20 (0.19) 
0.23(0.22) 
0.05 
0.29 (0.24) 
0.33 (0.27) 
0.1 
0.37 (0.27) 
0.40 (0.30) 
0.15 
0.44 (0.29) 
0.48 (0.33) 
0.20 
0.50 (0.30) 
0.53 (0.33) 
0.30 
0.61 (0.31) 
0.64 (0.34) 
 
 
Table 20 also gives the detectable differences in the proportion of infants with ≥4-fold rise in serum 
RSV-neutralizing antibody titer between the groups with 80% power. We will also use a one sided 
Fishers exact test at the 0.05 level for this comparison. This is done because this is an early study 
and we are willing to increase the probability of considering an inactive vaccine interesting in order 
to increase the probability of finding an active vaccine while maintaining small sample size. Any 
positive findings in this study will need to be explored further.  
 
With a sample size of 14 seronegative vaccine recipients, the 90% CI around a sample mean peak 
titer of 2.5 log10, with a standard deviation (SD) of 1.5 is (1.79, 3.21). This calculation uses a t-test. 
This ensures with 90% confidence that the true population mean peak titer is between 1.79 and 3.21 
log10, and with 95% confidence that the true population mean is not lower than 1.79 log10. 
 
With the same sample size of 14, if the true proportion of vaccine recipients who shed vaccine virus 
is 80% than there is probability 0.87 that the half width of the 90% CI will be less than 20%. If the 
true proportion of vaccine recipients who shed vaccine virus is 90% than there is probability 0.84 
that the half width of the 90% CI will be less than 18%. 
 
9.4 
Monitoring 
 
9.4.1 Site Monitoring Plan 
 
As per International Council for Harmonisation of Technical Requirements for Pharmaceuticals for 
Human Use (ICH-GCP) 5.18 and FDA 21 CFR 312.50, clinical protocols are required to be 
adequately monitored by the study sponsor. This study monitoring will be conducted according to 
the “NIAID Intramural Clinical Monitoring Guidelines.” Monitors under contract to the 
NIAID/OCRPRO will visit the clinical research site to monitor aspects of the study in accordance 
with the appropriate regulations and the approved protocol. The objectives of a monitoring visit will 
be: 1) to verify the existence of signed informed consent documents and documentation of the 
informed consent form (ICF) process for each monitored subject; 2) to verify the prompt and 
accurate recording of all monitored data points, and prompt reporting of all SAEs; 3) to compare 
REDCap data abstracts with individual subjects’ records and source documents (subjects’ charts, 
laboratory analyses and test results, physicians’ progress notes, nurses’ notes, and any other 
relevant original subject information); and 4) to help ensure investigators are in compliance with 
the protocol. The monitors also will inspect the clinical site regulatory files to ensure that regulatory 
requirements (Office for Human Research Protections, OHRP), FDA, and applicable guidelines 
(ICH-GCP) are being followed. During the monitoring visits, the investigator (and/or designee) and 
other study personnel will be available to discuss the study progress and monitoring visit. 
 

 
51 
The investigator (and/or designee) will make study documents (e.g., consent forms, REDCap data 
abstracts) and pertinent hospital or clinical records readily available for inspection by the local IRB, 
the FDA, the site monitors, and the NIAID staff for confirmation of the study data. 
 
A specific protocol monitoring plan will be discussed with the PI and study staff prior to 
enrollment. The plan will outline the frequency of monitoring visits based on such factors as study 
enrollment, data collection status and regulatory obligations.  
 
9.4.2 Monitoring by the NIAID Intramural Data and Safety Monitoring Board 
 
The NIAID Intramural DSMB is constituted to review the safety data of Intramural NIAID clinical 
studies that require DSMB oversight. The NIAID Intramural DSMB includes independent experts 
in infectious diseases, biostatistics, and clinical research that do not have direct involvement in the 
conduct of the study and have no significant conflicts of interests as defined by NIAID policy. Two 
to three additional ad hoc DSMB Expert Members with expertise in pediatric respiratory virus 
vaccine development will be added to the DSMB for review of this protocol. These ad hoc DSMB 
Expert Members will perform real-time ad hoc reviews of individual (unblinded) cases of LRIs and 
SAEs not attributed to an etiology or cause unrelated to the study product to assess whether 
detection of vaccine virus is associated with the illness. The DSMB will review the protocol prior to 
opening the study to enrollment. The DSMB will meet at least twice a year or on a schedule 
specified by the DSMB to review the completeness of the study data, the adherence to the protocol, 
and AE data. Cumulative safety data (pooled across arms, with the vaccine and placebo arms 
presented together) will be submitted to the DSMB Executive Secretary for DSMB review. The 
DSMB Executive Secretary will provide the PI with DSMB recommendations promptly, and the 
official DSMB Report will then be provided in a timely fashion through the office of the NIAID 
Clinical Director. The PI will submit the written DSMB recommendations to the IRB upon receipt. 
All SAEs, LRIs, UPs and IND safety reports will be reported by the PI to the DSMB at the same 
time that they are submitted to the IRB and/or regulatory sponsor (OCRPRO). The PI will notify 
the DSMB of any cases of intentional or unintentional unblinding as soon as possible. The PI will 
notify the Board at the time a pausing or halting criteria are met and obtain a recommendation 
concerning continuation, modification, or termination of the study. 
Ad hoc DSMB Expert Member reviews will be requested by the PI if pausing and stopping rules are 
triggered (Section 8.3, Table 18):  
• 
An SAE that cannot be attributed to an etiology or a cause unrelated to the study product 
occurs within 56 days of study product administration. 
 
Accrual and study product administration will stop pending review. 
 
Ad hoc DSMB Expert Member reviews will also be requested if 
 
• 
More than one Grade 4 fever occurs within 14 days of study product administration or  
• 
More than one Grade 3 or higher solicited AE (excluding rhinorrhea or fever) occurs within 
28 days of study product administration. 
• 
Any LRI that occurs within 28 days of study product administration  
In these cases, accrual and study product administration will continue while ad hoc DSMB Expert 
Member review is in progress. The review will be convened per DSMB guidelines. The site will 
send respiratory viral samples to the JHU CIR laboratory to determine shedding of RSV or 
adventitious viral agents, and the lab will send their results for ad hoc review directly to the ad hoc 
DSMB Expert Members. Information on treatment assignment will be provided to the ad hoc 

 
52 
DSMB Expert Members by the unblinded dispenser. The ad hoc DSMB Expert Members will 
review the relevant safety information and available data, including presence of vaccine virus 
shedding, whether other adventitious agents are present, and whether the participant received 
placebo or one of the candidate vaccines. The ad hoc DSMB Expert Members will review whether 
the AE, serious AE, or LRI can be attributed to an etiology, a cause, or a diagnosis unrelated to the 
study vaccine, and if it is associated with shedding of vaccine virus at the time of the event (even if 
another pathogen is identified). The ad hoc DSMB Expert Members will report their assessment to 
the DSMB. Based on (1) the severity of the event, (2) whether the participant received a candidate 
vaccine and (3) whether RSV and/or other agents are present in the nasal swab, the ad hoc DSMB 
Expert Members may recommend to the DSMB that enrollment be continued or paused pending 
full DSMB review.  
 
If the DSMB decides the study can continue unchanged, they will communicate their findings to the 
Protocol Team. Alternatively, the DSMB may recommend modifications to the study design. 
 
9.5 
Analyses 
 
9.5.1 Assessment of Primary Objectives 
 
Safety and immunogenicity data from all participants in Groups 1 and 2 who have been inoculated 
will be summarized together, including data from participants who discontinue study early or have 
some missed visits. In the immunogenicity analyses, those who do not provide data for the Day 28 
Visit or for the Day 56 Visit follow-up (due to early discontinuation or missed visit) will be treated 
as “failures”.  
 
Sensitivity analyses will be performed to check if the results are consistent with those when these 
participants are excluded. Participants who receive any of the disallowed treatments listed in 
Section 6.10 within the first 56 days after inoculation may be excluded from the immunogenicity 
evaluations after the time of the treatment. These participants, however, will be included in the 
safety evaluations for the duration of the study. These participants will not be replaced. Details of 
the analyses listed below will be included in the statistical analysis plan. 
 
The frequency of solicited AEs and unsolicited AEs, along with 90% CIs, during Study Days 0 to 
28 and of vaccine-related SAE during Study Days 0 to 56 will be summarized. In addition, line 
listing of individual clinical solicited AEs and unsolicited AEs, graded by severity, will be prepared 
for events occurring during Study Days 0 to 28 and vaccine-related SAE during Study Days 0 to 56. 
 
The proportion of participants that develop 4-fold or greater rises in RSV-neutralizing antibody titer 
following vaccination will be summarized. A line listing of the individual RSV antibody titer pre- 
and post-vaccination will be prepared. In addition, the geometric mean and median antibody titers 
will be provided for each treatment group. Line listings of individual RSV-neutralizing antibody 
responses as well as of antibody responses to the RSV F glycoprotein will be prepared as well. 
 
For Group 1, the proportion of participants with infection defined as recovery of vaccine virus from 
a nasal swab as determined by RT-PCR, and/or a ≥4-fold rise in neutralizing antibody titer to RSV, 
will be summarized. A line listing of the individual peak titer of vaccine virus shed and duration of 
virus shedding in nasal swabs by each individual will be prepared. In addition, the geometric mean 
peak titer and mean duration of virus shed will be provided for Group 1. 
 
Where appropriate, a 1-tailed Wilcoxon rank sum test will be used to test the hypothesis that the 
vaccinated group will exhibit greater peak viral titers and antibody titers following vaccination 

 
53 
compared to the placebo group. A 1-tailed Fisher’s exact test will be used to test the hypothesis that 
the vaccinated group will exhibit a greater proportion of participants who develop four-fold or 
greater rises in RSV-neutralizing antibody titer following vaccination compared to the placebo 
group. 
 
These will be the only formal statistical comparisons between the vaccinated and placebo groups. 
These tests will be carried out at a 5% significance level. 
 
9.5.2 Assessment of Secondary Objectives 
 
The summary of the frequency and severity of symptomatic, medically attended respiratory and 
febrile illness in vaccine and placebo recipients who experience natural infection with wt RSV 
during the RSV season will be presented. In addition, a line listing of the individual RSV antibody 
titer pre- and post-RSV Season Surveillance Period will be prepared. In addition, the geometric 
mean and median antibody titers will be provided for each treatment group. The adaptive immune 
responses to vaccine will be summarized for each treatment group.  
 
10 DATA HANDLING AND RECORD KEEPING 
 
10.1 Data Management and Coordination 
 
The Data Coordinating Center for this study will be housed at VUMC. The clinical sites will 
maintain adequate and accurate research records containing all information pertinent to the study 
for all screened and enrolled participants, including CRFs and supporting source data per the MOP. 
 
Data from source documentation for subjects enrolled in the study will be entered into the study data 
system. The data entry is to be completed on an ongoing basis during the study. Data entry shall be 
performed by authorized individuals who have a unique log-on and password. Corrections to the data 
system shall be tracked electronically (password protected) with time, date, individual making the 
correction, and what was changed. 
 
Source documents include all recordings of observations or notations of clinical activities, and all 
reports and records necessary for the evaluation and reconstruction of the clinical trial. Source 
documents may include the subject’s medical records and laboratory reports. Data will be collected 
directly from subjects during study visits and contacts. Data will be entered into the REDCap 
database developed by the Vanderbilt Coordinating Center.  
 
10.2 Essential and Source Documents and Access to Source Data 
 
Study-related documentation will be completed as required by the IRB, the sponsor, and regulatory 
authorities. Continuing review documentation will be submitted to the IRB as specified by the IRB. 
An annual report will be submitted by the sponsor to the FDA based on the anniversary date that 
the IND for the RSV LID/ΔM2-2/1030s vaccine went into effect. These reports will provide a brief 
description of the progress of the investigation as outlined in 21 CFR 312.33 and will include any 
revisions of the protocol not previously submitted to the FDA. 
All study records must be accessible for inspection, monitoring, and/or auditing during and after the 
conduct of the study by authorized representatives of the study sponsors and their contracted 
monitors, the FDA, regulatory authorities, IRB, OHRP, and other applicable regulatory entities. 
Records must be kept on-site throughout the period of study implementation; thereafter, instructions 
for off-site storage may be provided by NIH. No study records may be removed to an off-site 
location or destroyed prior to receiving approval from NIH. 

 
54 
 
Study-related documents will be maintained for a period of at least 2 years after final marketing 
approval of the vaccine, or at least 2 years after the formal discontinuation of clinical development 
of the product (or longer based upon local laws). The sponsor is required to inform the PI as to 
when such documents need no longer be retained. No study document should be destroyed without 
prior written agreement between the sponsor and the PI. Storage of all study- related documents 
will be such that confidentiality will be strictly maintained. These records are also to be maintained 
in compliance with IRB, state, and federal medical records retention requirements, whichever are 
longest. Should the PI wish to assign the study records to another party and/or move them to 
another location, the PI must provide written notification of such intent to the sponsor with the 
name of the person who will accept responsibility for the transferred records and/or their new 
location. The sponsor must be notified in writing, and written permission must be received from the 
sponsor prior to destruction or relocation of research records. 
 
10.3 Investigator’s Brochure 
 
The current version of the IB comprehensively describes all the available preclinical experience with 
the experimental vaccine. If relevant new information becomes available during the course of the 
trial, the PI will receive a revised IB or an amendment to the current version. 
 
10.4 Quality Control and Quality Assurance 
 
Essential documents and participant research records are subject to continuous quality control and 
quality assurance procedures consistent with the MOP. 
 
 
11 CLINICAL SITE MONITORING 
 
Site monitors under contract to NIAID will inspect study facilities and review participant study 
records including ICD, CRFs, medical records, laboratory records, and study product records, to 
ensure protection of study participants, compliance with the IRB approved protocol, and accuracy 
and completeness of records. The monitors also will review essential document files to ensure 
compliance with all applicable regulatory requirements. Study staff will make study facilities and 
documents available for inspection by the monitors. 
 
The sponsor will retain originals of the Form FDA 1572 and copies of other study documents as 
deemed necessary. 
 
Statement of Compliance 
 
The trial will be conducted in compliance with this protocol, ICH-GCP guidelines, FDA guidelines 
and applicable regulatory requirements. The site monitoring will be conducted according to the 
OCRPRO Clinical Trial Management Group’s Monitoring Plan. 
 
 

 
55 
 
12 HUMAN SUBJECTS PROTECTIONS 
 
12.1 Institutional Review Board/Ethics Committee Review and Approval  
 
Prior to study initiation, the PI will obtain IRB review and approval of this protocol and ICDs in 
accordance with 45 CRF 46. In addition to the initial review and approval, the IRB must review the 
study at least annually. The PI must also promptly report to the IRB any changes in the study and 
any UPs involving risks to participants or others. 
 
All IRB policies and procedures must be followed, and complete documentation of all 
correspondence to and from the IRBs must be maintained in the essential document files. 
 
A copy of the study approval (including approval of the ICD) is to be maintained in the 
investigator’s study document binder, and a copy will be supplied to the sponsor. 
 
During the study, the PI is responsible for providing the IRB with all documents subject to review 
(i.e., protocol amendments, ICD updates, advertisements, and any written information that may be 
provided to the participant’s parents/guardians). Study progress reports will be made to the IRB by 
the investigator in accordance with IRB guidelines and government regulations. 
 
12.2 Vulnerable Participants 
 
The NIH is mandated by law to ensure that children be included in clinical research when 
appropriate (31, 32). This study responds to that mandate and will provide clinical research data to 
inform RSV vaccine infectivity, safety and immunogenicity in children. Nonetheless, the infants 
who take part in this study are considered vulnerable participants per the US CFR, and site 
IRBs/IBCs must consider the potential risks and benefits to child participants as described in 45 
CFR 46 Subpart D (for children). 
 
12.3 Informed Consent 
 
In obtaining and documenting informed consent, the PI must comply with the applicable regulatory 
requirements, ICH-GCP guidelines, and ethical principles. The written ICD must be approved by 
the IRB prior to its use. 
 
Written informed consent for study participation will be obtained before any study-specific 
procedures are performed. The informed consent process will include information exchange, 
detailed discussion, and assessment of understanding of all required elements of informed consent, 
including the potential risks, benefits, and alternatives to study participation. 
 
As part of the informed consent process, parents/guardians will also be asked whether they agree to 
storage and future research testing of the biological specimens that remaining after all protocol- 
specified testing has been completed. Future research testing of residual specimens may be declined 
with no impact on other aspects of study participation. 
 
 

 
56 
12.4 Potential Benefits 
 
Participants may not receive any direct vaccine-related benefit from enrollment in this study. Some 
children who receive vaccine may be protected against infections with wt RSV that circulates in the 
community. It is hoped that information gained in this study will contribute to the development of a 
safe and effective vaccine for the prevention of illness associated with RSV infection. 
 
Parents/guardian may be offered child safety seat educational material and referral to community 
inspection stations by study staff, and may be offered certified lactation counseling services, if 
appropriate. 
 
12.5 Potential Risks 
12.5.1 Venipuncture 
 
Risks occasionally associated with venipuncture include pain and bruising at the site of 
venipuncture, lightheadedness, infection, and rarely syncope. Before each blood draw, we will offer 
to use anesthetic skin cream to decrease the pain. 
 
12.5.2 Nasal Swab 
 
Nasal swabs can cause discomfort and on rare occasions are associated with nose bleeds. 
 
12.5.3 Topical Anesthetic Cream 
 
Risks occasionally associated with the use of topical anesthetic cream include temporary skin 
discoloration, skin irritation, rash, hives, and rarely, dizziness or drowsiness. 
 
12.5.4 Receipt of Study Product 
 
If the study vaccine is insufficiently attenuated, participants could experience rhinorrhea, cough, 
fever, otitis media, or LRI. Immediate hypersensitivity reactions including urticaria, anaphylaxis, or 
other immunoglobulin E (IgE)-mediated responses are possible, as with any vaccine. With any 
investigational vaccine, there is a theoretical possibility of risks about which we have no present 
knowledge. Parents/guardians will be informed of any such risks should further data become 
available. 
 
The study participant’s family does not pay for the study product or research visits including 
examinations and laboratory tests that are part of this study, including evaluation of illness, if any. 
NIAID agrees that the funding for appropriate acute care will be provided through the NIAID 
contract for any side effects that are determined to be related to the administration of vaccine. 
 
12.6  Reimbursement/Compensation 
 
12.6.1 Study Compensation: Acute Phase and Surveillance 
 
Compensation will be in the form of either check or gift card. In addition, the parent/guardian will 
receive bus tokens, taxi fare, or parking passes as needed for study visits. Parent/guardian will be 
compensated only for those portions of the study that are completed. Compensation will be in 
accordance with IRB policies and procedures and will be subject to IRB approval. 
Participants may receive age-appropriate books or small toys. The total value of the books or toys 
will not exceed $10 per participant. 

 
57 
12.7 Privacy and Confidentiality 
 
All study procedures will be conducted in private and every effort will be made to protect 
participant privacy and confidentiality to the extent possible. Participant information will not be 
released without written permission to do so except as necessary for review, monitoring, auditing or 
as required by law, or as described in Section 9.4 and Section 10.2. 
 
All study-related information will be stored securely. Participant research records will be stored in 
locked areas with access limited to study staff. All laboratory specimens, CRFs, and other 
documents that may be transmitted off-site will be identified by coded number only. 
 
All local databases must be secured with password protected access systems. Lists, logbooks, 
appointment books, and any other documents that link subject identification numbers to personal 
identifying information should be stored in a separate, locked location in an area with limited 
access. 
 
12.8 Management of Incidental Findings 
 
Study clinicians will inform parents/guardians of all clinically meaningful physical exam findings 
and laboratory tests. When applicable, study clinicians will provide referrals to non-study sources of 
medical care for further evaluation and/or treatment of these findings. 
 
13 ADMINISTRATIVE PROCEDURES  
 
13.1 Regulatory Oversight 
 
CIR 335 is sponsored by the OCRPRO, DCR, NIAID, NIH. 
 
OCRPRO is responsible for regulatory oversight of this study. Safety-related information pertaining 
to the study product will be distributed prior to and during the conduct of the study, in accordance 
with its sponsor obligations. 
 
NIAID provides funding to the clinical research sites at which this study will be conducted. Each 
institute contracts with independent clinical site monitors who will perform monitoring visits as 
described in Section 9.4. As part of these visits, monitors will inspect study-related documentation 
to ensure compliance with all applicable local and US regulatory requirements. 
 
13.2 Protocol Registration 
 
Prior to implementation of this protocol, and any subsequent full version amendments, the CIR must 
have the protocol and the protocol ICDs approved, as appropriate, by their local IRB/IBC, local IBC, 
and any other applicable regulatory entity. 
 
For any future protocol amendments, upon receiving final IRB/IBC and any other applicable 
regulatory entity approvals, CIR should implement the amendment immediately. 
 
13.3 Study Implementation 
 
This study will be conducted in accordance with the protocol, ICH guidelines, and all applicable 
local and US regulations. Study implementation will also be guided by the study-specific MOP and 
other study implementation materials. 

 
58 
13.4 Protocol Deviation Reporting 
 
Protocol deviations must be documented in participant research records. Reasons for the deviations 
and corrective and preventive actions taken in response to the deviations should also be 
documented. See MOP for further instructions. 
 
Deviations will be reported to the IRB and other applicable review bodies in accordance with the 
policies and procedures of these review bodies. Serious deviations that are associated with 
increased risk to one or more study participants and/or significant impacts on the integrity of study 
data must also be reported following procedures specified in the MOP. 
 
13.5 ClinicalTrials.gov 
 
This protocol is subject to the US Food and Drug Administration Amendments Act of 2007 
(FDAAA), including registration in ClinicalTrials.gov. 
 
14 PUBLICATIONS 
 
Publication of the results of this trial will be governed by NIAID policies. Any presentation, 
abstract, or manuscript will be made available for review by the pharmaceutical and NIAID 
sponsors prior to submission. Publication or presentation approval will conform to any Cooperative 
Research and Development Agreement (CRADA) or other collaborative agreement in place. 
 
 

 
59 
15 ABBREVIATIONS 
 
AE 
adverse event 
ALRI 
acute lower respiratory infection 
cDNA 
complementary deoxyribonucleic acid 
CI 
confidence interval 
CIR 
Center for Immunization Research 
CRADA 
Cooperative Research and Development Agreement 
CRF 
case report form 
DCR 
Division of Clinical Research 
DMEM 
Dulbecco’s modified Eagle medium 
DSMB 
data and safety monitoring board 
EENT 
eyes, ears, nose, and throat 
ELISA 
enzyme-linked immunosorbent assay  
FDA 
US Food and Drug Administration 
FDAAA 
US Food and Drug Administration Amendments Act of 2007 
FWA 
Federal Wide Assurance 
GCP 
Good Clinical Practice 
HIPAA 
Health Insurance Portability and Accountability Act  
i.n. 
intranasally 
IB 
investigator’s brochure 
IBC 
institutional biosafety committee 
ICD 
informed consent document 
ICH 
International Council for Harmonisation of Technical Requirements for 
Pharmaceuticals for Human Use 
IgG 
immunoglobulin G 
IND  
Investigational New Drug application 
IRB 
institutional review board 
JHU 
Johns Hopkins University 
JHSPH 
Johns Hopkins Bloomberg School of Public Health 
LID 
Laboratory of Infectious Diseases 
LRI 
lower respiratory infection 
MOP 
Manual of Procedures 
mRNA 
messenger RNA 
NIAID 
National Institute of Allergy and Infectious Diseases 
NIH 
National Institutes of Health 
OCRPRO 
Office of Clinical Research Policy and Regulatory Operations 
ORF 
open reading frame 
PCR 
polymerase chain reaction 
PFU 
plaque forming unit(s) 
PI 
principal investigator 
PRNT 
plaque reduction neutralization test 
rDNA 
recombinant deoxyribonucleic acid 
REDCap 
Research Electronic Data Capture  
RNA 
ribonucleic acid 
RSV 
respiratory syncytial virus 
RT-PCR 
reverse transcription polymerase chain reaction 
rRT-PCR 
real-time reverse transcription polymerase chain reaction 
SAE 
serious adverse event 
SARS-CoV-2 
severe acute respiratory syndrome coronavirus 2 
SERF 
Safety Expedited Report Form  

 
60 
SOP 
standard operating procedure 
SRCP 
Safety Review and Communications Plan  
SUSAR 
serious and unexpected suspected adverse reaction 
UP 
unanticipated problem 
URI 
upper respiratory tract illness 
US 
United States 
VAR 
vaccine administration record 
VUMC 
Vanderbilt University Medical Center 
WCG IRB WIRB-Copernicus Group IRB  
wt 
wild-type 
 
 

 
61 
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Spector SA, Collins PL, McFarland EJ, Karron RA, International Maternal Pediatric Adolescent 
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viruses with deletions in the NS1, NS2, SH, and M2-2 genes are attenuated in vitro and in vivo. 
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stabilization analysis of the "248" temperature sensitive mutation for increased phenotypic 
stability of respiratory syncytial virus vaccine candidates. Vaccine 27:5667-76. 
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Recommendations for Preventive Pediatric Health Care. Pediatrics 143. 
30. 
Siberry GK, Diener-West M, Schappell E, Karron RA. 2002. Comparison of temple temperatures 
with rectal temperatures in children under two years of age. Clin Pediatr (Phila) 41:405-14. 
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Research Involving Human Subjects. 
 
 

 
64 
Appendix I: Tables Referenced in the Background Section 
Table 21: Schedule of Events: Group 1: RSV-Seronegative Participants; Intensive 
 
 
 
ACUTE PHASE 
 
POST-ACUTE 
PHASE 
 
 
Screening 
Day 0 
Day 1 
Day 2 
Day 3 
Day 4 
Day 5 
Day 6 
Day 7 
Day 8 
Day 9 
Day 10 
Day 11 
Day 12 
Day 13-27  
(contact each day) 
Day 28 
Day 29 
Day 30-55 
Day 56  
Illness Visit  
Early DC 
Study window  
 
± 1 day 
 
 
+7 days  
In person visit 
X 
X 
 
 
 
 
X 
 
X 
 
 
X 
 
X 
 
X 
 
* 
X 
X 
X 
Non-visit contact 
 
 
X 
X 
X 
X 
 
X 
 
X 
X 
 
X 
 
X 
 
X 
* 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Interim history 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
* 
X 
X 
X 
Physical exam  
(X) 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Clinical assessment 
(focused PE)b 
 
X 
 
 
 
 
X 
 
X 
 
 
X 
 
X 
 
(X)** 
 
* 
 
X 
 
Administer study product 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Blood for: immunologic 
assays 
5mLa (X)a 
 
 
 
 
 
 
 
 
 
 
 
 
 
5mLa 
 
 
5mLa 
 
5mLa 
Nasal swab for: 
viral detection & 
quantificationb 
 
 
 
 
 
 
X 
 
X 
 
 
X 
 
X 
 
(X)** 
 
* 
 
X** 
X 
Request adventitious 
agent assay 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
* 
 
X 
 
Total blood volume 
5mLa 
-- 
-- 
-- 
-- 
-- 
-- 
-- 
-- 
-- 
-- 
-- 
-- 
-- 
-- 
5mLa 
-- 
-- 
5mLa 
-- 
5mLa 
 
*  If a family reports an SAE that may meet the study pause or stop criteria, complete the indicated tasks (Table 18) 
**A clinical assessment is performed and a  nasal swab specimen is obtained only if the participant has febrile or respiratory illness or otitis media. Timing of visit and collection 
are outlined in Table 12 and Table 13.  
a Up to 5 mL of blood may be obtained for each blood draw.  Screening and preinoculation sample/s will not be obtained more than 42 days prior to inoculation.  Separate blood draws for 
screening and preinoculation samples may be performed if necessary. 
b If a Stay at Home Order is initiated or in the case of respiratory illness, the parent may be asked to obtain the nasal swab, and the clinical assessment may be completed via a 
remote or in-person research visit. During remote research visits parents will also be asked to measure the child’s temperature, heart rate and respiratory rate. 

 
65 
 
 
Table 22: Schedule of Events: Group 2: RSV-Seronegative Participants; Less Intensive 
 
 
ACUTE PHASE 
 
 
POST-ACUTE 
PHASE 
 
 
Screeninga 
Day 0 
Day 1-27 
(contact  
each day) 
Day 28 
 
Day 29 Day 30-55 
Day 56 
Illness Visit  Early DC 
Study window  
 
 
+/- 1 day  
 
+7 days 
 
In person visit 
X 
X 
 
X 
 
* 
X 
X 
X 
Non-visit contact 
 
X 
X 
 
X 
* 
 
 
 
Informed consent 
X 
 
 
 
 
 
 
 
 
History 
X 
 
 
 
 
 
 
 
 
Interim history 
 
X 
X 
X 
X 
* 
X 
X 
X 
Physical exam  
(X) 
X 
 
 
 
 
 
 
 
Clinical assessment 
(focused PE)b 
 
X 
 
(X)** 
 
* 
 
X 
 
Administer study 
product 
 
X 
 
 
 
 
 
 
 
Blood for: immunologic 
assays 
5mLa 
(X)a 
 
5 mLa 
 
 
5mLa 
 
5mLa 
Nasal swab for: 
viral detection & 
quantificationb 
 
 
(X)** 
(X)** 
 
* 
 
X 
X 
Request adventitious 
agent assay 
 
 
 
 
 
* 
 
X 
 
Total blood volume 
5mLa 
-- 
-- 
5 mLa 
-- 
-- 
5mLa 
-- 
5mLa 
 
*  If a family reports an SAE that may meet the study pause or stop criteria, complete the indicated tasks (Table 18) 
**A clinical assessment is performed and a nasal swab specimen is obtained only if the participant has febrile or 
respiratory illness or otitis media. Timing of visit and collection are outlined in Table 12 and Table 13.  
a Up to 5 mL of blood may be obtained for each blood draw.  Screening and preinoculation sample/s will not be obtained 
more than 42 days prior to inoculation.  Separate blood draws for screening and preinoculation samples may be 
performed if necessary. 
b If a Stay at Home Order is initiated or in case of respiratory illness, the parent may be asked to obtain the nasal 
swab, and the clinical assessment may be completed via a remote or in-person research visit.  During remote 
research visits parents will also be asked to measure the child’s temperature, heart rate and respiratory rate. 

 
66 
Appendix II: Schedule of Events: RSV Seasonal Surveillance 
 
Table 23: Schedule of Events: RSV Seasonal Surveillance 
 
 
 
Weekly contact 
Post-RSV season 
Illness Visit 
Early DC 
Visit period 
Date of seasonal 
enrollment pause to 
Mar 31st b 
Apr 1st to Apr 30th 
 
Allowable through 
September 30th in the 
event of delays due to 
a Stay at Home Order 
 
 
Clinical assessmenta 
(focused PE) 
 
 
X 
 
Interim history 
X 
 
X 
X 
LABORATORY EVALUATIONS 
Blood for: 
immunologic assays 
 
5 mLc 
 
5 mLc 
Nasal swab for 
viral detection & 
quantificationa 
 
 
X 
 
Request adventitious agent 
assay  
 
 
X 
 
TOTAL BLOOD 
VOLUME 
 
-- 
5 mLc 
-- 
5 mLc 
aIf a Stay at Home Order is initiated, the parent may be asked to obtain the nasal swab, and the clinical assessment 
may be completed via a remote or in-person research visit. 
bUnless acute follow-up is ongoing.  In this case, surveillance will begin once the acute follow-up period ends. 
cUp to 5 mL of blood may be obtained at each blood draw. 
 
 
 

 
67 
Appendix III: Definitions of Solicited Adverse Events 
 
Table 24: Definitions of Solicited Adverse Events 
 
Event 
Defined 
Fever 
Temporal or rectal temperatures ≥100.4oF 
Acute Otitis Media1 
Loss of tympanic membrane landmarks, accompanied by erythema and loss of 
mobility. May or may not be associated with fever or other respiratory symptoms. 
Confirmed with tympanometry if possible. 
Upper Respiratory Tract Illness (URI) 
Rhinorrhea 
Two or more consecutive days of clear or purulent discharge from the nares.  
Note: Not associated with crying, change of room temperature, or eating and 
drinking. 
Pharyngitis1 
Pharyngeal erythema accompanied by exudate or pharyngeal erythema with 
enlarged, tender lymph nodes.  
Note: May be associated with sore throat, or painful or difficult swallowing. 
Cough Without LRI  
Two or more consecutive days of 3 or more episodes of cough during a 15-minute 
timed observation period, or cough awakens child from sleep.  
Note: Not associated with eating, drinking or choking. 
Hoarseness 
An unnaturally deep or rough quality of voice. 
Lower Respiratory Tract Illness (LRI) 
Wheezing2,3 
Sustained, high pitched, musical breath sounds, especially during the expiratory 
phase, which do not clear with cough. 
Pneumonia1,2,3 
Rales and crackles, originating in the lower respiratory tract, usually accompanied 
by tachypnea, which do not clear with cough. May be confirmed by x-ray showing 
areas of consolidation. 
Laryngotracheobronchitis (Croup) 
1,2,3 
Barking cough, hoarseness, and inspiratory stridor. 
Rhonchi2,3 
Coarse breath sounds which are not transmitted noises from the upper airway and 
do not clear with cough. 
Rales2,3 
Abnormal lung sound heard through a stethoscope. Rales may be sibilant 
(whistling), dry (crackling) or wet (sloshy) depending on the amount and density of 
fluid refluxing back and forth in the air passages. 
1 Diagnosis must be made by a medical profession 
2 Must be sustained over 20 minute 
3 Clinical assessments must be made by a medical professional and confirmed by a second medical professional, if possible 
 
 

 
68 
 
Appendix IV: RSV Seasonality in Baltimore, MD; Nashville, TN;  
and Rochester, NY  
 
Figure 2: RSV Seasonality in Baltimore, MD (top), Nashville, TN (middle), and Rochester, 
NY (bottom) 
 
 
 
 
 
Baltimore, MD 
Rochester, NY