Evaluation of Infectivity and Illness of Norwalk GI.1 Virus Lot 001-09NV in the Human Challenge Model
Phase: PHASE1
Conditions: Norovirus Infection
Sponsor: WCCT Global

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 1 of 50 
Date: 21Sept 2018 
 
 
Clinical Study Protocol 
 
Protocol Title: 
Evaluation of Infectivity and Illness of Norwalk GI.1 Virus Lot 
001-09NV in the Human Challenge Model 
 
Protocol Number:  
VXA-G11-201.1 
 
 
IND Sponsor:  
WCCT Global 
3545 Howard Way,  
Costa Mesa, CA 92626 
Maria Apkarian 
Vice President, Early Clinical Development  
Email: maria.apkarian@wcct.com 
Phone: 714-252-0700; ext: 1019 
 
 
 
 
Funding Sponsor: 
Vaxart, Inc. 
 
Funding Sponsor POC:  
        David N. Taylor, MD 
Chief Medical Officer 
Vaxart, Inc. 
400 Oyster Point Blvd., Suite 222 
South San Francisco, CA 94080 
Email:  dtaylor@vaxart.com 
Mobile phone:  919-349-6109 
 
Protocol Version Number: 
1.1 
Amendment 1 Date: 
21 September 2018 
 
 
Confidentiality Statement 
 
This document is confidential and is to be distributed for review only to investigators, potential investigators, 
consultants, study staff, and applicable independent ethics committees or institutional review boards.  The 
contents of this document shall not be disclosed to others without written authorization from Vaxart (or others, 
as applicable), unless it is necessary to obtain informed consent from potential study subjects. 
 
 
SIGNATURE PAGE/STATEMENT OF COMPLIANCE 
 
 
 

Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
Version 1.1   
      Confidential
        Page 2 of 50 
Date: 21Sept 2018 
Protocol Title: 
Evaluation of Infectivity and Illness of Norwalk GI.1 Virus Lot 
001-09NV in the Human Challenge Model 
Protocol Number: 
VXA-G11-201.1 
Vaxart, Inc. ______________________________ 
________________ 
 David Taylor  
Date 
 Chief Medical Officer 
The trial will be conducted in accordance with the International Conference on Harmonisation (ICH) 
E6 and the Code of Federal Regulations on the Protection of Human Subjects (45 CFR Part 46). The 
Principal Investigator will assure that no deviation from, or changes to the protocol will take place 
without prior agreement from the sponsor and documented approval from the Institutional Review 
Board (IRB/Independent Ethics Committee (IEC), except where necessary to eliminate an immediate 
hazard(s) to the trial subjects. All personnel involved in the conduct of this study have completed 
Human Subjects Protection Training. 
I agree to ensure that all staff members involved in the conduct of this study are informed about their 
obligations in meeting the above commitments. 
Principal Investigator: _________________________ 
___________ 
Signature 
Date 
Name:  
________________________ 
Site & Address:  
_________________________ 
_________________________ 
_________________________ 
David Nguyen, MD 
WCCT Global, Inc. 
3545 Howard Way 
Costa Mesa, CA 92626

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 3 of 50 
Date: 21Sept 2018 
 
TABLE OF CONTENTS 
SIGNATURE PAGE/STATEMENT OF COMPLIANCE ............................................. 1 
LIST OF ABBREVIATIONS AND ACRONYMS ....................................................... 6 
PROTOCOL SUMMARY ......................................................................................... 7 
SCHEMATIC OF STUDY DESIGN ........................................................................ 12 
INTRODUCTION:  BACKGROUND INFORMATION AND SCIENTIFIC 
RATIONALE ........................................................................................................ 13 
1.1 
Norovirus disease etiology, transmission and epidemiology ............................. 13 
1.2 
Previous experience with the Norwalk GI.1 virus ............................................ 14 
1.3 
Study Rationale ........................................................................................... 16 
1.4 
Potential Risks and Benefits .......................................................................... 17 
 
Known Potential Risks ...................................................................................... 17 
1.5 
Overall Development Strategy ...................................................................... 18 
2 
HYPOTHESIS, OBJECTIVES AND PURPOSE ............................................ 18 
2.1 
Study Hypothesis / Hypotheses ..................................................................... 18 
2.2 
Study Objectives ......................................................................................... 18 
 
Primary Objective ............................................................................................. 18 
 
Secondary Objectives........................................................................................ 18 
 
Exploratory Objectives: .................................................................................... 18 
3 
STUDY DESIGN AND ENDPOINTS ........................................................... 19 
3.1 
Description of the Study Design .................................................................... 19 
3.2 
Study Endpoints .......................................................................................... 19 
 
Primary Endpoints ............................................................................................ 19 
 
Secondary Endpoints ........................................................................................ 19 
 
Exploratory Endpoints ...................................................................................... 19 
4 
STUDY ENROLLMENT AND WITHDRAWAL .......................................... 21 
4.1 
Subject Inclusion Criteria ............................................................................. 21 
4.2 
Subject Exclusion Criteria ............................................................................ 21 
4.3 
Withdrawal from Study ................................................................................ 23 
 
Reasons for Withdrawal or Termination........................................................... 23 
 
Handling of Subject Withdrawals or Termination ............................................ 23 
4.4 
Premature Termination or Suspension of Study ............................................... 23 
5 
STUDY AGENT ......................................................................................... 23 
5.1 
Study Agent(s) and Control Description ......................................................... 23 
5.2 
Product Description ..................................................................................... 24 
 
Acquisition ........................................................................................................ 24 
5.3 
Formulation, Appearance, Packaging, and Labeling ........................................ 24 
 
Formulation ....................................................................................................... 24 
 
Packaging .......................................................................................................... 24 
 
Labeling ............................................................................................................ 24 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 4 of 50 
Date: 21Sept 2018 
5.4 
Product Storage and Stability ........................................................................ 25 
 
Storage .............................................................................................................. 25 
 
Stability ............................................................................................................. 25 
5.5 
Dosage, Preparation and Administration of Study Intervention/Investigational 
Product 25 
 
Investigational agent:  Norwalk virus Lot 001-09NV ...................................... 25 
 
Route of administration..................................................................................... 25 
 
Norovirus dosage .............................................................................................. 25 
 
Frequency of administration ............................................................................. 25 
 
Preparation of dose ........................................................................................... 25 
 
Starting Dose and Dose Escalation Schedule ................................................... 26 
 
Dose Adjustments/Modifications/Delays ......................................................... 26 
 
Product Storage and Stability............................................................................ 26 
5.6 
Study Agent Accountability Procedures ......................................................... 26 
6 
STUDY PROCEDURES AND SCHEDULE .................................................. 27 
6.1 
Study Screening .......................................................................................... 27 
 
Visit 00A. Pre-Screening visit (Outpatient; Days -60 to Screening) ................ 27 
 
Visit 00B. Screening visit (Outpatient, Days -30 to -3) .................................... 27 
6.2 
Inpatient Containment Period ........................................................................ 28 
 
Visit 00C. Challenge Baseline - Acclimatization (Day 1, 1 day prior to 
challenge) ........................................................................................................................ 28 
 
Visit 01. Challenge Day (Day 2)....................................................................... 28 
 
Visits 01 – 05. Post-Challenge Observation Period (Day 2 through Day 6 [+1 
Day) 
28 
6.3 
Outpatient Visits .......................................................................................... 30 
 
Visit 06. Outpatient Clinic Visit 1 (Day 9 ± 1) ................................................. 30 
 
Visit 07. Outpatient Clinic Visit 2 (Day 14 ± 3) ............................................... 30 
 
Visit 08. Outpatient Clinic Visit 3 (Day 28 ± 3) ............................................... 30 
 
Visit 09. Final Follow-up phone call (Day 45 ± 3) ........................................... 30 
6.4 
Unscheduled Visit(s) .................................................................................... 30 
7 
Management of Expected Norovirus Illness .................................................... 31 
7.1 
Clinical Evaluation ...................................................................................... 31 
7.2 
Measurement of Diarrhea and Vomitus .......................................................... 31 
7.3 
Management of Fluid Loss ........................................................................... 31 
7.4 
Indications for Concomitant Medications ....................................................... 32 
8 
ASSESSMENT OF SAFETY ....................................................................... 32 
8.1 
Definition of Adverse Event ......................................................................... 32 
 
Grading of Severity of an Adverse Event ......................................................... 33 
 
Relationship to Challenge Dose ........................................................................ 33 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 5 of 50 
Date: 21Sept 2018 
8.2 
Definition of Serious Adverse Event .............................................................. 33 
8.3 
Study Halting Rules ..................................................................................... 34 
8.4 
Safety Oversight .......................................................................................... 34 
9 
CLINICAL MONITORING ......................................................................... 34 
10 
STATISTICAL CONSIDERATIONS............................................................ 35 
10.1 
Hypotheses ................................................................................................. 35 
10.2 
Sample Size Considerations .......................................................................... 35 
10.3 
Analysis ..................................................................................................... 35 
11 
SOURCE DOCUMENTS AND ACCESS TO SOURCE DATA/DOCUMENTS 37 
11.1 
Source Documentation ................................................................................. 37 
11.2 
Data Management ........................................................................................ 37 
12 
GOOD CLINICAL PRACTICE COMPLIANCE ............................................ 38 
13 
ETHICAL CONSIDERATIONS (AND INFORMED CONSENT) ................... 38 
13.1 
Ethical Standard .......................................................................................... 38 
13.2 
Institutional Review Board ........................................................................... 38 
13.3 
Informed Consent Process ............................................................................ 38 
13.4 
Subject Confidentiality ................................................................................. 39 
14 
Literature Cited ........................................................................................... 40 
APPENDIX A:  PROTOCOL REVISIONS .............................................................. 43 
APPENDIX B:  CHALLENGE VIRUS .................................................................... 44 
APPENDIX C: SCHEDULE OF STUDY VISITS AND EVALUATIONS .................. 47 
APPENDIX D: ADVERSE EVENT GRADING SCALES ......................................... 49 
APPENDIX E:  MODIFIED VESIKARI SCALE (17 POINTS) .................................. 50 
 
TABLES 
Table 1:  Number of subjects to be challenged according to dose ..................................... 12 
Table 2: Norwalk virus infection and illness rates after challenge with NV 8fIIa. .............. 14 
Table 3: Dose response for Norwalk strain 8fIIa and 8fIIb .............................................. 15 
Table 4: Summary of Norovirus Challenge Studies Completed in C. Moe’s Lab (Emory 
Univ.)........................................................................................................................ 15 
Table 5:  Symptoms reported after experimental challenge with Norwalk strain 8fIIb ........ 16 
Table 6:  Number of subjects to be challenged according to dose and study site ................ 19 
Table 7:  Power (%) to Detect an Event ........................................................................ 35 
Table 8:  SOPs for Facilities and Operations .................................................................. 44 
Table 9:  Facilities and Operations Controls .................................................................. 45 
Table 10:  Lot Release Tests and Specifications (Bulk Harvest Drug Substance). .............. 46 
Table 11:  Lot Release Tests and Specifications Final Fill Patient Dose Drug Product. ....... 46 
 
 
 
 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 6 of 50 
Date: 21Sept 2018 
LIST OF ABBREVIATIONS AND ACRONYMS 
 
AE 
 
Adverse Events 
ALT 
 
Alanine aminotransferase 
ASC 
Antibody secreting cell 
BT50 
histo-blood group binding antigen blocking antibody titer 
BUN 
blood urea nitrogen 
CDC 
 
Centers for Disease Control and Prevention 
CFR 
 
Code of Federal Regulations 
CIOMS  
Council for International Organizations of Medical Sciences 
cGMP  
Current Good Manufacturing Practices 
CRF 
 
Case Report Form 
ELISA  
Enzyme-linked Immunosorbent Assay 
FDA 
 
Food and Drug Administration 
FUT2   
gene encoding for α (1,2) fucosyltransferase 
GI 
 
Norovirus Genogroup I 
GII 
 
Norovirus Genogroup II 
GC 
 
Genome copies 
GCP 
 
Good Clinical Practices 
GLP 
 
Good Laboratory Practices 
GMP 
 
Good Manufacturing Practices 
HBGA 
Histo-blood group antigen 
HBsAg  
Hepatitis B surface antigen 
HCV 
 
Hepatitis C virus 
HIPAA  
Health Insurance Portability and Accountability Act 
HIV 
 
Human Immunodeficiency Virus 
ICH 
 
International Conference on Harmonisation 
IEC 
 
Independent or Institutional Ethics Committee 
IgA 
 
Immunoglobulin A 
IgG 
 
Immunoglobulin G 
IND 
 
Investigational New Drug Application 
IRB 
 
Institutional Review Board 
ISM 
 
Independent Safety Monitor 
NIAID  
National Institute of Allergy and Infectious Diseases 
NV 
 
Norwalk Virus 
NoV 
 
Norovirus 
NVG 
 
Norovirus gastroenteritis 
PBMC  
Peripheral Blood Mononuclear Cells 
PCR 
 
Polymerase Chain Reaction 
PHI 
 
Protected Health Information 
PI 
 
Principal Investigator 
QA 
 
Quality Assurance 
qRT-PCR 
Quantitative Reverse Transcriptase Polymerase Chain Reaction 
SAE 
 
Serious Adverse Event/Serious Adverse Experience 
SMV 
 
Snow Mountain Virus, a Norovirus GII virus 
SOP 
 
Standard Operating Procedure 
UNC 
 
University of North Carolina at Chapel Hill 
USDA  
United States Department of Agriculture 
US EPA 
United States Environmental Protection Agency 
VLP 
 
Virus-like Particle 
VP1 
Viral protein 1, major capsid or surface protein of viruses 
 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 7 of 50 
Date: 21Sept 2018 
PROTOCOL SUMMARY 
 
Study Title 
Evaluation of Infectivity and Illness of Norwalk GI.1 Virus Lot 
001-09NV in the Human Challenge Model 
Protocol Number 
VXA-G11-201.1 
Sponsor 
WCCT Global 
IND Number 
14697 
Trial Phase 
Phase 1 
Investigational Sites 
1-2 clinical sites with isolation wards 
Investigational Products 
Challenge strain:  Norovirus G1.1 (Norwalk Virus Inoculum Lot 001-09NV) 
Study Hypotheses 
Norwalk virus (NV) will cause norovirus gastroenteritis (NVG) related to norovirus 
(NoV) infection in the challenge model in more than 50% of subjects challenged 
Rationale 
There is a need for safe, highly infectious NoV inocula for use in NoV vaccine-
challenge studies to assess the efficacy of NoV vaccines and examine the immune 
response among vaccinated and unvaccinated subjects.  
 
Study Objectives 
 
 
 
 
Primary:  
• 
Evaluate the infectivity and safety of the human challenge model with NV 
inoculum as measured by the number infected, number that become ill, and the 
number of serious adverse events (SAEs).  
• Infection status will be determined by: 1) virus detection in stool or emesis 
samples by quantitative reverse transcriptase-polymerase chain reaction 
(qRT-PCR) or 2) seroconversion through anti-NV antibody enzyme-linked 
immunosorbent assays (ELISAs). 
Secondary: 
• 
Determine the duration of viral shedding in stool and emesis samples after 
challenge. 
• 
Solicited gastrointestinal symptoms 
• 
Immunologic measurements of: 
• Anti-NV Immunoglobulin G (IgG) and Immunoglobulin A (IgA) 
Exploratory: 
• NV specific antibody response 
• Histo-blood group binding antigen (HBGA) blocking antibody titers (BT50). 
• Antibody Secreting Cells (ASC) response 
 
Study Endpoints 
 
Primary Endpoints: 
• 
Occurrence of NVG within 7 days post-challenge (Study Day 9) in subjects 
for each dose group 
• 
Occurrence of SAEs in subjects for each dose group 
Secondary Endpoints: 
• 
Occurrence of any systemic solicited symptoms in subjects for each dose 
group 
(systemic solicited signs or symptoms are defined as diarrhea, vomiting, 
headache, nausea, fever, abdominal cramps or pain, abdominal gurgling or 
bloating, myalgia)  
• 
Severity of NVG using the modified Vesikari Scale up to 7 days post-
challenge  
• 
Duration of NVG among challenged subjects up to 7 days post challenge 
• 
Occurrence of evidence of NV infection (with challenge strain) in subjects 
up to 28 days post-challenge  

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 8 of 50 
Date: 21Sept 2018 
• 
Percentage of subjects with seroconversion in serum anti-Norwalk pre-
challenge to 28 days post-challenge 
• 
Time to cessation of gastro-intestinal illness 
• 
Duration of shedding 
 
Exploratory Endpoints: 
• 
Number (percent) of subjects with at least a 4-fold rise in NV-specific 
antibody titers post challenge. 
• 
Number (percent) of subjects that seroconvert post-challenge, subdivided by 
illness status. 
• 
Number (percent) of subjects with at least a 4-fold rise in HBGA BT50 from 
baseline compared to Day 28 
• 
ASC IgA and IgG, Day 1 and Day 6 and/or Day 9 
• 
Fecal IgA and saliva IgA, pre-challenge to post-challenge 
 
Study Definitions 
NVG is a composite endpoint for the analysis of clinical illness and is defined as 
meeting one or more definitions of NV Infection and one or more of the definitions 
of Acute Gastroenteritis. 
 
Acute Gastroenteritis: 
• 
Diarrhea: ≥ 3 loose or liquid stools or > 400 to 600 grams of loose or liquid 
stools produced in any 24-hour period or  
• 
Vomiting: ≥ 2 vomiting episodes in any 24-hour period or 
• 
One vomiting episode plus any loose or liquid stool in any 24-hour period or 
• 
One vomiting episode plus at least 2 of the following 5 events:  headache, 
nausea, oral temperature ≥ 37.6°C, abdominal cramps or pains, abdominal 
gurgling or bloating or myalgia in any 24-hour period. 
 
NV Infection: 
• 
NV infection as detected by qRT-PCR in one or more post-challenge stool or 
emesis samples through Day 7 post-challenge (Study Day 9). 
• 
IgA/IgG ELISAs for anti-NV, ≥ 4-fold rise in titer in serum on Challenge 
Day 28 compared to pre-challenge. 
Study Design 
Once informed consent has been obtained from the subject and s/he is determined 
eligible for the study, the subject will be admitted to the isolation unit. Up to 16 
secretor-positive, A or O blood type subjects will receive the NV inoculum. Eight 
subjects will receive the moderate challenge dose in the first challenge cohort, and 8 
subjects will receive the higher dose in the second challenge cohort. Subjects will be 
monitored in the isolation unit for at least 5 days after challenge (+ 1 day) and will 
have additional follow-up at Days 9 ± 1, 14 ± 3, 28 ± 3 and 45 ± 3.  During the 
inpatient stay and follow-up visits, emesis (if available), stool, blood, and saliva 
samples will be collected from study subjects for analysis of virus excretion and 
antibody response. 
 
 
 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 9 of 50 
Date: 21Sept 2018 
Number of Subjects to be Challenged with Norwalk Virus Strain Lot 001-09 NV 
by Dose 
 
  
Number of subjects 
Lot 001-09 NV 
Challenge 
1 
Challenge 
2 
Total 
Moderate dose, 3.6x105 GC 
8 
  
8 
Higher dose, 1x106 GC 
  
8 
8 
GC = genome copies 
Study Population 
Healthy adults 18 to 49 years old, inclusive.  Subjects who are blood group A or O 
and H type-1 antigen secretor positive (by saliva test) will be selected for their 
susceptibility to NV. 
Number of Subjects 
Sixteen subjects will be enrolled in the study.  A total of 8 subjects will receive the 
moderate dose and 8 will receive the higher dose.  After an assessment of safety, 8 
subjects will receive the higher dose in the second challenge.   
Eligibility Criteria 
Inclusion Criteria 
1. Male or female between the ages of 18 – 49 years, inclusive  
2. General good health, without significant medical illness, based on medical 
history, physical examination, vital signs, and clinical laboratories (CBC, 
chemistry, and urinalysis) as determined by the investigator in consultation 
with the research monitor and sponsor.  
3. Willing to participate after written informed consent obtained.  
4. Available for all planned visits and to spend at least 5 days in confinement.   
5. Confirmed blood type (A or O). 
6. Demonstrated to be H type-1 antigen secretor positive (by saliva test).  
7. Body mass index between 17 and 30 at screening.  
8. Female subjects must have a negative pregnancy test at screening and pre-
challenge and fulfill one of the following criteria: 
a. At least 1 year post-menopausal; 
b. Surgically sterile; 
c. Use of oral, implantable, transdermal or injectable contraceptives for 
60 days prior to challenge and until 60 days after challenge; 
i. A reliable form of contraception must be approved by the 
Investigator (e.g., double barrier method, Depo-Provera, 
intrauterine device, Norplant, oral contraceptives, 
contraceptive patches. 
ii. Male subjects must agree not to father a child or donate 
sperm from challenge until 60 days after challenge. 
9. Available to return for follow-up visits following discharge from the 
inpatient unit and deliver stool specimens to the investigator promptly. 
 
Exclusion Criteria: 
1. Presence of a significant medical condition, (e.g., psychiatric conditions, or 
gastrointestinal disease, such as peptic ulcer, symptoms or evidence of active 
gastritis or gastroesophageal reflux disease, inflammatory bowel disease, 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 10 of 50 
Date: 21Sept 2018 
alcohol or illicit drug abuse/dependency, or other laboratory abnormalities 
which in the opinion of the investigator precludes participation in the study. 
2. History of cancer or cancer treatment within past 3 years (excluding basal 
cell carcinoma or squamous cell carcinoma) 
3. Presence of immunosuppression or medical condition possibly associated 
with impaired immune responsiveness, including diabetes mellitus or 
angioedema.  
4. Donation or use of blood or blood products within 4 weeks prior to challenge 
or planned donation during the study period 
5. Diagnosed bleeding disorder or significant bruising or bleeding difficulties 
that could make blood draws problematic 
6. Any condition that resulted in the absence or removal of the spleen 
7. Evidence of confirmed infection with human immunodeficiency virus (HIV), 
hepatitis B surface antigen (HBsAg) or hepatitis C virus (HCV) with 
confirmatory assays. 
8. Abnormal stool pattern (fewer than 3 per week or more than 3 per day).  
9. Use of antibiotics, proton pump inhibitors, H2 blockers or antacids within 7 
days before challenge and for 60 days after challenge. 
10. Use of medication know to affect the immune function (e.g., systemic 
corticosteroids and others) within 7 days before challenge or for 60 days 
after challenge. 
11. Regular use of nonsteroidal anti-inflammatory drugs, sulfonylureas, and 
angiotensin II blockers within 7 days before challenge and for 60 days after 
challenge. 
12. Evidence of recent (within 2 months) or of current nonbacterial 
gastroenteritis suggestive of NV infection [vomiting or unformed or watery 
stools (> 2 during a 24-hour period)]. 
13. Any gastroenteritis within the past 2 weeks. 
14. Acute disease within 72 hours prior to challenge defined as the presence of a 
moderate or severe illness with or without fever (as determined by the 
Investigator through medical history and physical examination). 
(Assessment may be repeated during screening period) 
15. Stool sample with occult blood at screening  
16. Positive stool/fecal for enteric pathogens (e.g., salmonella, campylobacter, 
E. coli 0157:H7, and shigella) as detected by the Biofire assay at screening. 
17. Any significant hospitalization within the last year which in the opinion of 
the investigator or sponsor could interfere with study participation.  
18. History of drug, alcohol or chemical abuse within 1 year prior to challenge 
19. Positive urine drug screen for drugs of abuse or alcohol breath test at 
screening or baseline. 
20. Consistent/habitual smoking within 2 months prior to challenge as per 
medical interview. Consistent/habitual smoking is defined as the smoking of 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 11 of 50 
Date: 21Sept 2018 
one or more packs of cigarettes a day. Smoking will not be permitted during 
the inpatient stay. 
21. Administration of any investigational vaccine, drug or device within 8 weeks 
preceding challenge, or planned use of the above stated for the duration of 
the study.  
22. Other condition that in the clinical judgment of the investigator would 
jeopardize the safety or rights of a subject participating in the trial, would 
render the subject unable to comply with the protocol or would interfere with 
the evaluation of the challenge stage or the evaluation of the challenge stage. 
Occupational- 
1. Living with or having daily contact with children age 5 years or less or a 
woman known to be pregnant or nursing. This includes significant contact at 
home, school, day-care, or equivalent facilities. 
2. Living with or having daily contact with elderly persons aged ≥ 70 years or 
more, or infirmed, diapered individuals, persons with disabilities or 
incontinent persons. This includes work or visits to nursing homes and day-
care or equivalent facilities. 
3. Employment in the food service industry, such as restaurants, or cafeteria 
facilities. Specifically, this will include persons whose employment requires 
food handling and processing in the 4 weeks following challenge. 
4. Health-care workers with patient contact expected in the 4 weeks following 
challenge. 
5. Expected contact (through employment or at home) with 
immunocompromised persons (HIV-positive, receiving immunosuppressive 
medications such as oral steroids, anti-neoplastic agents) in the 4 weeks 
following challenge. 
6. Employment as an airline flight attendant or cruise ship crew, scheduled to 
work in the 4 weeks following challenge. 
7. Persons planning to be in a confined environment (e.g., a cruise, camp etc.) 
in the 4 weeks following challenge. 
Study Duration 
• 
Sixty days pre-screening, recruitment and study specific screening 
• 
Five days in isolation ward (minimum) 
• 
Four follow up clinic visits after discharge on Days 9, 14, 28, and 45 
(Day 45 is a phone call) 
Randomization 
This is an open label study. The challenge cohorts will be enrolled sequentially. 
Microbiological 
Assessments 
During the challenge phase all stools will be weighed/measured for volume and 
graded.  All stools will be collected daily and tested for NoV. 
Safety Assessments/ 
Clinical Monitoring 
Challenge period and safety follow up:  
• 
Unsolicited adverse events (AEs) through Day 45 
• 
Pre-challenge and daily throughout the confinement period post-challenge: 
Following challenge, study subjects will be monitored for solicited 
gastrointestinal and other symptoms (systemic solicited signs or symptoms are 
defined as diarrhea, vomiting, headache, nausea, fever, abdominal cramps or 
pain, abdominal gurgling or bloating, myalgia) and vital signs in the clinical 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 12 of 50 
Date: 21Sept 2018 
research unit every 2 hours while awake during the first 48 hours post-
challenge, and then every 8 hours on Days 3 to 5 post-challenge.   
o Assessment of safety laboratory panels (chemistry and hematology) on 
the day of discharge. Additional time points may be collected if 
clinically indicated per the discretion of the Investigator. 
• 
Follow-up clinic evaluations on Days 9, 14, 28, and 45 (Day 45 is a phone call) 
Sample Size 
Estimate/Data Analysis 
The purpose of this study is to verify that Lot 001-09 NV is infectious and able to 
cause illness and to determine the titer of NV inoculum which causes infectivity in 
>50% of subjects.  A higher and moderate inoculum dose will be studied.  The dose 
that is both safe and able to induce illness in the majority of subjects will be chosen 
for use in vaccine evaluation studies.   
 
 
SCHEMATIC OF STUDY DESIGN 
 
A total of 16 eligible healthy young adults will be challenged with either the moderate or higher dose 
of NV Lot 001-09 NV.  Once informed consent has been obtained from the subject and s/he is 
determined eligible for the study, the subject will be admitted to the clinical research unit to receive the 
NV inoculum.  Subjects will be monitored in isolation for at least 5 days (+ 1 day) after challenge.  
During the inpatient stay, emesis (if available), stool, blood, and saliva samples will be collected from 
study subjects.  Discharge from the research unit will be contingent upon:  the absence of diarrhea and 
absence of moderate or high-grade objective reactogenicity (diarrhea, fever, and vomiting). After 
discharge subjects will have additional follow-up at Days 9 ± 1, 14 ± 3, 28 ± 3, and 45 ± 3.  The study 
subjects will be divided into 2 groups (Table 1).  In challenge 1, 8 subjects will receive the moderate 
dose.  In challenge 2, 8 subjects will receive the higher dose. 
 
Table 1:  Number of subjects to be challenged according to dose  
 
  
Number of subjects 
Lot 001-09 NV 
Challenge 
1 
Challenge 
2 
Total 
Moderate dose, 3.6x105 GC 
8 
  
8 
Higher dose, 1x106 GC 
  
8 
8 
GC = genome copies 
 
 
 
 
 
 
 
 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 13 of 50 
Date: 21Sept 2018 
INTRODUCTION:  BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE 
1.1 
Norovirus disease etiology, transmission and epidemiology 
Noroviruses (NoV) are the major cause of epidemic gastroenteritis in the United States and a significant 
cause of severe diarrhea in young children in developing countries (1, 2). NoVs are also the most 
frequent cause of acute gastroenteritis after ingestion of raw shellfish (3-5). NoV infection causes 
symptoms of vomiting, watery diarrhea, nausea, abdominal cramps, fever, and general malaise. NoVs 
are classified by the Centers for Disease Control and Prevention (CDC) and National Institute of 
Allergy and Infectious Diseases (NIAID) as Bioterrorism Category B Priority Pathogens based on their 
high transmissibility, low infectious dose, and serious public health and economic impact. Transmission 
of NoV occurs via ingestion of fecal-contaminated food and water, exposure to contaminated fomites 
or aerosolized emesis, and direct person-to-person contact (6-14).  In rare cases, transmission can occur 
through organ transplantation (13, 14). A low median infectious dose of 18 genomic copies has been 
described (15). In certain individuals, the virus can be shed for 3 weeks or longer after infection (16-
18). These viruses are the second most important cause of acute gastroenteritis in young children (19, 
20) and may cause about 20% of endemic gastroenteritis in families (21). Each year in the United States, 
the public health impact of NoV is evidenced by the estimated 23 million infections that result in an 
estimated 50,000 hospitalizations and 310 fatal cases (22). Gastroenteritis induced by NoV is self-
limiting and rarely fatal, especially in healthy adults. Fatality in children and the elderly is usually 
caused by severe dehydration after NoV infection (2, 23, 24). No vaccine is currently available. 
NoVs belong to the family Caliciviridae and can be subdivided into 5 distinct genogroups. Genogoups 
I, II, and IV cause disease in humans, and genogroups I and II are the major cause of infection and 
outbreaks in humans. Each genogroup is further subdivided into clusters, and clusters are divided into 
strains. There are at least 8 clusters for genogroup I (GI) and 17 clusters for genogroup II (GII) (25). 
The first NoV to be identified is Norwalk virus (NV) and is a prototype virus for the G I.1 cluster.  
Several genetic determinants of host susceptibility to NoV infection have been observed. Parrino et al. 
reported that a subset of subjects was repeatedly susceptible to NV infection and a second subset was 
repeatedly resistant to infection after challenged with NV (26).  Our group found that a member of the 
ABO histo-blood group family, the FUT2 allele (ie, the gene encoding for α (1,2) fucosyltransferase), 
conferred susceptibility to NV infection (27). Individuals who were homozygous recessive for the 
FUT2 gene are considered secretor negative (28) and do not become infected regardless of NV dose. 
In addition, saliva samples from these individuals did not bind to NV virus-like particles (VLPs). The 
FUT2 gene encodes an α (1,2) fucosyltransferase that produces the carbohydrate H type 1 found on 
epithelial cells and in mucosal secretions (29). In addition, individuals of the B blood group are more 
resistant to NoV infection, while those of the O blood group are more susceptible to NoV infection (27, 
30). Together, this data suggests that the ABO histo-blood group components, including FUT2, may 
be necessary for NV binding and infection and are, therefore, important genetic determinants of 
susceptibility to NV infection. These genetic components apply only to NV. Other NoV strains may 
infect individuals who are “genetically resistant” to 1 strain of NoV (31). For example, we have shown 
that infection with Snow Mountain virus (SMV) (GII.2) is not secretor dependent (32). 
NoV strains are genetically diverse and infection with a single strain does not confer long-term 
sterilizing immunity, but rather short-term protection (33). Similarly, long-term immunity has been 
difficult to achieve for some enteric vaccines, possibly due to the rapid decline of intestinal 
immunoglobulin A (IgA) compared with longer-term serum Immunoglobulin G (IgG) responses (34). 
Mucosal IgA likely plays a pivotal role in NoV protection, but human challenge studies have shown 
that serum IgA, memory B cell responses, and serum histo-blood group antigen (HBGA) blocking titers 
(BT50) are all potential immunological correlates of protection (35-39).  

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 14 of 50 
Date: 21Sept 2018 
1.2 
Previous experience with the Norwalk GI.1 virus  
In a study by Atmar et al. subjects received a challenge dose of 8fIIa in a multisite trial to evaluate a 
NV vaccine (35).  Subjects were challenged orally with 48 reverse-transcriptase-polymerase-chain-
reaction (RT-PCR) units of NV (approximately 10 times the amount of inoculum required to infect 
50% of persons to whom it is administered) (36). After virus inoculation, study subjects were assessed 
for symptoms and signs of gastroenteritis at least twice daily until discharge (the minimum length of 
stay was 96 hours [4 days]), and stool samples were collected to identify NV.  
Viral gastroenteritis was defined as evidence of NV infection and 1 or more of the following symptoms 
during the inpatient stay: (1) production of >200 grams of watery feces in a 24‐hour period; (2) vomiting 
plus production of < 200 grams of watery feces on the same or consecutive days; or (3) vomiting plus 
at least 1 constitutional symptom (abdominal cramps or pain, nausea, bloating, loose feces, fever 
> 37.6°C, myalgia) on the same or consecutive days.  NV infection was defined as evidence of fecal 
virus shedding by real‐time RT‐PCR or antigen detection or seroresponse (4‐fold or greater antibody 
increase) in total NV serum antibody from the pre‐challenge to the day 30 post‐challenge time points. 
In the per-protocol analysis NV associated gastroenteritis occurred in 69% of the placebo recipients 
(Table 2). The Vesikari disease severity score was 6.7 among subjects in the placebo group with NVG.  
The onset occurred 33.8 hours after challenge and the illness had a median duration of 29.4 hours (range 
0 to 108 hours).   
Table 2: Norwalk virus infection and illness rates after challenge with NV 8fIIa.     
 
 Per-protocol analysis 
Vaccine 
Placebo 
  
N = 38 
N = 39 
  
no. (%) 
NV infection and illness 
14 (37) 
27 (69) 
NV infection by RT-PCR 
23 (61) 
32 (82) 
Vesikari score 
  
  
  All subjects 
3.6 
5.5 
  NV infection 
5.0 
6.1 
  NV infection and illness 
6.4 
6.7 
Duration of NV illness 
  
  
  Median in hours. 
14.5 
29.4 
  Range in hours. 
0 to 85.5 
0 to 108 
Time to onset in hours. 
35.9 
33.8 
       From Atmar et al. (35) 
 
 
After the Atmar study, NV strain 8fIIa was passed in a human and the resultant strain was designated 
8fIIb. Teunis et al. compared the infection and illness rates for 8fIIa and 8fIIb (15). In contrast to Atmar 
who measured the dose RT-PCR units, Teunis measured dose as genomic copies. According to Atmar, 
1 RT-PCR-detectable unit is equivalent to about 400 NV genome copies (GCs). Based on this 
conversion factor, the dose of 48 RT-PCR units used in the vaccine trial in Table 1 is equivalent to 
about 1.92x104 GCs.  However, Liu determined in titration studies that 1 RT-PCR-detectable unit is 
equivalent to about 12-38 NV GCs (40). 
Teunis et al. exposed 53 subjects to doses of 8fIIa ranging from 3x101 to 3x108 GCs (15).  A dose 
response was observed with a peak illness rate in 6/8 (75%) of subjects at a dose of 3x105 GC (Table 3). 
Doses above this level did not increase the illness rate.  The daughter strain 8fIIb was given at doses 
ranging from 7x105 to 2x 107.  Nine (33%) of 27 subjects became ill at those doses.  Although the attack 
rate was not statistically different for 8fIIa and 8fIIb, there was a decrease in illness rate with 8fIIb.    

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 15 of 50 
Date: 21Sept 2018 
Table 3: Dose response for Norwalk strain 8fIIa and 8fIIb 
Secretor positive status 
8fIIa 
dose 
(GC) 
No. of 
subjects 
No. 
Infected 
% 
Infected 
No. 
Ill 
% 
Ill 
3x101 
8 
0 
0 
0 
0.0 
3x102 
9 
0 
0 
0 
0.0 
3x103 
9 
3 
33.3 
1 
11.1 
3x104 
3 
2 
66.7 
1 
33.3 
3x105 
8 
7 
87.5 
6 
75.0 
3x106 
7 
3 
42.9 
1 
14.3 
3x107 
3 
2 
66.7 
2 
66.7 
3x108 
6 
5 
83.3 
4 
66.7 
Total 
53 
22 
41.5 
15 
28.3 
8fIIb 
dose 
  
  
  
  
  
7 x 105 
8 
3 
37.5 
2 
25.0 
7 x 106 
18 
14 
77.8 
7 
38.9 
2 x 107 
1 
1 
100.0 
NA 
  
Total 
27 
18 
66.7 
9 
33.3 
Source: adapted from Teunis (15)   
NV strain 8fIIb was used as a human challenge strain in 2 other studies (Table 4) conducted in Dr. 
Christine Moe’s lab at Emory University. At a dose of 107 GC, 10 out of 13 (76.9%) subjects became 
infected.  In all subjects the dose was well tolerated and no SAEs were reported (41, 42).   
Table 4: Summary of Norovirus Challenge Studies Completed in C. Moe’s Lab (Emory Univ.) 
Trial 
Sponsor 
Year 
Challenge 
strain 
Dose 
(GC) 
No. subj. 
challenged 
No. 
infected 
% 
infected 
NV persistence in water 
US EPA 
2006 
8FIIb 
107 
13 
10 
76.9 
NV persistence in oysters 
USDA 
2009 
8FIIb 
unknown 
51 
16 
31.4 
US EPA = United States Environmental Protection Agency 
USDA = United State Department of Agriculture 
The most common symptoms reported by Leon et al. (43) among 13 infected subjects NV 8fIIb 
were low grade fever, nausea, vomiting and diarrhea (Table 5).   

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 16 of 50 
Date: 21Sept 2018 
Table 5:  Symptoms reported after experimental challenge with Norwalk strain 8fIIb  
Symptom 
No. (%) of subjects with 
symptom 
n=13 
Chills 
3 (23) 
Cramping 
3 (23) 
Diarrhea 
6 (46) 
Fatigue 
5 (38) 
Fever 
12 (92) 
Headache 
2 (15) 
Myalgia 
4 (31) 
Nausea 
8 (62) 
Emesis 
5 (38) 
WBC shift 
12 (92) 
1.3 
Study Rationale 
There is a need for safe, highly infectious NoV inocula for use in NoV vaccine-challenge studies to 
assess the efficacy of NoV vaccines and examine the immune response among vaccinated and 
unvaccinated subjects. 
Vaxart hypothesizes that NV infection and illness can be elicited following NV challenge.  The NV Lot 
001-09 NV inoculum will be tested for safety and dose as an investigational challenge product in this 
study.  Assessing the safety of the NV inoculum, the immune determinants of host susceptibility to NV, 
and the immune response to NV challenge and infection will support or reject this hypothesis. 
Selection of study population. This study will enroll normal healthy subjects, male or female, between 
the ages of 18 and 49 who fulfill all eligibility criteria.  Because illness is being induced in subjects, it 
is important to make sure that the subjects have no preexisting conditions that may be complicated by 
NVG.  Children (younger than 18) will be excluded because they may not fully understand and comply 
with study procedures, are often in contact with large groups of other susceptible children (schools, 
daycare, etc.), and are not the target population for the NoV vaccines currently under development. 
Older adults will also be excluded because of a possible weaker immune system, a higher likelihood of 
preexisting conditions and complications from NoV infection, and possible contact with large groups 
of other susceptible older adults (e.g., hospitals, elderly care facilities). 
Route of administration. The study subjects will be challenged with an oral dose of safety-tested NV 
inoculum in water.  This inoculum will be preceded and followed by an oral dose of bicarbonate (baking 
soda) dissolved in water.  Bicarbonate will neutralize stomach acidity for NV infection.  Bicarbonate 
has been used in all human NoV challenge studies to neutralize stomach acid.  For each subject, the 1 
or 3 vials of inoculum (1 or 3 mL) will be diluted in 100 mL of sterile distilled water immediately prior 
to challenge because it makes it easier for the subjects to ingest the inoculum.  The oral route is easy to 
administer and there is high compliance among all our subjects in our previous studies and the studies 
of others. 
NV strain Lot 001-09NV has not been administered to human subjects, however, as noted above, there 
is extensive experience with the parent strains NV 8fIIa and 8fIIb.  To assess the safety and basic 
infectivity of the NV inoculum, the first 8 subjects will be challenged with a moderate dose of NV 
(1x105 GC, approximately 0.5 mL of NV inoculum [1 mL vial of inoculum]) before testing a higher 
dose. 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 17 of 50 
Date: 21Sept 2018 
The second challenge will be with 8 subjects at a higher dose.  Based on experience with previous NoV 
challenge studies and the NV dose-response model, it is proposed to challenge these 8 subjects with 
dose of 106 GC of NV (3 vials of inoculum per subject).  In the previous NV challenge studies, infection 
rates ranging from 37.5% to 87.5% were observed among secretor-positive status subjects who ingested 
NV doses between 3.24x105 and 6.92x106 GC (47, 26).  An increase in illness rates was not observed 
with doses greater than 106 NV GC in the previous challenge studies.  A dose of 106 GC for NV should 
induce an infection rate of 55 to 79% as determined by the dose-response model.  
1.4 
Potential Risks and Benefits 
There are no benefits to the subjects for their participation in this research study.  Subjects who undergo 
challenge with NoV should expect to have diarrhea; in some cases the diarrhea can be severe. NoV 
illness may also be associated with nausea, vomiting, abdominal cramping or discomfort, loss of 
appetite, muscle aches, and tiredness. The electrolyte losses with the secretory diarrhea may result in 
cardiac conduction abnormalities, if uncorrected. Intravascular volume losses with diarrhea can be 
associated with postural hypotension, shock, and death, if uncorrected.  
 
Known Potential Risks 
 
Challenge with NV Lot 001-09NV  
The intended NV dose of 3.6x105 or 1x106 GC is expected to elicit acute watery diarrhea within 18-48 
hours of ingestion in about half of the subjects. Persons that are blood group A or O and secretor-
positive are known to be more susceptible to NV. Nausea or vomiting, abdominal cramping or 
discomfort, and loss of appetite are also common symptoms. Fever is uncommon.  Dehydration can 
occur through loss of fluid from liquid stool and emesis. Since NoV infection is short-lived lasting 
usually 2 or 3 days severe dehydration is uncommon. Symptoms of severe dehydration can involve dry 
mouth, decreased urine, thirst, cold clammy skin, hypotension, lethargy, stupor, and muscle cramping. 
The complications of severe fluid loss include hypoglycemia (low blood sugar), acidosis, kidney 
failure, pulmonary edema (fluid in lungs), arrhythmia (heart rhythm abnormalities), coma, and death. 
Dehydration will be managed with aggressive fluid rehydration (oral and/or intravenous) with 
potassium repletion. It is expected that NoV shedding will occur in the stool; however, transmission 
from person to person is mitigated by housing the subjects on the research isolation ward until they 
meet the protocol discharge criteria. Subjects that maintain the standard hygiene (i.e., hand washing 
with soap and water after defecation) are unlikely to transmit the strain person to person.  
 
Risk of Allergic Reaction 
There is a very rare risk for an allergic reaction to the challenge inoculum. Allergic reactions generally 
can range from mild (for example, skin rash, itching, swelling, or numbness) to severe (for example, 
low blood pressure, difficulty breathing, shock, heart arrest, or death). The symptoms of a mild allergic 
reaction typically go away without treatment, but some cases may require treatment with antihistamines 
or steroids (medications used to treat allergic reactions). In the case of more severe allergic reactions 
such as shock, immediate and intensive medical treatment is necessary. Although the risk of an allergic 
reaction is very small, epinephrine, antihistamines, and other equipment will be available to treat 
anaphylaxis or immediate-type hypersensitivity reactions. 
 
Risk with Pregnancy 
NoV infection in a pregnant woman can harm the fetus. All female study subjects will be tested for 
pregnancy prior to challenge. Any pregnancies which occur between challenge and Day 28 post-
challenge will be reported and followed up. 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 18 of 50 
Date: 21Sept 2018 
 
Risk with Blood Draws  
Blood will be drawn at several times during the study and may also be performed to help manage the 
diarrheal illness. The drawing of blood may cause pain, bruising, feeling faint, fainting, needle site 
infections, swelling, and rarely other infections.  Bruising at the site of blood drawing can be prevented 
by applying pressure for several minutes.  To reduce the risk of infection, the skin site is prepared with 
an alcohol wipe and sterile equipment is used.  
 
Risks to Confidentiality  
Personal health information will be collected as a part of this study and efforts will be made to maintain 
confidentiality. There is a small risk of loss of confidentiality that an unauthorized person may gain 
access to viewing the research records. To maintain confidentiality, all study records will be stored in 
a secure location, such as a locked office and/or locked cabinet. Electronic data will be password-
protected.  Study records and specimens obtained will be coded.  Research records will only be shared 
with authorized personnel and only in connection with carrying out the obligations relating to the study. 
Every effort will be made to keep the records as confidential as possible, within the limits of the law. 
 
Known Potential Benefits  
This is a healthy subject study which does not provide any guarantee of benefit. The benefit is largely 
the scientific knowledge to be gained from the study. 
1.5 
Overall Development Strategy 
The purpose of this study is to evaluate the infectivity and illness rate of two different doses of the NV 
inocula in a human challenge model as measured by the number infected, number that become ill, and 
the number of serious adverse events (SAEs). Depending on the results this model may be used to 
evaluate vaccine efficacy of the Vaxart NoV vaccine. 
2 
HYPOTHESIS, OBJECTIVES AND PURPOSE 
2.1 
Study Hypothesis / Hypotheses 
Norwalk norovirus G1.1 Lot 001-09NV at a moderate or high dose will cause NoV gastroenteritis 
(NVG) in the challenge model in ≥ 50% of subjects challenged. 
2.2 
Study Objectives 
 
Primary Objective 
• Evaluate the infectivity and safety of the human challenge model with NV inoculum as 
measured by the number infected, number that become ill, and the number of SAEs.  
 
Infection status will be determined by: 1) virus detection in stool or emesis 
samples by quantitative reverse transcriptase-polymerase chain reaction (qRT-
PCR) or 2) seroconversion through anti-NV antibody enzyme-linked 
immunosorbent assays (ELISAs). 
 
Secondary Objectives 
• Determine the duration of viral shedding in stool and emesis samples after challenge. 
• Solicited gastrointestinal symptoms 
• Immunologic measurements of: 
 
Anti-NV IgG and IgA 
 
Exploratory Objectives: 
• NV specific antibody response 
• HGBA BT50. 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 19 of 50 
Date: 21Sept 2018 
• Antibody Secreting Cells (ASC) response 
 
3 
STUDY DESIGN AND ENDPOINTS 
3.1 
 Description of the Study Design  
A total of 16 eligible healthy young adults will be challenged with either the moderate or higher dose 
of NV strain Lot 001-09NV.  Once informed consent has been obtained from the subject and s/he is 
determined eligible for the study, the subject will be admitted to the clinical research unit to receive the 
NV inoculum.  Subjects will be monitored in isolation for at least 5 days (+ 1 day) after challenge.  
During the inpatient stay, emesis (if available), stool, blood, and saliva samples will be collected from 
study subjects.  Discharge from the research unit will be contingent upon:  the absence of diarrhea and 
absence of moderate or high-grade objective reactogenicity (diarrhea, fever, and vomiting; see 
Appendix D). After discharge subjects will have additional follow-up at days 9 ± 1, 14 ± 3, 28 ± 3, and 
45 ± 3.  The study subjects will be divided into 2 groups (Table 6).  In Challenge 1, 8 subjects will 
receive the moderate dose and subsequently in Challenge 2, 8 subjects will receive the higher dose. 
Table 6:  Number of subjects to be challenged according to dose and study site 
  
Number of subjects 
Lot 001-09 NV 
Challenge 1 
Challenge 2 
Total 
Moderate dose, 3.6x105 GC 
8 
  
8 
Higher dose, 1x106 GC 
  
8 
8 
GC = genome copies 
3.2 
Study Endpoints 
 
Primary Endpoints 
• 
Occurrence of NVG within 7 days post-challenge (Study Day 9) in subjects for each 
dose group 
• 
Occurrence of SAEs in subjects for each dose group 
 
Secondary Endpoints 
• 
Occurrence of any systemic solicited symptoms in subjects for each dose group 
(systemic solicited signs or symptoms are defined as diarrhea, vomiting, headache, 
nausea, fever, abdominal cramps or pain, abdominal gurgling or bloating, myalgia)  
• 
Severity of NVG using the modified Vesikari Scale (Appendix E) up to 7 days post-
challenge  
• 
Duration of NVG among challenged subjects up to 7 days post challenge 
• 
Occurrence of evidence of NV infection (with challenge strain) in subjects up to 28 
days post-challenge  
• 
Percentage of subjects with seroconversion in serum anti-Norwalk pre-challenge to 
28 days post-challenge 
• 
Time to cessation of gastro-intestinal illness 
• 
Duration of shedding 
 Exploratory Endpoints 
• 
Number (percent) of subjects with at least a 4-fold rise in NV-specific antibody titers 
post challenge. 
• 
Number (percent) of subjects that seroconvert post-challenge, subdivided by illness 
status. 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 20 of 50 
Date: 21Sept 2018 
• 
Number (percent) of subjects with at least a 4-fold rise in HBGA BT50 from 
baseline compared to Day 28 
• 
ASC IgA and IgG, Day 1 and Day 6 and/or Day 9 
• 
Fecal IgA and saliva IgA, pre-challenge to post-challenge 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 21 of 50 
Date: 21Sept 2018 
4 
STUDY ENROLLMENT AND WITHDRAWAL 
4.1 
Subject Inclusion Criteria 
 
1. Male or female between the ages of 18-49 years, inclusive  
2. General good health, without significant medical illness, based on medical history, physical 
examination, vital signs, and clinical laboratories (CBC, chemistry, and urinalysis) as 
determined by the investigator in consultation with the research monitor and sponsor.  
3. Willing to participate after written informed consent obtained. 
4. Available for all planned visits and to spend at least 5 days in confinement. 
5. Confirmed blood type (A or O). 
6. Demonstrated to be H type-1 antigen secretor positive (by saliva test). 
7. Body mass index between 17 and 30 at screening. 
8. Female subjects must have a negative pregnancy test at screening and pre-challenge and 
fulfill one of the following criteria: 
a. At least 1 year post-menopausal; 
b. Surgically sterile; 
c. Use of oral, implantable, transdermal or injectable contraceptives for 60 days prior to 
challenge and until 60 days after challenge; 
• A reliable form of contraception must be approved by the Investigator (e.g., 
double barrier method, Depo-Provera, intrauterine device, Norplant, oral 
contraceptives, contraceptive patches. 
• Male subjects must agree not to father a child or donate sperm from 
challenge until 60 days after challenge. 
9. Available to return for follow-up visits following discharge from the inpatient unit and 
deliver stool specimens to the investigator promptly. 
4.2 
 Subject Exclusion Criteria 
1. Presence of a significant medical condition, (e.g., psychiatric conditions, or gastrointestinal 
disease, such as peptic ulcer, symptoms or evidence of active gastritis or gastroesophageal 
reflux disease, inflammatory bowel disease, alcohol or illicit drug abuse/dependency, or other 
laboratory abnormalities which in the opinion of the investigator precludes participation in 
the study. 
2. History of cancer or cancer treatment within past 3 years (excluding basal cell carcinoma or 
squamous cell carcinoma) 
3. Presence of immunosuppression or medical condition possibly associated with impaired 
immune responsiveness, including diabetes mellitus or angioedema.  
4. Donation or use of blood or blood products within 4 weeks prior to challenge or planned 
donation during the study period 
5. Diagnosed bleeding disorder or significant bruising or bleeding difficulties that could make 
blood draws problematic 
6. Any condition that resulted in the absence or removal of the spleen 
7. Evidence of confirmed infection with human immunodeficiency virus (HIV), hepatitis B 
surface antigen (HBsAg) or hepatitis C virus (HCV) with confirmatory assays. 
8. Abnormal stool pattern (fewer than 3 bowel movements per week or more than 3 per day).  

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 22 of 50 
Date: 21Sept 2018 
9. Use of antibiotics, proton pump inhibitors, H2 blockers or antacids within 7 days before 
challenge and for 60 days after challenge. 
10. Use of medication know to affect the immune function (e.g., systemic corticosteroids and 
others) within 7 days before challenge or for 60 days after challenge.     
11. Regular use of nonsteroidal anti-inflammatory drugs, sulfonylureas, and angiotensin II 
blockers within 7 days before challenge and for 60 days after challenge. 
12. Evidence of recent (within 2 months) or of current nonbacterial gastroenteritis suggestive of 
NV infection [vomiting or unformed or watery stools (> 2 during a 24-hour period)]. 
13. Any gastroenteritis within the past 2 weeks. 
14. Acute disease within 72 hours prior to challenge defined as the presence of a moderate or 
severe illness with or without fever (as determined by the Investigator through medical 
history and physical examination). (Assessment may be repeated during screening period) 
15. Stool sample with occult blood at screening  
16. Positive stool/fecal for enteric pathogens (e.g., salmonella, campylobacter, E. coli 0157:H7, 
and shigella) as detected by the Biofire assay at screening. 
17. Any significant hospitalization within the last year which in the opinion of the investigator or 
sponsor could interfere with study participation.  
18. History of drug, alcohol or chemical abuse within 1 year prior to challenge 
19. Positive urine drug screen for drugs of abuse or alcohol breath test at screening, or baseline. 
20. Consistent/habitual smoking within 2 months prior to challenge. Consistent/habitual smoking 
is defined as the smoking of one or more packs of cigarettes a day. Smoking will not be 
permitted during the inpatient stay. 
21. Administration of any investigational vaccine, drug or device within 8 weeks preceding 
challenge, or planned use of the above stated for the duration of the study.  
22. Other condition that in the clinical judgment of the investigator would jeopardize the safety 
or rights of a subject participating in the trial, would render the subject unable to comply with 
the protocol or would interfere with the evaluation of the challenge stage or the evaluation of 
the challenge stage. 
Occupational: 
1. Living with or having daily contact with children age 5 years or less or a woman known to be 
pregnant or nursing. This includes significant contact at home, school, day-care, or equivalent 
facilities. 
2. Living with or having daily contact with elderly persons aged 70 years or more, or infirmed, 
diapered individuals, persons with disabilities or incontinent persons. This includes work or 
visits to nursing homes and day-care or equivalent facilities. 
3. Employment in the food service industry, such as restaurants, or cafeteria facilities. 
Specifically, this will include persons whose employment requires food handling and 
processing in the 4 weeks following challenge. 
4. Health-care workers with patient contact expected in the 4 weeks following challenge. 
5. Expected contact (through employment or at home) with immunocompromised persons 
(HIV-positive, receiving immunosuppressive medications such as oral steroids, anti-
neoplastic agents) in the 4 weeks following challenge. 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 23 of 50 
Date: 21Sept 2018 
6. Employment as an airline flight attendant or cruise ship crew, scheduled to work in the 4 
weeks following challenge. 
7. Persons planning to live in a confined environment (e.g., a cruise, camp, etc.) in the 4 weeks 
following viral challenge. 
4.3 
Withdrawal from Study 
 
Reasons for Withdrawal or Termination 
Participation in the study is strictly voluntary.  Subjects have the right to withdraw from the study at 
any time and for any reason, without penalty.  The Principal Investigator and/or designee may, at her/his 
discretion, withdraw a subject from continuing in the study if it is in the subject’s best interest, or if the 
subject is not willing or able to comply with the study requirements.  The reason for withdrawal will 
be documented. 
 
Handling of Subject Withdrawals or Termination 
Every effort will be made to undertake protocol-specified safety follow-up procedures to capture AEs, 
SAEs. In the event of withdrawal from study, reasonable efforts should be made to conduct the 
following procedures: 
• 
Review diary card/ memory aid if still in use prior to withdrawal 
• 
Updating any ongoing AE/SAEs that remain ongoing at time of subject’s last visit prior to 
withdrawal  
• 
Query about AEs, SAEs and concomitant medications if the interval between the subject’s 
last visit and the time of withdrawal is within the protocol defined reporting period 
• 
Physical examination 
• 
Blood for safety laboratory testing if withdrawal occurs before visit 28 
• 
Update contact information 
4.4 
Premature Termination or Suspension of Study  
This study may be suspended or prematurely terminated if there is sufficient reasonable cause. 
Written notification, documenting the reason for study suspension or termination, will be provided 
by the suspending or terminating party to investigator, funding agency, the IND/IDE sponsor and 
regulatory authorities. If the study is prematurely terminated or suspended, the PI will promptly 
inform the Instituitional Review Board (IRB) and will provide the reason(s) for the termination or 
suspension. 
Circumstances that may warrant termination or suspension include, but are not limited to:  
• 
Determination of unexpected, significant, or unacceptable risk to subjects  
• 
Insufficient compliance to protocol requirements  
• 
Data that are not sufficiently complete and/or evaluable  
• 
Determination of futility  
Study may resume once concerns about safety, protocol compliance, data quality is addressed and 
satisfy the sponsor, IRB and/or Food and Drug Administration (FDA). 
5 
STUDY AGENT 
5.1 
Study Agent(s) and Control Description  
The inoculum for NV was prepared from a 20% suspension of a liquid stool from a NV-infected 
subject in a previous human challenge study. This inoculum was prepared by extracting the virus 
from the stool suspension after several washes, sterilely filtering the virus extract into vials, and 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 24 of 50 
Date: 21Sept 2018 
determining the titer of the extract. These procedures were performed under Good Manufacturing 
Practices conditions at the University of North Carolina at Chapel Hill (UNC). From there, the 
inoculum was sent to an outside contractor for safety testing. The preparation, qualification, and 
quantification of this inoculum was submitted to the FDA for investigational new drug application 
(IND) review. 
5.2 
Product Description  
 
Acquisition 
The clinical grade product will be obtained from the NoV Processing Facility located at the University 
of North Carolina at Chapel Hill. The facility is designed to produce inocula of NoV under Current 
Good Manufacturing Practices (cGMP). Briefly, the inoculum used in the present study was prepared 
as follows. Stool samples were obtained from NV-infected donors who have passed a health screening. 
NV was extracted from the virus-containing stool sample by a series of 5-6 washes with sterile water. 
Washes were performed by manually creating a 20% stool suspension in water followed by high speed 
centrifugation to pellet solid material. The supernate was removed to a clean tube and a volume of fresh 
sterile water was added back to the stool sample. The stool sample was then resuspended, mixed, 
washed, and centrifuged again to pellet solids. This process was then repeated until all washes were 
completed. Pooled washes created a partially-purified bulk substance. Washes from different donor 
samples were not included in this pool. Samples from the partially purified bulk material were then 
removed for specific lot release tests including viral titer of the pooled material. 
The total volume of the material was then filtered twice through 0.2 micro filters and again pooled as 
bulk purified product. Samples from the purified bulk material were then removed for specific lot 
release tests and viral titer tests. The material was stored at 4ºC until the results of the pooled viral titer 
were known. The material was then portioned out and diluted with sterile water to the desired 
concentration(s) for filling bulk containers for different sublots and/or the single use vials required for 
the specific clinical study. The material was then filled and frozen down at -80ºC until the completion 
of all lot release tests, the final qualification and release of the material, and the shipment to the clinical 
site. 
Prior to use in patients, the product, acquired as a single-patient/single-use vial, undergoes final 
processing as described in Appendix B. 
5.3 
Formulation, Appearance, Packaging, and Labeling 
 
Formulation 
Both the filled, purified product and the final patient use material are formulated in pure, distilled water 
with no other additives. Both the filled, purified product and the final subject use material may be 
formulated in a range of different concentrations of virus to allow for the creation of further sub-lots of 
material at new concentrations of virus, and/or changes in dosing regimens, respectively. 
 
Packaging 
The filled, purified material is provided to the clinical site in 1 mL sterile cryovials containing sufficient 
material for one final processing step just prior to use in a single subject. The final patient use material 
is packaged in sterile cups. 
 
Labeling 
The filled, purified NV inoculum is labeled with the name of the manufacturer, the name of the product, 
the lot number of the product, the concentration of the virus, the date of manufacturing and a statement 
stating For Investigational Use Only. 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 25 of 50 
Date: 21Sept 2018 
5.4 
Product Storage and Stability 
 
Storage 
The filled, purified material is stored long term in a controlled -80°C freezer. The final subject use 
material can be stored short term in either a 4°C refrigerator or can be held short term on wet ice. The 
final subject material is not held or stored for more than 8 hours. 
 
Stability  
The long-term stability of frozen clinical-grade NoV prepared using the established procedures at the 
NoV Processing Facility in North Carolina has not been determined. Stability will be determined by 
periodically removing a vial of the filled, purified material from produced banks of vials and testing 
the material for sterility and viral titer via RNA qRT-PCR. The stability of the final subject use material 
has been pre-set at 8 hours.  
5.5 
Dosage, Preparation and Administration of Study Intervention/Investigational Product 
 
Investigational agent:  Norwalk virus Lot 001-09NV  
The agent used in this subject challenge trial is a safety-tested NV inoculum (Lot 001-09NV, IND 
14697). 
 
Route of administration 
Subjects will receive a single oral dose of safety-tested inocula. The oral route was chosen because of 
ease of administration and successful precedent with this route from all other NoV challenge studies. 
 
Norovirus dosage  
Subjects will be challenged with either 3.6x105 or 1x106 GC of NV based on information from past 
challenge studies and the NV dose-response model.  The dose-response model and experience with this 
dose indicates that this dose is sufficient to result in an infection rate between 55% to 79% among 
susceptible, secretor-positive status individuals.  The moderate dose is a single-patient dose (one 1-mL 
vial for a total of 1 mL of NV inoculum Lot 001-09NV, IND 14697) and the high dose is a single-
patient dose (three 1-mL vials for a total of 3 mL of NV inoculum Lot 001-09NV, IND 14697). 
 
Frequency of administration  
The intervention will be a single oral challenge with NV inoculum. 
 
Preparation of dose  
For the moderate dose one (1) vial and for the high dose three (3) vials per subject will be thawed under 
sterile conditions and swabbed with disinfectant.  One or three vials of inoculum will be added to  
100 mL of distilled water in a sterile, disposable, sealable cup under sterile conditions.  After mixing, 
the solution will look like a plastic glass of clear drinking water.  The sealed cup will be transported on 
ice to the subject for challenge. From previous work, the inoculum in water will be stable and infectious 
for at least 61 days. 
Since the inoculum contains live infectious human pathogen, biohazard precautions will be observed.  
This includes disposing of all waste in biohazard bags, cleaning equipment and materials that have 
come into potential contact with the inocula with 10% bleach solution.  Cups used for administration 
and any leftover inocula should also be cleaned with bleach and discarded.  If the subject, person 
administering dose, or person preparing inocula spills the inocula, the affected area must be 
immediately cleaned with a 10% bleach solution.  Hands should be washed thoroughly with soap and 
water. 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 26 of 50 
Date: 21Sept 2018 
 
Starting Dose and Dose Escalation Schedule   
The starting dose of Lot 001-09NV, 1 vial containing approximately 3.6x105 GC, will be administered 
orally to eight subjects.  If this dose is well tolerated, a dose of 3 vials containing approximately 1x106 
GC will be administered orally to the second cohort of 8 subjects contingent upon review of safety and 
infectivity data from cohort 1.   
 
Dose Adjustments/Modifications/Delays 
Not applicable 
 
Product Storage and Stability 
The storage and final preparation of subject doses will be performed at the study site pharmacy.  In 
general, the overall process for shipping virus from the manufacturing facility in North Carolina, storing  
it in the research site pharmacy, and performing the final manipulations are as follows. Once the virus 
has completed all lot release testing and a certificate of analysis has been signed off on, the inocula are 
shipped frozen by overnight courier to the study sites. Data loggers and shipping documents are 
included in the shipping container to monitor temperature and document the transfer of the materials. 
When the virus is received at the study site, the materials and the container are inspected, and the status 
of the product is recorded. The material is then placed in a controlled -80˚C freezer and its location in 
the freezer is recorded in the freezer records. Clinical material is stored in a dedicated compartment of 
the freezer and is separated from any other materials in the freezer.  
To prepare subject doses, the appropriate amount of material for the dose is removed from the freezer 
and its removal is recorded in the freezer records. The material is transferred to a biosafety cabinet in 
the laboratory and allowed to thaw at room temperature. The Biosafety cabinet is broken down and 
cleaned/sanitized prior to use and it is dedicated for use only with the product being worked on 
throughout the final preparation process. The inoculum vials (1 mL each) will be thawed under sterile 
conditions and swabbed with disinfectant. The inocula (1 mL or 3 mL) will be added to 100 mL of 
distilled water in a sterile, disposable, sealable cup under sterile conditions. After mixing, the solution 
will look like a plastic glass of clear drinking water. The sterile cup must be sealed and transported on 
ice to the subject for challenge. From previous work, the inocula in water will be stable and infectious 
for at least 61 days.  
5.6 
Study Agent Accountability Procedures 
The site pharmacist is required to maintain complete records of all study products received from the 
Sponsor (or designee) and will be responsible for maintaining an accurate record of subject dosing, and 
an accountability record of the viral inocula for this study.  The site pharmacist will also be responsible 
for ensuring the security of these documents.  Partially used vials will not be used for human 
administration or for in vitro experimental studies. At the end of the study, the site will receive 
instruction from the Sponsor regarding the final disposition of any remaining study products.   

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 27 of 50 
Date: 21Sept 2018 
6 
STUDY PROCEDURES AND SCHEDULE 
See Appendix C for The Schedule of Study Visits and Evaluations. 
6.1 
Study Screening  
 Visit 00A. Pre-Screening visit (Outpatient; Days -60 to Screening) 
The purpose of the first clinical visit is to pre-identify potential voluneers for secretor status and ABO 
blood type.  Since 80% of a population is secretor positive and secretor positivity is an eligibility 
criterion, we need to screen over 20 eligible individuals to reach our target population of 16 secretor-
positive subjects.  However, we expect to screen more than 50 secretor-positive individuals to identify 
16 that meet all the study inclusion and exclusion criteria. Healthy men and women 18 to 49 years of 
age will be recruited from the areas surrounding the study site(s) in the USA).   
Pre-screening visit checklist  
• 
Informed Consent 
• 
ABO blood typing 
• 
Saliva test for secretor status 
• 
Demographics 
• 
Eligibility criteria 
Visit 00A pre- screening tests will be conducted under a separate pre-screening ICF.  Eligible subjects 
will be required to sign a separate Informed Consent Forms (ICF) for study participation at the 
screening visit.  If the subject is secretor negative or blood type B or AB (genetically resistant), the 
subject will be told he or she does not fulfill eligibility criteria and will not be enrolled in the study. 
 
Visit 00B. Screening visit (Outpatient, Days -30 to -3) 
If the subject is secretor positive (genetically susceptible) and blood type A or O, he or she will be 
invited to a full screening visit at the designated outpatient visit site. 
At this screening visit, the Study Investigator will perform a clinical assessment and blood will be 
collected for laboratory tests. At the time of screening, blood cell counts, blood chemistry, liver 
function, HIV, HBsAg, and HCV status will be tested (pregnancy will be assayed by blood test). Vital 
signs will also be collected (temperature, blood pressure, heart rate, breathing rate) as well as height 
and weight for BMI calculation. A medical history and review of concomitant medications will also be 
performed. The Study Investigator will provide counseling as needed to subjects on the results of these 
tests, especially on HIV, HBV, and HCV status. Medical history, physical exam, vital signs and lab 
results must be within normal limits, or abnormalities deemed not clinically significant, at the time of 
screening for the subjects to participate in the study.  Subjects who are eligible to participate in the 
study will be contacted to come to the inpatient unit for a 5-day admission.  Subjects will be asked to 
bring a screening stool sample before they receive the NV challenge. The screening stool specimen will 
be tested for enteric pathogens and occult blood.  
Screening visit checklist 
• 
Demographics 
• 
Medical interview 
• 
Eligibility criteria 
• 
Physical Examination 
• 
Vital signs 
• 
Concomitant medications 
• 
ECG 
• 
Blood screen for HIV, HBsAg and HCV  

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 28 of 50 
Date: 21Sept 2018 
• 
Blood for safety laboratory evaluation 
• 
Urinalysis 
• 
Drug Screen (Urine, alcohol breath test) 
• 
Stool sample for enteric pathogens and occult blood 
• 
Serum Pregnancy test (females) 
6.2 
Inpatient Containment Period 
 
Visit 00C. Challenge Baseline - Acclimatization (Day 1, 1 day prior to 
challenge) 
Study subjects will begin their inpatient stay 1 day before challenge. Subjects will be assigned to a 
single room and instructed about the protocol-required procedures (e.g., stool handling), hygiene 
practices, and the “Rules and Procedures” to be followed while on the inpatient unit. Subjects will also 
be monitored for evidence that a subject may demonstrate behaviors which might pose a safety risk to 
themselves, other subjects, or staff could be cause for ineligibility for challenge and the remainder of 
the inpatient stay.  Refusal to comply with protocol-required procedures, adherence to hygiene practices 
could constitute ineligibility. Any subject who is deemed ineligible will be discharged, prior to 
challenge.  
All subjects that continue to demonstrate eligibility and provide continuing consent will fast (defined 
by nothing by mouth except for water), starting from the midnight prior to the challenge day.  
The following assessments will be made as described in Appendix C: 
• 
Medical Interview 
• 
Targeted physical exam 
• 
Vital signs 
• 
Blood sample for safety laboratory tests 
• 
Urinalysis 
• 
Drug Screen (Urine, alcohol breath test) 
• 
Urine pregnancy test (females) 
• 
Blood samples for immunology 
• 
Fecal sample for immunology  
• 
Saliva sample for immunology 
 
Visit 01. Challenge Day (Day 2) 
On the morning of challenge, fasting subjects will have baseline vitals (temperature, blood pressure, 
heart rate, breathing rate) recorded and a final eligibility confirmation (medical history and targeted 
physical examination) will be completed prior to oral ingestion of the challenge inoculum.   
Subjects will have fasted overnight and have nothing by mouth, except water, for 90 minutes before 
and after ingestion of the challenge inoculum.  Subjects will drink 100 mL of sodium bicarbonate 
solution (~1.3% NaHCO3) prior to viral challenge; approximately 1 minute later, subjects will ingest 
the NV inoculum (Lot 001-09NV, IND 14697) suspended in 100 mL of distilled water.   
 
Visits 01 – 05. Post-Challenge Observation Period (Day 2 through Day 6 
[+1 Day) 
Following ingestion of the challenge inoculum, the following procedures will be performed: 
• 
Study subjects will be monitored for gastrointestinal symptoms and vital signs in the clinical 
research unit every 2 hours while awake during the first 48 hours post-challenge, and then 
every 8 hours on Day 3 to challenge phase discharge. 
• 
Fecal samples will be collected. 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 29 of 50 
Date: 21Sept 2018 
• 
All stools will be graded for consistency (grade 1 to 5) and any diarrheal stool (grade 3 or 
higher) will be weighed. 
• 
Saliva samples will be collected  
• 
All emesis will be weighed and an emesis sample collected.  
• 
Following challenge, symptoms will be assessed and the maximum symptom severity for the 
day will be determined using a standard rating scale. 
• 
Anticipated subjective symptoms include:  diarrhea, vomiting, headache, nausea, fever, 
abdominal cramps or pain, abdominal gurgling or bloating, myalgia.  These adverse 
symptoms will be graded. 
• 
The maximum temperature, total diarrheal stool volume, number of diarrheal stools, total 
vomitus volume, and number of vomiting episodes will be calculated for each 24 h period 
during the inpatient stay.   
• 
On day of discharge  (Day 6 + 1 day)  
o Blood sample will be collected for safety labs and PBMC isolation 
o Diary card will be distributed 
o Discharge criteria must be assessed and met (per checklist) 
The nursing staff will monitor the subject’s vital signs and assess for signs and symptoms of acute NoV 
infection every 2 hours while awake and while the subject is in the isolation unit over the first 48 hours.  
Rating scales (Appendix D and E) will be used to classify diarrhea, nausea, and vomiting. Subjects will 
also be asked to rate symptoms of myalgia and fatigue as mild, moderate or severe.  AEs will also be 
collected during the inpatient stay. During the first 5 days after challenge, subjects will receive daily 
weight, fluid intake, and fluid output measurements.  The Study Investigator, or his/her designated 
representative, will monitor subjects daily. The subjects will remain in the inpatient unit at least 5 days 
after challenge following enteric isolation procedures.  All staff in contact with subjects will be asked 
to wear Personal Protective Equipment of at least disposable gloves, gowns, and masks.   
A portion of stool and emesis samples passed by the subjects during their inpatient stay will be collected 
and stored at 4°C (See analysis section 10.3 and Appendix C, Schedule of Events).  These specimens 
will be tested for the presence of the NoV challenge strain by qRT-PCR. Fecal and saliva samples 
collected before challenge and 28 days after challenge will be tested for NoV viral protein 1 (VP1) 
antibody (see Appendix C, Schedule of Events). 
On the day of discharge from the inpatient unit, approximately 60 mL of whole blood will be collected 
for peripheral blood mononuclear cell (PBMC) isolation and a sample for safety labs. 
 
Discharge Criteria 
Study subjects will be evaluated for discharge 5 days after challenge (Day 6). If subject is still 
symptomatic with NV illness and it is clinically indicated, they will remain in the isolation unit for an 
additional day (Day 7). At the time of discharge, subjects will be instructed on the importance of hand 
washing and careful personal hygiene and given antimicrobial soap.  Subjects will be asked to follow 
appropriate sanitation and hygiene for 1 month following virus ingestion.  At the time of discharge, 
subjects will be given stool collection kits to take home so that they can bring a stool sample within 24 
hours of their return on day 9 ± 1 (first follow-up visit).  Subjects will also be given a memory aid 
(diary) to chart any change in signs, symptoms, or medication use following discharge.  This memory 
aid will be returned to the clinical site at the day 9 visit. 
 
Early Termination/Early Discharge 
Subjects that desire to withdraw from the study or are withdrawn by the Investigator (eg, due to 
continuing non-compliance or safety concerns) during the inpatient period will be given instructions 
on appropriate follow up. If a subject desires to leave the inpatient containment unit early, the study 
staff ensure that the subject is no longer having symptoms, diarrhea, or emesis. A document of early 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 30 of 50 
Date: 21Sept 2018 
termination/withdrawal will be completed by the study staff and co-signed by the subject.  The subject 
will not be compensated for any inpatient days that are not completed, including the day of early 
termination. 
6.3 
Outpatient Visits 
 
Visit 06. Outpatient Clinic Visit 1 (Day 9 ± 1) 
Symptom memory aids will be collected.  A medical interview, targeted physical exam if indicated and 
vital signs will be performed.  Whole blood specimens will be collected and processed for PBMC 
isolation.  Saliva specimens will be collected.  Subjects will bring in a stool collected within 24 hours 
of day 9 visit.  Subjects will be given stool collection kits to take home, so they can bring a stool 
specimen collected within 24 hours of each of their follow-up visits.  Subjects will be contacted to 
remind them of their follow-up appointment and to bring a stool specimen with them to their next 
appointment.  Subjects who do not bring in a stool specimen will be asked to drop off a specimen the 
next day.  At the clinic, stool samples will be processed per Lab Manual.  
 
Visit 07. Outpatient Clinic Visit 2 (Day 14 ± 3) 
Subjects will undergo the following evaluations:  
• 
Medical Interview 
• 
Targeted physical exam will be performed if indicated.   
• 
Vital signs (temperature, blood pressure, heart rate, breathing rate) 
• 
Stool specimen to assess viral shedding.   
 
Visit 08. Outpatient Clinic Visit 3 (Day 28 ± 3) 
Subjects will undergo the following evaluations:  
• 
Medical Interview 
• 
Targeted physical exam will be performed if indicated.   
• 
Vital signs (temperature, blood pressure, heart rate, breathing rate) 
• 
Urine pregnancy test (females) 
• 
Blood specimens for immunology tests 
o 20 ml for serum  
• 
Stool specimen to assess viral shedding.   
 
Visit 09. Final Follow-up phone call (Day 45 ± 3)  
A final follow up visit can be completed by phone.  The visit will only be for the reporting of SAEs.   
6.4 
Unscheduled Visit(s) 
Subjects whose Day 28 stool sample is positive for norovirus shedding will be asked to return to clinic 
for additionalfecal testing on or before Day 45. Any need for further follow up will be evaluated on a 
case by case basis. Subjects that experience any serious or severe AEs or experience an event of concern 
can be scheduled for an outpatient visit to have further evaluation. If an unscheduled visit occurs, a 
member of the clinical study team (PI, subinvestigator, nurse coordinator, or clinical nurse) will 
interview and evaluate the subject to determine the cause of the visit and provide care as needed. 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 31 of 50 
Date: 21Sept 2018 
7 
Management of Expected Norovirus Illness 
7.1 
Clinical Evaluation 
After NoV challenge, subjects will remain on the ward for at least 5 days.  Vital signs (temperature, 
blood pressure, heart rate, breathing rate) will be measured every 2 hours during waking hours over the 
first 2 days and at least every 8 ± 1 hour thereafter by staff. Subjects will be interviewed daily by a 
study Investigator to determine the occurrence of illness signs and symptoms (e.g., diarrhea, vomiting, 
headache, nausea, fever, abdominal cramps or pain, abdominal gurgling or bloating, myalgia) which 
occurred during the previous study day; these data will be recorded on a standardized form and graded 
in severity according to a standardized scale.  A focused physical examination may be performed at the 
discretion of the Investigator according to the nature of a subject’s complaint. 
7.2 
Measurement of Diarrhea and Vomitus 
Since diarrhea is anticipated to be a common occurrence, all subjects will be expected to collect every 
stool that is passed, from the time of challenge until discharge.  Subjects will be instructed to use a 
plastic stool collection basin (hat). Subjects will be instructed on how not to collect urine in the same 
container. All stools will be weighed and graded by the study staff.  The grading of stool is based on 
consistency and the definition of diarrhea is a grade 3 or higher stool, as follows: 
• 
Grade 1 – well formed (normal stool, does not take the shape of the container) 
• 
Grade 2 – soft (normal stool, does not take the shape of the container) 
• 
Grade 3 – thick liquid (diarrhea, takes the shape of the container readily) 
• 
Grade 4 – opaque watery diarrhea 
• 
Grade 5 – rice water diarrhea (clear watery) 
Any grade 3 or higher stool (diarrheal stool) must be weighed, to estimate the volume of fluid loss 
(assume approximately 1-gram diarrheal stool = 1 mL of fluid lost).  
Similarly, any episodes of vomiting should be collected in either a stool “hat” or a plastic “kidney” 
basin, provided.  If a vomiting or diarrhea episode is not able to be collected in a basin (e.g., the subject 
has an “accident” while sleeping or before they are able to reach a toilet), then the volume of the output 
will be estimated. 
7.3 
Management of Fluid Loss 
Subjects who develop diarrheal stools (grade 3 or higher) will begin oral fluid replacement at 1.5 times 
the stool volume. Vomitus will be replaced with oral fluids in equal amounts, 1:1 ratio.  If a subject 
develops severe watery diarrhea or persistent vomiting and cannot maintain full hydration by oral 
means, IV fluid replacement will be administered.   
Assessment of dehydration may include urine specific gravity and serum electrolytes (Sodium, 
Potassium, Chloride, Bicarbonate) and renal function (BUN, and creatinine).   
An Investigator is available by telephone or beeper at all times.  Nurses will notify the on-call 
Investigator if any of the following occurs in a subject who is experiencing diarrhea and/or vomiting: 
• 
Syncope 
• 
Complaint of dizziness or lightheadedness or established orthostatic hypotension 
• 
Urine specific gravity > 1.025 
• 
> 500 mL behind in ORS replacement 
• 
Vomiting of ≥ 500 mL once or total volume within the past 4 hours 
• 
High fever ≥ 39°C (102.1°F) 
• 
Severe headache, severe malaise, or severe abdominal pain 
• 
Subject has a complaint for which he/she requests treatment 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 32 of 50 
Date: 21Sept 2018 
• 
Any other clinical situation that concerns the nurse 
7.4 
Indications for Concomitant Medications 
Any concomitant medication, prescription or over-the-counter, will be evaluated for continuation 
during the inpatient setting (e.g., long-standing single-agent anti-hypertensive medication or cholesterol 
medication).  Any such medication will need to be discussed with and approved by the investigator 
prior to admission.  The supply of medication will be the responsibility of the subject and will be handed 
over to the research staff upon admission; daily administration will be recorded.  Any un-declared 
prescription or over-the-counter medications that are discovered during the inpatient stay will constitute 
a violation of the ward “Rules and Procedures.”  
Other medications may be administered during the study period as follows: 
• 
Smoking is not allowed on the ward, but subjects will be able to request a nicotine patch.  
• 
Anti-pyretics and analgesics (i.e., ibuprofen, acetaminophen, aspirin, or similar non-steroidal 
agents) may be prescribed for severe headaches, other pains, or fevers (e.g., sustained 
temperatures of ≥ 39°C).   
• 
At the investigator’s discretion (e.g., upon review of serum electrolyte results during severe 
diarrhea), oral potassium and/or IV fluids may be administered for repletion of electrolyte 
losses. 
• 
Other medications, which are deemed necessary for the safety and welfare of the subject  
The prescription of any medication must be ordered and signed by the investigator and each 
administration recorded. 
8 
ASSESSMENT OF SAFETY 
The assessment of the safety of the study drug and challenge agent will be through the detection and 
documentation of AEs, both solicited AEs and unsolicited AEs, and/or clinically significant laboratory 
abnormalities, through 28 days post-challenge.  Only the occurrence of SAEs will be reported between 
Days 28 and 45. 
8.1 
Definition of Adverse Event 
An AE is any untoward medical occurrence in a subject after administration of the investigational drug 
and that does not necessarily have a causal relationship with the investigational drug. An AE can 
therefore be any unfavorable and unintended sign (including abnormal laboratory findings), symptoms, 
physical examinations, or disease temporally associated with the use of the investigational drug, 
whether related to the investigational drug.  This definition includes exacerbations of pre-existing 
conditions.  Stable pre-existing conditions which do not change in nature or severity during the study 
are not considered AEs; however, these should be reported as part of the medical history. 
Solicited AEs are pre-specified AEs that could potentially be in association with NoV infection. 
Investigators will attempt to assign causality of solicited AEs to NoV infection or an alternate cause. 
The pre-specified solicited signs or symptoms will be captured in the designated collection tool for 
solicited AEs up until Study Day 9. After this time point, all AEs (unsolicited) will be captured on the 
AE log. 
Unsolicited AEs are any AEs reported spontaneously by the subject, observed by the study personnel 
during study visits or those identified during review of medical records or source documents. 
Investigators will attempt to assign causality of solicited AEs to NoV infection or an alternate cause. 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 33 of 50 
Date: 21Sept 2018 
 
Grading of Severity of an Adverse Event 
Severity of AEs:  All AEs will be assessed by the clinician using a protocol-defined grading system.  
For events not included in the protocol-defined grading system, the following guidelines will be used 
to quantify severity:  
Mild:  events require minimal or no treatment and do not interfere with the subject’s daily 
activities. 
Moderate:  events result in a low level of inconvenience or concern with the therapeutic 
measures. Moderate events may cause some interference with functioning. 
Severe:  events interrupt a subject’s usual daily activity and may require systemic drug 
therapy or other treatment. Severe events are usually incapacitating. 
Life threatening:  any adverse drug experience that places the subject, in the view of the 
investigator, at immediate risk of death from the reaction as it occurred, i.e., it does not 
include a reaction that had it occurred in a more severe form, might have caused death. 
Changes in the severity of an AE should be documented to allow an assessment of the duration of the 
event at each level of intensity to be performed.  AEs characterized as intermittent require 
documentation of onset and duration of each episode. 
 
Relationship to Challenge Dose 
Relationship (causality or attribution) of all AEs to NoV infection, or to an alternate etiology (unrelated 
to the study) is part of the documentation process, but it is not a factor in determining what is (or is not) 
reported in the study.  If there is any doubt as to whether a clinical observation is an AE, the event 
should be reported.  All AEs must have their relationship assessed using 1 of 2 terms:  related to NoV 
infection, or not related (an alternate etiology can be identified and is likely or feasible).  To help assess, 
the following guidelines are used. 
Related to norovirus challenge - There is a reasonable possibility that the NV infection 
caused the AE. Reasonable possibility means that there is evidence to suggest a 
causal relationship between the NoV illness and the AE, and there is no reasonable 
alternate etiology. 
Not Related – There is not a reasonable possibility that the event is related to NoV and there 
is a reasonable alternate etiology.   
8.2 
Definition of Serious Adverse Event  
A SAE is any AE that results in any of the following outcomes: 
1. Death 
2. A life-threatening event. Life-threatening events mean that the study subject was, in the 
opinion of the site Investigator or Sponsor, at risk of death at the time of the event; it does 
not refer to an event which hypothetically might have caused death if it were more 
severe.  
3. Requires inpatient hospitalization or prolongation of existing hospitalization  
4. Results in persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions  
5. Congenital abnormality or birth defect 
6. Important medical event that may not result in one of the above outcomes but may 
jeopardize the health of the study subject and/or requires medical or surgical intervention 
to prevent one of the outcomes listed in the above definition of SAE. Examples of such 
medical events include allergic bronchospasm requiring intensive treatment in an 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 34 of 50 
Date: 21Sept 2018 
emergency room or at home, blood dyscrasias or convulsions that do not result in 
inpatient hospitalization, or the development of drug dependency or drug abuse.  
All SAEs will be: 
• recorded in the research record  
• reported to the local IRB, per local IRB guidelines 
• reviewed and evaluated by a study clinician and the PI 
• followed through resolution by a study clinician 
• All deaths and immediately life-threatening events, whether related or unrelated, will be 
reported to the study sponsor within 24 hours of site awareness.  Other SAEs regardless of 
relationship, will be reported to the study sponsor within 72 hours of site awareness.  
8.3 
Study Halting Rules 
The study plans to have 2 cohorts of subjects challenged. After the first cohort is challenged there will 
be a safety assessment to ensure halting criteria are not present. All subsequent study subjects will 
continue to be actively monitored and managed for their clinical illness (if during the inpatient period) 
and continued to be followed for safety information (if during the outpatient period). 
The halting rules refer to suspected adverse reactions and will be triggered automatically if any of the 
events described below are met during the conduct of the study: 
 
• One or more subjects experience a ‘related’ SAE 
• Two or more subjects experience a (grade 3) systemic adverse events and/or two or more (grade 3) 
non-GI adverse events of the same type regardless of causality, within 3 days after challenge. Refer 
to section 1.4.1.1 of the protocol for known potential risks with the challenge NV Lot 001-09NV. 
8.4 
Safety Oversight 
An Independent Safety Monitor (ISM) will perform the oversight of safety for this study. The ISM is a 
scientist or clinician that is not involved with the conduct of the study. The primary responsibility of 
the ISM is to monitor subject safety. The ISM considers study-specific data as well as relevant 
background information about the disease, test agent, and target population under study. The ISM will 
review challenge data shortly after completion of the inpatient phase. The ISM is empowered to suspend 
the study, recommend amendments to the protocol, and/or to request further information. 
The ISM will be responsible for reviewing the cumulative safety data, including a review of safety 
laboratory test results and AE reporting, should there be a halt in the study.  If the study is halted, no 
further challenges will be performed; all enrolled subjects will continue to be followed, the management 
of diarrhea or other symptoms will continue until resolution. 
9 
CLINICAL MONITORING 
Site monitoring is conducted to ensure that the rights and well-being of human subjects are protected, 
that the reported trial data are accurate, complete, and verifiable, and that the conduct of the trial follows 
the currently approved protocol/amendment(s), with Good Clinical Practice (GCP), and with applicable 
regulatory requirement(s). Monitoring refers to the methods used by sponsors of investigational studies, 
or Contract Research Organizations (CROs) delegated site monitoring responsibilities, to oversee the 
conduct of, and reporting of data from, clinical investigations. Site monitoring includes ensuring 
appropriate clinical investigator supervision of study site staff and third-party contractors.  
• Monitoring for this study will be managed by the IND Sponsor 
• Vaxart will be provided copies of monitoring reports within 30 days of visit.  
• Details of clinical site monitoring are documented in a Clinical Monitoring Plan (CMP). 
The CMP describes in detail who will conduct the monitoring, at what frequency monitoring 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 35 of 50 
Date: 21Sept 2018 
will be done, at what level of detail monitoring will be performed, and the distribution of 
monitoring reports.  
10 STATISTICAL CONSIDERATIONS 
10.1 
Hypotheses 
This is not a hypothesis-driven study and thus no formal hypothesis testing is planned. The purpose of 
this study is to verify that NV strain Lot 001-09NV is infectious and able to cause illness.  A higher 
and moderate inoculum dose will be studied. The dose that is both safe and able to induce illness in the 
majority of subjects will be chosen for use in vaccine evaluation studies.   
10.2 
Sample Size Considerations 
The sample size chosen for this study is not based on power calculations, but rather based on 
appropriateness for a challenge strain that has not been administered to human subjects. The study plans 
to challenge 8 subjects to a moderate dose of the challenge strain before challenging 8 subjects at a 
higher dose of the challenge strain, for a total of 16 subjects challenged. Table 7 illustrates the 
probability (%) of observing one or more events of any specific type given hypothetical “true” event 
rates. While these results could be applied to any event rate that follows a binomial distribution, they 
are included primarily to understand the probability of observing one or more AE or SAE given the 
number of subjects.  
Table 7:  Power (%) to Detect an Event 
Event Frequency 
N=8 
N=16 
0.01% 
0.080 
0.160 
0.10% 
0.797 
1.588 
1.00% 
7.726 
14.854 
10.00% 
56.953 
81.470 
10.3 
Analysis  
The primary endpoint is to evaluate the safety of the human challenge model with NV inoculum as 
measured by the number infected, number that become ill, and the number of SAEs. Because the 
numbers of subjects are small, descriptive statistics will be used for the following:  
• Number (%) infected and ill by challenge dose  
• Symptom profile and symptom severity (no./%) by dose 
• Number (%) of SAEs and SAEs by dose  
 
Secondary: 
• Immune response to NV  
• 
Serum NV specific IgA and IgG by dose, at Day 0 and Day 28 
 
In the ELISA to determine anti-NV IgG seroconversion will be performed. Each specimen is tested at 
a single dilution (1:400), and the IgG titer is calculated relative to the standard curve of the positive 
control. Specimens that do not give a signal in the linear part of the standard curve will be retested at 
a higher (1:2000) or lower (1:100) dilution as appropriate. Each specimen is tested in duplicate 
positive (coated with NV VLPs) and negative (coated with buffer) test wells in order to control for the 
effect of background signal for each individual specimen.  
 
Seroconversion is defined as a 4-fold or greater rise in IgG titer compared to the IgG titer in the 
prechallenge specimen. A sample of 1µl of sera is sufficient for this assay. A negative control 
includes a blank well with no antigen but assayed for binding of anti-NV antibodies. 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 36 of 50 
Date: 21Sept 2018 
 
• Determine the length of viral shedding in stool and emesis samples after challenge. 
• Quantitate the level of viral shedding by dose 
 
Exploratory: 
 Number (percent) of subjects with at least a 4-fold rise in NV-specific antibody titers post 
challenge. 
 Number (percent) of subjects that seroconvert post-challenge, subdivided by illness status. 
 Number (percent) of subjects with at least a 4-fold rise in HBGA BT50 from baseline 
compared to Day 28 
 ASC IgA and IgG, Day 1 and Day 6 and/or Day 9 
 Fecal IgA and saliva IgA, pre-challenge to post-challenge 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 37 of 50 
Date: 21Sept 2018 
11 SOURCE DOCUMENTS AND ACCESS TO SOURCE DATA/DOCUMENTS 
11.1 
Source Documentation 
Source data are all information, original records of clinical findings, observations, or other activities in 
a clinical trial necessary for validation of the clinical data.  Examples of these original documents and 
data records include, but are not limited to, hospital records, clinical and office charts, laboratory notes, 
memoranda, subjects’ memory aid or evaluation checklists, pharmacy dispensing records, recorded 
data from automated instruments, copies or transcriptions certified after verification as being accurate 
and complete, microfiches, photographic negatives, microfilm or magnetic media, x-rays, and subject 
files and records kept at the pharmacy, at the laboratories, and medico-technical departments involved 
in the clinical trial.  All information on the Case Report Form (CRF) will be traceable to these source 
documents, which are generally maintained in the subject’s study file.  The source documents will 
include a copy of the signed Informed Consent/ Health Insurance Portability and Accountability Act 
(HIPAA) authorization. The source document data collection forms for Screening, Inpatient Pre-
Challenge to Day of Challenge, Inpatient Post-Challenge, Flow Sheet of Stool and Emesis Record, 
Outpatient Visits and AEs will also serve as CRF data collection instruments.  
The investigator is responsible for ensuring the accuracy, completeness, legibility, and timeliness of 
the data reported. Source documents are maintained for recording data for each subject enrolled in this 
clinical study. Study subjects’ data collected on the CRF during the trial will only be identified by 
subject number.  If, as an exception, it is necessary for safety or regulatory reasons to identify the 
patient, both the Sponsor and the Investigator are bound to keep this information confidential. 
All the information required by the protocol should be provided; any omissions require explanation.  
Each source document and corresponding CRF should be completed and available for monitoring 
and/or collection within a timely manner so that the monitor may check the entries for completeness, 
accuracy and legibility, ensure the CRF is signed by the Investigator, and transmit the data to the 
Sponsor. 
All source documents and CRF should be completed in a neat, legible manner to ensure accurate 
interpretation of data. Black or blue ink is required to ensure clarity of reproduced copies. When making 
a change or correction, cross out the original entry with a single line and initial and date the change. 
DO NOT ERASE, OVERWRITE OR USE CORRECTION FLUID OR TAPE ON THE ORIGINAL.  
The Investigator or designee must enter the information required by the protocol onto the CRF 
provided.  The Sponsor’s clinical site monitor will review the CRF for completeness and accuracy and 
instruct site personnel to make any required corrections or additions.  
11.2 
Data Management 
Source data verification of all key safety, laboratory, and clinical data in the database will be conducted 
by the study monitor after data entry has been completed by the site staff.  Coexistent medical 
conditions, AEs and other medical events will be coded using MedDRA dictionary. Concomitant 
medications will be coded using WHO-Drug dictionary. When the database has been declared to be 
complete and accurate, the database will be locked.  Any changes to the database after that time can 
only be made by joint written agreement of the study team. 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 38 of 50 
Date: 21Sept 2018 
12 GOOD CLINICAL PRACTICE COMPLIANCE 
• 
This study will be conducted in accordance with the protocol and with the following: 
• 
Consensus ethical principles derived from international guidelines including the 
Declaration of Helsinki and Council for International Organizations of Medical Sciences 
(CIOMS) International Ethical Guidelines 
• 
Applicable ICH Good Clinical Practice (GCP) Guidelines 
• 
Applicable laws and regulations 
13 ETHICAL CONSIDERATIONS (AND INFORMED CONSENT) 
13.1 
Ethical Standard 
The investigator will ensure that this study is conducted in full conformity with the principles set forth 
in The Belmont Report:  Ethical Principles and Guidelines for the Protection of Human Subjects of 
Research of the US National Commission for the Protection of Human Subjects of Biomedical and 
Behavioral Research (April 18, 1979) and codified in 45 Code of Federal Regulations (CFR) Part 46 
and/or the International Conference on Harmonisation (ICH) E6; 62 Federal Regulations 25691 (1997). 
13.2 
Institutional Review Board 
The local institution must provide for the review and approval of this protocol and the associated 
informed consent documents by an appropriate ethics review committee or IRB. Any amendments to 
the protocol or consent materials must also be approved before they are placed into use unless it is in 
the best interest of the subjects’ safety to implement changes prior to approval. 
Prior to enrollment of subjects into this clinical study, the protocol and the informed consent form(s) 
will be reviewed and approved by the appropriate IRB. Any amendments to the protocol or consent 
materials will also be reviewed and approved by the appropriate IRB. The responsible official for the 
IRB will sign the IRB letter of approval of the protocol prior to the start of this clinical study. Should 
amendments to the protocol be required, the amendments will be submitted to the IRB; an IRB letter 
of approval of the amendment must be obtained prior to acting upon the amendment in the protocol. 
13.3 
Informed Consent Process 
Prior to consenting for the full study, subjects will initially provide informed consent for pre-screening 
to test for secretor status and ABO blood type. Eligible subjects will be required to sign a separate 
Informed Consent Forms (ICF) before any assessments or evaluations required by the study are 
performed.  Informed consent will be initiated prior to the individual’s agreeing to participate in the 
study and continues throughout the individual’s study participation.  Extensive discussion of risks and 
possible benefits of this therapy will be provided to the subject.  Consent forms describing in detail the 
study, study procedures and risks are given to the potential subject and written documentation of 
informed consent is required prior to starting any study procedure.  Consent forms will be IRB-
approved, and the subject will be asked to read and review the document. Upon reviewing the 
document, the investigator will explain the research study to the subject and answer any questions that 
may arise.  The subjects will sign the informed consent document prior to any procedures being done 
specifically for the study.  The subject should have the opportunity to discuss the study with their 
surrogates or think about it prior to agreeing to participate.  The subject may withdraw consent at any 
time throughout the course of the trial.  A copy of the informed consent document will be given to the 
subject for their records.  The rights and welfare of the subject will be protected by emphasizing to 
them that the quality of their medical care will not be adversely affected if they decline to participate 
in this study. 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 39 of 50 
Date: 21Sept 2018 
13.4 
Subject Confidentiality 
Subject (subject) confidentiality is strictly held in trust by the investigators, their staff, and the Sponsor.  
This confidentiality is extended to cover testing of biological samples and other testing in addition to 
the clinical information relating to subject. 
The study protocol, documentation, data, and all other information generated will be held in strict 
confidence.  No information concerning the study or the data will be released to any unauthorized third 
party without prior written approval of the sponsor. 
The study monitor or other authorized representatives of the sponsor may inspect all documents and 
records required to be maintained by the investigator, including but not limited to, medical records 
(office, clinic, or hospital) and pharmacy records for the subjects in this study.  The clinical study site 
will permit access to such records. 
Subject identity data will be contained in paper study records which will be kept in a locked file cabinet 
and in a secure electronic database, accessible only to authorized users at each clinical site. The study 
database will be user-restricted and password-protected. The study database will identify subjects by a 
coded study Subject ID number assigned by clinical site personnel, thus subjects will not be identified 
by name. 
 
 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 40 of 50 
Date: 21Sept 2018 
14 Literature Cited 
1. Fankhauser RL, Noel JS, Monroe SS, Ando T, Glass RI. Molecular epidemiology of 
"Norwalk-like viruses" in outbreaks of gastroenteritis in the United States. J Infect 
Dis. 1998;178(6):1571-8. 
2. Parks CG, Moe CL, Rhodes D, Lima A, Barrett L, Tseng F, et al. Genomic diversity 
of "Norwalk like viruses" (NLVs):  pediatric infections in a Brazilian shantytown. J 
Med Virol. 1999;58(4):426-34. 
3. Shieh Y, Monroe SS, Fankhauser RL, Langlois GW, Burkhardt W, Baric RS. 
Detection of Norwalk-like virus in shellfish implicated in illness. J Infect Dis. 
2000;181 Suppl 2:S360-6. 
4. Parks CG, Moe CL, Rhodes D, Lima A, Barrett L, Tseng F, et al. Genomic diversity 
of "Norwalk like viruses" (NLVs):  pediatric infections in a Brazilian shantytown. J 
Med Virol. 1999;58(4):426-34. 
5. Shieh Y, Monroe SS, Fankhauser RL, Langlois GW, Burkhardt W, Baric RS. 
Detection of Norwalk-like virus in shellfish implicated in illness. J Infect Dis. 
2000;181 Suppl 2:S360-6. 
6. Shieh YC, Calci KR, Baric RS. A method to detect low levels of enteric viruses in 
contaminated oysters. Appl Environ Microbiol. 1999;65(11):4709-14. 
7. Rippey SR. Infectious diseases associated with molluscan shellfish consumption. Clin 
Microbiol Rev. 1994;7(4):419-25. 
8. Becker KM, Moe CL, Southwick KL, MacCormack JN. Transmission of Norwalk 
virus during football game. N Engl J Med. 2000;343(17):1223-7. 
9. Berg DE, Kohn MA, Farley TA, McFarland LM. Multi-state outbreaks of acute 
gastroenteritis traced to fecal-contaminated oysters harvested in Louisiana. J Infect 
Dis. 2000;181 Suppl 2:S381-6. 
10. Kuritsky JN, Osterholm MT, Greenberg HB, Korlath JA, Godes JR, Hedberg CW, et 
al. Norwalk gastroenteritis:  a community outbreak associated with bakery product 
consumption. Ann Intern Med. 1984;100(4):519-21. 
11. Long SM, Adak GK, O'Brien SJ, Gillespie IA. General outbreaks of infectious 
intestinal disease linked with salad vegetables and fruit, England and Wales, 1992-
2000. Commun Dis Public Health. 2002;5(2):101-5. 
12. Lawson HW, Braun MM, Glass RI, Stine SE, Monroe SS, Atrash HK, et al. 
Waterborne outbreak of Norwalk virus gastroenteritis at a southwest US resort:  role 
of geological formations in contamination of well water. Lancet. 
1991;337(8751):1200-4. 
13. Baron RC, Murphy FD, Greenberg HB, Davis CE, Bregman DJ, Gary GW, et al. 
Norwalk gastrointestinal illness:  an outbreak associated with swimming in a 
recreational lake and secondary person-to-person transmission. Am J Epidemiol. 
1982;115(2):163-72. 
14. Marks PJ, Vipond IB, Carlisle D, Deakin D, Fey RE, Caul EO. Evidence for airborne 
transmission of Norwalk-like virus (NLV) in a hotel restaurant. Epidemiol Infect. 
2000;124(3):481-7. 
15. Kaufman SS, Chatterjee NK, Fuschino ME, Magid MS, Gordon RE, Morse, DL, et 
al. Calicivirus enteritis in an intestinal transplant recipient. Am J Transplant. 
2003;3(6):764-8. 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 41 of 50 
Date: 21Sept 2018 
16. Nilsson M, Hedlund KO, Thorhagen M, Larson G, Johansen K, Ekspong A, et al. 
Evolution of human calicivirus RNA in vivo:  accumulation of mutations in the 
protruding P2 domain of the capsid leads to structural changes and possibly a new 
phenotype. J Virol. 2003;77(24):13117-24. 
17. Teunis, P.F., et al., Norwalk virus:  how infectious is it? J Med Virol, 2008. 80(8):  p. 
1468-76. 
18. Rockx B, De Wit M, Vennema H, Vinje J, De Bruin E, Van Duynhoven Y, et al. 
Natural history of human calicivirus infection:  a prospective cohort study. Clin Infect 
Dis. 2002;35(3):246-53. 
19. Graham DY, Jiang X, Tanaka T, Opekun AR, Madore HP, Estes MK. Norwalk virus 
infection of volunteers:  new insights based on improved assays. J Infect Dis. 
1994;170(1):34-43. 
20. Patterson T, Hutchings P, Palmer S. Outbreak of SRSV gastroenteritis at an 
international conference traced to food handled by a post-symptomatic caterer. 
Epidemiol Infect. 1993;111(1):157-62. 
21. Glass RI, Noel J, Ando T, Fankhauser R, Belliot G, Mounts A, et al. The 
epidemiology of enteric caliciviruses from humans:  a reassessment using new 
diagnostics. J Infect Dis. 2000;181 Suppl 2:S254-61. 
22. Pang XL, Honma S, Nakata S, Vesikari T. Human caliciviruses in acute 
gastroenteritis of young children in the community. J Infect Dis. 2000;181 Suppl 
2:S288-94. 
23. Koopmans M, Vinje J, de Wit M, Leenen I, van Der Poel W, van Duynhoven Y. 
Molecular epidemiology of human enteric caliciviruses in The Netherlands. J Infect 
Dis. 2000;181 Suppl 2:S262-9. 
24. Mead PS, Slutsker L, Dietz V, McCaig LF, Bresee JS, Shapiro C, et al. Food-related 
illness and death in the United States. Emerg Infect Dis. 1999;5(5):607-25. 
25. Green KY, Belliot G, Taylor JL, Valdesuso J, Lew JF, Kapikian AZ, et al. A 
predominant role for Norwalk-like viruses as agents of epidemic gastroenteritis in 
Maryland nursing homes for the elderly. J Infect Dis. 2002;185(2):133-46. 
26. Ward J, Neill A, McCall B, Stafford R, Smith G, Davison R. Three nursing home 
outbreaks of Norwalk-like virus in Brisbane in 1999. Commun Dis Intell. 
2000;24(8):229-33. 
27. Zheng DP, Ando T, Fankhauser RL, Beard RS, Glass RI, Monroe SS. Norovirus 
classification and proposed strain nomenclature. Virology. 2006;346(2):312-23. 
28. Parrino TA, Schreiber DS, Trier JS, Kapikian AZ, Blacklow NR. Clinical immunity 
in acute gastroenteritis caused by Norwalk agent. NEJM. 1977;297(2):86-9. 
29. Lindesmith L, Moe C, Marionneau S, Ruvoen N, Jiang X, Lindblad L, et al. Human 
susceptibility and resistance to Norwalk virus infection. Nat Med. 2003;9(5):548-53. 
30. Kelly RJ, Rouquier S, Giorgi D, Lennon GG, Lowe JB. Sequence and expression of a 
candidate for the human Secretor blood group alpha(1,2)fucosyltransferase gene 
(FUT2). Homozygosity for an enzyme-inactivating nonsense mutation commonly 
correlates with the non-secretor phenotype. J Biol Chem. 1995;270(9):4640-9. 
31. Rouquier S, Lowe JB, Kelly RJ, Fertitta AL, Lennon GG, Giorgi D. Molecular 
cloning of a human genomic region containing the H blood group 
alpha(1,2)fucosyltransferase gene and two H locus-related DNA restriction 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 42 of 50 
Date: 21Sept 2018 
fragments. Isolation of a candidate for the human Secretor blood group locus. J Biol 
Chem. 1995;270(9):4632-9. 
32. Hutson AM, Atmar RL, Graham DY, Estes MK. Norwalk virus infection and disease 
is associated with ABO histo-blood group type. J Infect Dis. 2002;185(9):1335-7.  
33. Hutson AM, Atmar RL, Estes MK. Norovirus disease:  changing epidemiology and 
host susceptibility factors. Trends Microbiol. 2004;12(6):279-87. 
34. Lindesmith L, Moe C, Lependu J, Frelinger JA, Treanor J, Baric RS. Cellular and 
humoral immunity following Snow Mountain virus challenge. J Virol. 
2005;79(5):2900-9. 
35. Johnson PC, Mathewson JJ, DuPont HL, Greenberg HB. Multiple-challenge study of 
host susceptibility to Norwalk gastroenteritis in US adults. The Journal of infectious 
diseases 1990; 161(1): 18-21.  
36. Kilhamn J, Jertborn M, Svennerholm AM. Kinetics of local and systemic immune 
responses to an oral cholera vaccine given alone or together with acetylcysteine. 
Clinical and diagnostic laboratory immunology 1998; 5(2): 247-50.  
37. Atmar RL, Bernstein DI, Harro CD, et al. Norovirus vaccine against experimental 
human Norwalk Virus illness. NEJM 2011; 365(23): 2178-87.  
38. Atmar RL, Opekun AR, Gilger MA, Estes MK, Crawford SE, Neill FH, Ramani S, 
Hill H, Ferreira J, Graham DY. Determination of the 50% human infectious dose for 
Norwalk virus. J Infect Dis. 2014;209:1016-22. 
39. Reeck A, Kavanagh O, Estes MK, et al. Serological correlate of protection against 
norovirus-induced gastroenteritis. The Journal of infectious diseases 2010; 202(8): 
1212-8.  
40. Lindesmith L, Moe C, Marionneau S, et al. Human susceptibility and resistance to 
Norwalk virus infection. Nat Med 2003; 9(5): 548-53.  
41. Ramani S, Estes MK, Atmar RL. Correlates of Protection against Norovirus Infection 
and Disease-Where Are We Now, Where Do We Go? PLoS pathogens 2016; 12(4): 
e1005334. 
42. Liu P, Hsiao HM, Jaykus LA, Moe C. Quantification of Norwalk virus inocula: 
Comparison of endpoint titration and real-time reverse transcription-PCR methods. J 
Med Virol. 2010;82:1612-6.   
43. Leon JS, Kingsley DH, Montes JS, Richards GP, Lyon GM, Abdulhafid GM, Seitz 
SR, Fernandez ML, Teunis PF, Flick GJ, Moe CL. Randomized, double-blinded 
clinical trial for human norovirus inactivation in oysters by high hydrostatic pressure 
processing. Appl Environ Microbiol. 2011;77:5476-82. 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 43 of 50 
Date: 21Sept 2018 
APPENDIX A:  PROTOCOL REVISIONS 
 
Version  Date 
Significant Revisions 
Ethics/Regulatory 
Approvals 
1.1 
21 Sept 2018 
Removed Section 1.4.1.4, Rectal swab 
Modified list of systemic solicited signs or 
symptoms 
 
 
 
Modified Section 8.3, Study Halting Rules 
 
 
 
Added Adverse Events following Challenge to 
Appendix C 
 
 
 
Modified Appendix D 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 44 of 50 
Date: 21Sept 2018 
APPENDIX B:  CHALLENGE VIRUS 
Preparing Norovirus Inoculum According to cGMP 
The facility that was used to manufacture the inoculum is in the Michael Hooker Research Center at 
the University of North Carolina in Chapel Hill, NC. The facility consists of a processing room for 
producing inocula, a controlled access room for storage of released raw materials and controlled 
documents, a segregated lab bench to perform quality control tests, and a controlled access -80oC 
freezer used to store finished products. To avoid any cross contamination between products, only one 
product was produced at a time and the production room(s) and their associated equipment were 
broken down and sanitized between products. The Processing facility does not have HEPA filtered 
air. However, the facility generally has between Class 1000-Class 10,000 air during normal 
operations. All open steps were performed in a Class 100 Biosafety cabinet. 
Standard Operating Procedures Used in the Facility 
The facility has written Standard Operating Procedures (SOPs) that cover all operations (Table 8). A 
list of the SOPs that are used in the facility is shown in the tables below. Manufacturing data is 
recorded in production batch records that are prepared for each lot of material produced. Quality 
control data is recorded in logbooks assigned to each quality control program. Original versions of 
production and quality control records are maintained in the facility and copies are provided to 
investigators and regulatory groups as necessary. 
Table 8:  SOPs for Facilities and Operations   
SOP No. 
SOP Description 
1000.01 
 
1002.01 
 
1003.02 
 
1004.01 
 
1005.01 
 
1006.01 
 
1007.01 
 
1008.01 
 
1011.01 
 
1012.01 
 
 
1013.01 
1014.01 
 
2001.02 
2020.01 
 
2032.01 
 
2033.01 
 
2034.01 
 
2052.01 
 
2053.01 
 
2054.01 
 
2505.01 
2506.01 
3001.01 
 
3002.01 
 
3004.02 
 
3005.01 
 
3006.01 
 
3007.01 
 
Standard Operating Procedures and Forms 
Employee Training 
Data Entry and Error Correction 
Signature Records and Signing Authorities 
Gowning and Flow for the Clinical Core of the JVL 
Formulation Lot Number Assignment 
External Regulatory Inspections 
Shipping 
Sampling Technique 
Technology Transfer 
Validation Protocol and Report 
Personnel Hygiene 
Processing Norovirus Infected Stool & Manufacturing 
Norovirus 
Control of Raw Materials 
Clinical Core Production Room Usage 
Laminar Flow Biological Safety Cabinets 
Sample Storage and Tracking 
Raw Material Specifications 
Formulation Master Record  
Product Specification 
Batch Record for Processing Norovirus Samples 
Vialing Purified Norovirus 
Cleaning, Maintaining and Monitoring Equipment 
Preparation of Sanitation and Disinfectant Solutions 
Cleaning and Sanitizing the NPF 
Equipment Calibration 
Pipette Aids 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 45 of 50 
Date: 21Sept 2018 
3008.01 
 
3009.01 
 
3010.01 
 
4005.01 
 
4006.01 
4007.02 
4008.02 
 
5001.01 
 
5002.01 
 
5003.01 
 
5005.01 
 
5006.01 
 
5007.01 
5008.1 
Operating, Maintaining and Calibrating the Met One  
RCS Air Sampler 
Equipment Identification 
Equipment Logbooks 
pH Measurement 
Environmental Monitoring for the NPF 
Determining Viral Titer of GI Norovirus by PCR 
Determining Viral Titer of GII Norovirus by PCR 
Responsibilities of Quality Assurance 
Quality Assurance Audits 
Documenting and Investigating Quality Variations 
Temporary Change Control 
Clinical Labels 
Production Lot Number Assignment 
Product Release 
 
Quality Control/Quality Assurance 
Compliance with cGMP is maintained through a quality systems approach. This approach involves 
developing specific quality control programs to address each of the regulatory requirements of Good 
Manufacturing Practice (GMP). The specific quality control and quality assurance programs that are 
used to maintain cGMP are listed in Table 9 below. Details on the facilities and operations control 
programs have been compiled in a Type V Facilities Drug Master File that will be maintained at the 
FDA. The investigator and other regulatory entities can access this file through letters of reference as 
necessary.  
Table 9:  Facilities and Operations Controls 
Controls Description 
Controls over Facility and Equipment 
Controls over Organization and Personnel 
Sterilization and Cleaning Controls 
Raw Materials Controls 
Environmental Monitoring 
Packaging and labeling Controls 
Holding and Distribution Controls 
Laboratory Testing Controls 
Records, Documents and Change Controls 
Corrective and Preventative Action Programs 
Independent Quality Assurance Program 
 
Drug Product Safety Testing 
All products produced in the facility that will be used in humans were tested for safety using 
established procedures. Testing for drug safety and sterility was performed by a contract-testing lab 
(WuXi-Apptec) under full Good Laboratory Practice (GLP). Testing for drug purity and potency was 
performed in the facility using standardized procedures. The results of lot release tests were reviewed 
by the Laboratory Director for quality assurance, accuracy, completeness, and for any problems. Once 
all safety tests have been completed, a certificate of analysis was prepared for each specific lot of 
material. After final review, the material is then released to the investigator. A list of the safety tests 
that were performed and the release specifications is shown below (Table 10 and Table 11). 
 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 46 of 50 
Date: 21Sept 2018 
Table 10:  Lot Release Tests and Specifications (Bulk Harvest Drug Substance). 
 
Test 
Method/Laboratory 
Specification 
Result NV 
Sterility 
including 
Bacteriostasis 
+Fungistasis 
Immersion USP/21 CFR 610.12 
Wu-Xi Apptec Protocol 
#30744,30736, and 30751 
 
Negative 
 
Negative 
 
Mycoplasma 
Points to consider for Viral 
Stocks, GLP 
Wu-Xi Apptec Protocol # 30200 
Negative 
Negative 
 
Endotoxin 
BET/LAL Gel Clot I/A Assay, 
GMP 
Wu-Xi Apptec Protocol # 30739 
< 500,000 
EU/mL 
 
3640 EU/mL 
In Vitro Adventitious 
Virus 
GLP, 3 Cell Lines, 28 days 
Wu-Xi Apptec Protocol # 30625 
Negative 
 
Negative 
 
In Vivo Virus 
Adult and Suckling mice, Eggs 
Wu-Xi Apptec Protocol # 30027 
Negative 
Negative 
Viral Titer 
Quantitative RT-PCR 
NPF SOP #4007, #4008 
 
>5 x 10e5 
genomes/mL 
5 x 10e6 
genomes/mL 
 
Identity 
RT-PCR 
Norovirus 
Strain NV 
NV 
 
Table 11:  Lot Release Tests and Specifications Final Fill Patient Dose Drug Product. 
 
Test 
Method/Laboratory 
Specification 
Result NV 
Sterility 
including 
Bacteriostasis 
+Fungistasis 
Immersion USP/21 CFR 610.12 
Wu-Xi Apptec Protocol #30744, 30751 
and 30736 
Negative 
Negative 
Mycoplasma 
Points to consider for Viral Stocks, GLP 
Wu-Xi Apptec Protocol # 30200 
Negative 
Negative 
Endotoxin 
BET/LAL Gel Clot I/A Assay, GMP 
Wu-Xi Apptec Protocol # 30743 
< 5000 
EU/mL 
235 EU/mL 
 
 
 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 47 of 50 
Date: 21Sept 2018 
APPENDIX C: SCHEDULE OF STUDY VISITS AND EVALUATIONS 
 
  
  
Pre-
Screening 
visit  
Screening 
visit  
Challenge phase (Inpatient) 
Follow up Visits 
Study Day 
 -60 to -
Screening 
 -30 to -3 
1 Pre 
2 Chal 
3 
4 
5 
6 /Disc 
9 
14 
28 
45 
Compliance Range 
  
  
  
  
  
  
  
  
± 1 d 
± 3 d ± 3 d 
± 3 d 
Visit  
00A 
00B 
00C 
1 
2 
3 
4 
5 
6 
7 
8 
9 
Outpatient 
X 
X 
  
  
  
  
  
  
X 
X 
X 
X 
Inpatient stay 
  
  
X 
X 
X 
X 
X 
X 
  
  
  
  
Informed Consent 
X 
X  
  
  
  
  
  
  
  
  
  
  
ABO blood typing 
X 
  
  
  
  
  
  
  
  
  
  
  
Saliva test for secretor status 
X 
  
  
  
  
  
  
  
  
  
  
  
Demographics 
X 
X  
  
  
  
  
  
  
  
  
  
  
Weight, Height, BMI 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
 
 
Eligibility criteria 
X 
X 
  
  
  
  
  
  
  
  
  
  
Medical interview 
  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Physical Exam, (X) = targeted 
  
X 
(X) 
(X) 
(X) 
(X) 
(X) 
(X) 
(X) 
(X) 
(X) 
  
Vital signs 
  
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
  
Concomitant medications 
  
X 
  
  
  
  
  
  
  
  
  
  
ECG 
  
X 
  
  
  
  
  
  
  
  
  
  
Screen for HIV, HBsAg and HCV  
  
X 
  
  
  
  
  
  
  
  
  
  
Safety laboratory evaluation 
  
X 
X 
  
  
  
  
X 
  
  
  
  
Drug screen (urine, alcohol breath) 
  
X 
 X 
  
  
  
  
  
  
  
  
  
Stool sample for enteric pathogens 
and occult blood 
  
X 
  
  
  
  
  
  
  
  
  
  
Pregnancy test (females) 
  
X 
X 
  
  
  
  
  
  
  
X  
  
Challenge 
  
  
  
X 
  
  
  
  
  
  
  
  
Symptom grading 
  
  
  
X 
X 
X 
X 
X 
  
  
  
  
Adverse events 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Stool weighing/grading 
  
  
  
X 
X 
X 
X 
X 
X 
X 
X 
  
Emesis weighing 
  
  
  
X 
X 
X 
X 
X 
  
  
  
  
Norovirus shedding (fecal/emesis) 
  
  
  
X 
X 
X 
X 
X 
X 
X 
X 
  
Discharge from inpatient 
  
  
  
  
  
  
  
X 
  
  
  
  
Diary card (issue and/or return) 
  
  
  
  
  
  
  
X 
X 
  
  
  
Phone interview 
  
  
  
  
  
  
  
  
  
  
  
X 
Immunology  
  
  
  
  
  
  
  
  
  
  
  
  
Serum sample (antibody) 
  
  
20 ml 
  
  
  
  
  
  
  
20 ml 
  
Whole blood sample (PBMCs) 
  
  
60 ml 
  
  
  
  
60 ml 
60 ml 
  
  
  
Fecal sample (IgA) 
  
  
X 
  
  
  
  
  
  
  
X 
  
Saliva sample (IgA) 
  
  
X 
  
  
  
  
  
  
  
X 
  
Assay Description 
  
  
  
  
  
  
  
  
  
  
  
  
qRT-PCR, Fecal 
  
  
X 
X 
X 
X 
X 
X 
X 
X 
X 
  
qRT-PCR, Emesis 
  
  
  
X 
X 
X 
X 
X 
  
  
  
  
VP1 IgG/IgA ELISA, Serum 
  
  
X 
  
  
  
  
  
  
  
X 
  
Assay Description (Exploratory) 
  
  
  
  
  
  
  
  
  
  
  
  
BT50, Serum 
  
  
X 
  
  
  
  
  
  
  
X 
  
ASC (IgG+IgA), PBMC 
  
  
X 
  
  
  
  
X 
X 
  
  
  
VP1 IgA ELISA, Fecal 
  
  
X 
  
  
  
  
  
  
  
X 
  
VP1 IgA ELISA, Saliva 
  
  
X 
  
  
  
  
  
  
  
X 
  

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 48 of 50 
Date: 21Sept 2018 
 
a. A serum pregnancy test will be performed at screening and a urine pregnancy test will be performed before challenge and on Day 28 on all 
Females. 
b. Screening laboratory to include:  Complete Blood Count (CBC); Chemistry panel for ALT, Creatinine, Albumin, Total Bilirubin, Sodium, 
Potassium, Bicarbonate, Chloride, and BUN; Serology for HBsAg, anti-HCV, and HIV; Blood Typing; and Urinalysis 
c. Safety laboratory to include:  Complete blood count (CBC) with differential and Chemistry panel for ALT, Creatinine, Albumin, Total Bilirubin, 
Sodium, Potassium, Bicarbonate, Chloride, and BUN 
d. Height will only be collected at Screening Visit to calculate BMI.  Measure body Weight only during Inpatient Challenge phase.    
e. The observation and management of norovirus illness and stool grading and stool cultures are intended to be performed throughout the post-
challenge inpatient period, until discharge criteria are satisfied 
f. At Day 28 visit, if the stool specimen is positive for norovirus, subject will return to clinic weekly until they test negative or through Day 45. 
 
ASC = antibody secreting cell; BUN = blood urea nitrogen; PBMC = peripheral blood mononuclear cell; ELISA = enzyme-linked immunosorbent 
assay; BT50 = histo-blood group binding antigen blocking antibody titers; qRT-PCR = quantitative reverse transcriptase-polymerase chain reaction; 
VP1 = viral protein 1. 
 
 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 49 of 50 
Date: 21Sept 2018 
APPENDIX D: ADVERSE EVENT GRADING SCALES 
Grading of Stool Consistency 
normal stool 
loose or diarrheal stool 
Grade 1 
Grade 2 
Grade 3 
Grade 4 
Grade 5 
Well formed; 
does not take the 
shape of the 
container 
Soft; 
does not easily take 
the shape of the 
container 
Thick liquid stool; 
easily takes the 
shape of the 
container 
Opaque watery 
diarrheal stool 
Clear watery or “rice 
water” diarrheal 
stool 
 
Diarrhea Severity 
Mild 
Moderate 
Severe 
2 or more loose stools of ≥ 200gms 
within 48 hours 
or 
a single loose stool of ≥ 300gms 
Cumulative loose stools of ≥ 
1000gms 
Cumulative loose stools of ≥ 
3000gms 
  
Systemic symptoms 
Mild 
Grade 1 
Moderate 
Grade 2 
Severe 
Grade 3 
Potentially Life 
Threatening 
Grade 4 
Diarrhea 
(refer to table above) 
Requires 
hospitalization 
Vomiting (episodes/24 hour) 
1-2 
3-4 
≥ 5 
Fever, °C (°F) 
38.0 – 38.4 
(100.4 – 101.1) 
38.5 – 38.9 
(101.3 – 102) 
≥ 39 
(≥ 102.2) 
Solicited symptoms include:  
headache, nausea, abdominal 
cramps or pain, abdominal 
gurgling or bloating, myalgia 
No interference 
with activity 
Some interference 
with activity 
Prevents daily 
activity 
Requires 
hospitalization 
 
 
 
 
 
 

 
 
Protocol Number: VXA-G11-201.1 
________________________________________________________________________________ 
 
 
Version 1.1                                                 Confidential                                                    Page 50 of 50 
Date: 21Sept 2018 
APPENDIX E:  MODIFIED VESIKARI SCALE (17 POINTS) 
 
Duration of Diarrhea 
(days) 
Points 
1 
1 
 2-3 
2 
 ≥ 4 
3 
Maximum number of 
diarrhea stools/24 h 
  
 1-3 
1 
 4-5 
2 
 ≥ 6 
3 
Duration of Vomiting 
(days) 
  
1 
1 
2 
2 
≥ 3 
3 
Maximum number of 
vomiting episodes/24 h 
  
0 
0 
1 
1 
 2-4 
2 
≥ 5 
3 
Fever (°C) 
  
≤ 37 
0 
37.1-38.4 
1 
38.5-38.9 
2 
≥ 39 
3 
Dehydration 
  
None 
0 
IV treatment 
2