Safety and Immunogenicity Evaluation of the Malaria Vaccine, RTS,S/AS01, in Healthy Thai Adults
Phase: PHASE2
Conditions: Malaria Vaccine
Sponsor: University of Oxford

 
 
 
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SAFETY AND IMMUNOGENICITY EVALUATION OF THE MALARIA 
VACCINE, RTS,S/AS01, IN HEALTHY THAI ADULTS 
 
Protocol Number: BAKMAL 1605 
OxTREC: 54 - 16 
Date and Version No:  2/11/2017 version 5.0 
 
Principal Investigator: 
 
 
 
 
 
 
 
 
 
Site Principal Investigator 
Lorenz von Seidlein 
 
Mahidol-Oxford Tropical Medicine Research Unit (MORU) 
Faculty of Tropical Medicine 
Mahidol University 
420/6 Rajvithi Road 
Bangkok 10400 
Thailand 
Tel. +66-(0)2-3549170 
Fax. +66-(0)2-3549169 
mobile Thailand:  
+66 9 2648 6322 
Professor Sasithon Pukrittayakamee 
 
Sub-Investigators:  
Professor Nicholas White 
Professor Nicholas Day 
Prof Arjen M. Dondorp 
Dr. Chris Ockenhouse 
Dr. Podjanee Jittamala 
Dr. Borimas Hanboonkunupakarn 
 
Sponsor:  
Oxford University 
Clinical Trials and Research Governance  
Joint Research Office, Block 60, Churchill Hospital,  
Old Road, Headington, Oxford, OX3 7LE, United Kingdom 
Tel: 01865 572224 
Fax: 01865 572228 
Email: ctrg@admin.ox.ac.uk 
 
Funding partner:  
PATH 
2201 Westlake Avenue, Suite 200 
Seattle, Washington, 98121, USA 
 

 
 
 
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Confidentiality Statement 
This document contains confidential information that must not be disclosed to anyone other than the 
Sponsor, the Investigator Team, regulatory authorities, and members of the Research Ethics 
Committee(s). 
 
Investigator Agreement and Conflict of Interest 
 
“I have read this protocol and: 
- 
agree to abide by all provisions set forth therein. 
- 
agree to comply with the principles of the International Conference on Harmonisation 
Tripartite Guideline on Good Clinical Practice. 
- 
and declare no conflict of interest, according to the current version of the Declaration of 
Helsinki”  
 
 
 
 
 
 
Principal Investigator 
 
Principal Investigator Signature 
 
Date  
 
 

 
 
 
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TABLE OF CONTENTS 
 
1 
SYNOPSIS ........................................................................................................................ 
   8 
2 
BACKGROUND AND RATIONALE .................................................................................... 
  11 
3 
OBJECTIVES .................................................................................................................... 
  13 
4 
TRIAL DESIGN .................................................................................................................. 
  14 
4.1 
Summary of Trial Design .................................................................................................... 14 
4.2 
Primary Outcome Measures ............................................................................................... 14 
4.3 
Trial Participants ................................................................................................................. 15 
4.4 
Indications for deferral of vaccination .................................................................................. 16 
4.5 
Absolute contraindications to further vaccination ................................................................ 17 
4.6 
Expenses and Benefits ....................................................................................................... 17 
4.7 
Potential Risks for Study Participants ................................................................................. 18 
4.8 
Study Procedures ............................................................................................................... 20 
4.9 
Definition of Start and End of Trial ...................................................................................... 26 
4.10 Participant withdrawal from the study ................................................................................. 26 
4.11 Participant withdrawal from the study agent ........................................................................ 27 
4.12 Pregnancy .......................................................................................................................... 27 
4.13 Source Data ....................................................................................................................... 28 
5 
TREATMENT OF TRIAL PARTICIPANTS ......................................................................... 
  28 
5.1 
Description and administration of the study agents ............................................................. 28 
5.2 
Storage of vaccines and anti-malarial medications ............................................................. 30 
6 
SAFETY REPORTING ....................................................................................................... 
  31 
6.1 
SAFETY ............................................................................................................................. 31 
6.2 
Safety definitions ................................................................................................................ 31 
6.2.1 Definition of an adverse event ............................................................................................ 31 
6.2.2 Definition of a serious adverse event .................................................................................. 32 
6.3 
Solicited adverse events ..................................................................................................... 33 
6.3.1 Solicited local (injection-site) adverse events ...................................................................... 33 
6.3.2 Solicited general adverse events ........................................................................................ 33 
6.4 
Clinical laboratory parameters and other abnormal assessments qualifying as adverse events 
or serious adverse events ........................................................................................................... 33 
6.5 
Adverse events of specific interest ..................................................................................... 34 
6.5.1 Potential immune-mediated diseases (pIMD) ..................................................................... 34 
6.5.2 Meningitis ........................................................................................................................... 35 
6.6 
Events or outcomes not qualifying as adverse events or serious adverse events ............... 35 
6.6.1 Pregnancy .......................................................................................................................... 35 
6.7 
Detecting and recording adverse events and serious adverse events ................................. 36 

 
 
 
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6.7.1 Recording adverse events, serious adverse events and pregnancies ................................. 36 
6.7.2 Post-Study adverse events and serious adverse events ..................................................... 36 
6.8 
Active questioning to detect adverse events and serious adverse events ........................... 36 
6.9 
Assessment of intensity ...................................................................................................... 36 
6.10 Assessment of causality ..................................................................................................... 39 
6.11 Assessment of outcomes .................................................................................................... 40 
6.12 Safety (ANALYSIS) ............................................................................................................ 40 
6.13 Analysis of safety ................................................................................................................ 41 
7 
Holding rules and safety monitoring ................................................................................... 
  41 
8 
STATISTICAL Analysis ...................................................................................................... 
  42 
8.1 
Endpoints ........................................................................................................................... 42 
8.2 
The Number of Participants ................................................................................................ 43 
8.3 
Inclusion in Analysis ........................................................................................................... 45 
8.4 
Overall plan ........................................................................................................................ 45 
8.5 
Analysis of baseline characteristics .................................................................................... 46 
8.6 
Analysis of immunogenicity ................................................................................................ 46 
9 
DIRECT ACCESS TO SOURCE DATA/DOCUMENTS ...................................................... 
  47 
10 QUALITY CONTROL AND QUALITY ASSURANCE PROCEDURES ................................ 
  47 
11 ETHICS.............................................................................................................................. 
  47 
11.1 Declaration of Helsinki ........................................................................................................ 47 
11.2 ICH Guidelines for Good Clinical Practice .......................................................................... 47 
11.3 Approvals ........................................................................................................................... 47 
11.4 Participant Confidentiality ................................................................................................... 48 
12 DATA HANDLING AND RECORD KEEPING..................................................................... 
  48 
13 INSURANCE ...................................................................................................................... 
  49 
14 PUBLICATION POLICY ..................................................................................................... 
  49 
15 APPENDIX A: SUMMARY OF STUDY ARMS AND PROCEDURES ................................. 
  50 
16 REFERENCES .................................................................................................................. 
  52 
 
 
 

 
 
 
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AMENDMENT HISTORY 
Amendment 
No. 
Protocol 
Version 
No. 
Date 
issued 
Author(s) 
of 
changes 
Details of Changes made 
1 
V 2.0 
6/02/2017 
Lorenz von 
Seidlein 
- Increase of blood volume 
for the immunology panel 
in order to have sample 
leftover for future use 
- Revision of antimalarial 
drugs dosing schedule 
and drugs level tests 
- Addition of a biorepository 
sample management  
- The changes to address 
ECs comments 
 Subject compensation to 
be 1,000 THB/visit 
 Addition of appropriate 
contraceptive methods  
 Addition of informed 
consent process for pre-
post counselling for HIV  
screening, report and 
treatment 
2 
V 3.0 
14/03/2017 
Lorenz von 
Seidlein 
- Revision of study 
procedures and outcome 
analysis for gr. 7 
participant at M1D0 and 
M1D7  
3 
V 4.0 
11/05/2017 
Lorenz von 
Seidlein 
- Revision to allow the use 
of screening lab tests for 
enrollment evaluation if 
interval between and 
screening and enrolment 
is three days or less. 
4 
V 5.0 
2/11/2017 
Lorenz von 
Seidlein 
- Revision to allow 
additional PK 
assessments if additional 
data are required. 
 
 
 
 
 
 
 
 
 
 

 
 
 
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LIST OF ABREVIATIONS:  
 
AE 
Adverse event 
ALT 
Alanine aminotransferase 
anti-CS 
Antibody to the P. falciparum circumsporozoite (CS) repeat 
domain 
anti-HBs 
Antibody to the hepatitis B surface antigen 
AS01B 
GSK’s proprietary Adjuvant System containing MPL, QS-21 and 
liposome (50 µg MPL and 50 µg QS-21) 
AS01E 
GSK’s proprietary Adjuvant System containing MPL, QS-21 and 
liposome (25 µg MPL and 25 µg QS-21) 
AST 
Aspartate aminotransferase 
CI 
Confidence interval 
CREA 
Creatinine 
CRF 
Case report form 
CS 
Circumsporozoite protein of P. falciparum 
DHA-PIP 
 
Dihydroartemisinin–piperaquine 
DSMB 
Data safety monitoring board 
ECG 
Electrocardiogram 
ELISA 
Enzyme linked immunosorbent assay 
EPT 
Endpoint titre 
FDA 
Food and Drug Administration, United States 
GCP 
Good clinical practice  
GSK 
GlaxoSmithKline 
Hb 
Haemoglobin 
HBsAg 
Hepatitis B surface antigen 
HBV 
Hepatitis B virus 
HCV 
Hepatitis C virus 
Hep B 
Hepatitis B 
HIV 
Human immunodeficiency virus 
IB 
Investigator’s brochure 
ICF 
Informed consent form 
ICH 
International Committee on Harmonization 
IEC 
Independent ethics committee 
IgG 
Immunoglobulin G 
IM 
Intramuscular 
IRB 
Institutional review board 

 
 
 
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IU 
International unit 
kg 
Kilogram 
MedDRA 
Medical Dictionary for Regulatory Activities 
mg 
Milligram 
mL 
Milliliter 
ms 
Millisecond 
MPL® 
3-deacylated monophosphoryl lipid A 
MVI 
Malaria Vaccine Initiative 
P. falciparum 
Plasmodium falciparum 
PFS 
Pre-filled syringe 
PI 
Principal Investigator 
PLT 
Platelets 
PQ 
 
 
Primaquine 
QS-21 
‘Quillaja saponaria 21’: a triterpene glycoside purified from the 
bark of the soap bark tree, Quillaja saponaria 
RTS 
Hybrid protein comprising HBs (hepatitis B surface antigen) and 
CSP portions 
RTS,S 
Particulate antigen, containing both RTS and HBs proteins 
SAE 
Serious adverse event 
SLD-PQ 
 
Single low dose Primaquine 
SOP 
Standard operating procedure 
ULN 
Upper limit of normal 
WBC 
White blood cells 
WRAIR 
Walter Reed Army Institute for Research 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
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1 SYNOPSIS 
Study Title 
Safety and immunogenicity evaluation of the malaria vaccine, 
RTS,S/AS01, in healthy Thai adults 
Study Design 
Randomized, open label, single centre,  Phase 2 study  
Study Participants 
 
190 healthy non-pregnant Thai adults, aged 18-55 years, 
inclusive, will be recruited.  
 
Study arms 
See Table 3 for dosing table 
 
1. RTS,S/AS01B Fractional dose group  (Group 1, n=20) will 
receive RTS,S/AS01B standard dose at Month 0 and Month 1 
+ RTS,S/AS01B fractional dose (1/5th dose) at Month 2. 
2. Double RTS,S/AS01E Fractional dose group (Group 2, n=20) 
will receive a double dose of RTS,S/AS01E standard dose at 
Month 0 and Month 1 + a double dose of RTS,S/AS01E 
fractional dose (1/5th dose) at Month 2.    
3.  RTS,S/AS01E Standard dose group (Group 3, n=30) will 
receive RTS,S/AS01E standard dose at Month 0, Month 1 and 
Month 2. 
4. RTS,S/AS01E + DHA-PIP+PQ Standard dose group (Group 4, 
n=30) will receive RTS,S/AS01E standard dose + DHA-
PIP+PQ at Month 0, Month 1 and Month 2  
5. RTS,S/AS01E Fractional dose group (Group 5, n=30) will 
receive RTS,S/AS01E standard dose at Month 0 and Month 1 
+ RTS,S/AS01E fractional dose (1/5th dose) at Month 2. 
6. RTS,S/AS01E + DHA-PIP+PQ Fractional dose group (Group 6, 
n=30) will receive RTS,S/AS01E standard dose + DHA-
PIP+PQ at Month 0 and Month 1 + RTS,S/AS01E fractional 
dose (1/5th dose) + DHA-PIP+PQ at Month 2. 
7. RTS,S/AS01E + DHA-PIP+PQ Fractional two-dose group 
(Group 7, n=30) will receive RTS,S/AS01E standard dose + 
DHA-PIP+PQ at Month 0 + RTS,S/AS01E fractional dose 
(1/5th dose) + DHA-PIP+PQ at Month 2. 
 

 
 
 
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Standard dose RTS,S/AS01B: 50µg RTS,S + standard dose AS01B 
(0.5ml containing 50µg MPL + 50µg QS21) 
Standard dose RTS,S/AS01E: 25µg RTS,S + standard dose AS01E 
(0.5ml containing 25µg MPL + 25µg QS21) 
Fractional dose RTS,S/AS01B (1/5th dose): 10µg RTS,S + 1/5 
standard dose AS01B (0.1ml containing 10µg MPL + 10µg QS21)  
Fractional dose RTS,S/AS01E (1/5th dose): 2.5µg RTS,S + 1/5 
standard dose AS01E (0.1ml containing 2.5µg MPL + 2.5µg QS21)  
DHA-PIP: Dihydroartemisinin–piperaquine co-formulated, given on 
day of vaccination (day 0) and each of the subsequent two days 
(days 1 and 2 post-vaccination). 
PQ: Primaquine, given on day of vaccination (day 0). 
 
Number of vaccine vials 
needed  
 
60 vials RTS,S/AS01B (adult formulation)  
 
540 vials RTS,S/AS01E (standard formulation)  
Planned Study Period  
6 months for each participant, from receipt of first vaccination 
3 months to recruit 190 eligible volunteers 
Total 9 months 
Objectives 
 
1) To assess the safety and immunogenicity of the standard 
formulation of the RTS,S vaccine (RTS,S/AS01E) in Thai 
adults.  
 
2) To assess the safety and immunogenicity of the adult 
formulation of the RTS,S vaccine (RTS,S/AS01B) in Thai 
adults.  
 
3) To compare the safety and immunogenicity of a fractional 
dose RTS,S regime (where the third dose is a 1/5th of the 
standard dose) using the adult formulation (RTS,S/AS01B) to 
the safety and immunogenicity of fractional dose RTS,S 
regimes using either single or double doses of the standard 
formulation (RTS,S/AS01E), in Thai adults.  G1 vs G2 vs G5 
 
4) To compare the safety and immunogenicity of fractional 
dose regime (where the third dose is a 1/5th of the standard 
dose) using a single dose of the standard formulation 
(RTS,S/AS01E) to the safety and immunogenicity of fractional 

 
 
 
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dose RTS,S regime using a double dose of the standard 
formulation (RTS,S/AS01E), in Thai adults. G2 vs G 5) 
 
5) To compare the serologic response to RTS,S/AS01E 
vaccine when co-administered with DHA-PIP + SLD-PQ with 
RTS,S/AS01E vaccine alone in adults, when RTS,S/AS01E is 
given in either a fractional dose regime (where the third dose is 
a 1/5th of the standard dose) or a full standard dose regime. G2 
vs G3 and G4 vs G6 
 
6) To compare the serologic response to RTS,S/AS01E 
vaccine co-administered with DHA-PIP + SLD-PQ, when 
RTS,S/AS01E is given in a fractional two-dose regimen (Month 
0, standard dose and Month 2, fractional (1/5th) dose) with 
RTS,S/AS01E vaccine co-administered with DHA-PIP + SLD-
PQ, when RTS,S/AS01E is given in a fractional three-dose 
regimen (Month 0 and Month 1, standard doses and Month 2, 
fractional (1/5th) dose)  G6 vs G7 
Primary Outcomes 
 
The safety of the investigational vaccine in each group: 
o Occurrence of serious adverse events (SAEs) from the 
date of the first vaccination to 29 days after the last 
vaccination, according to the MedRA classification. 
o Occurrence of SAEs during the whole study period, i.e. 
during a 6 month follow up period from the receipt of 
first vaccination, according to the MedRA classification. 
 
 
For groups 1 to 6, the concentration of antibodies against 
Plasmodium falciparum circumsporozoite (anti-CS antibody), 
one month after the first dose (at Study month 1), one month 
after the second dose (at Study month 2), one month after the 
third dose (at Study Month 3) and six months after the first 
dose (at Study Month 6). 
 
For group 7, the concentration of antibodies against 
Plasmodium falciparum circumsporozoite (anti-CS antibody), 
one month after the first dose (at Study month 1), two months 
after the first dose (at Study month 2), one month after the 
second dose (at Study month 3), and six months after the first 
dose (at Study Month 6). 

 
 
 
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Trial centre 
Hospital for Tropical Disease 
Faculty of Tropical Medicine 
Mahidol University 
420/6 Rajvithi Road 
Bangkok 10400 
Thailand 
Medical monitor 
Elizabeth Ashley (MORU) 
DSMB (chair) 
Philip Bejon (KEMRI/Kilifi Wellcome Trust) 
Study monitor 
Jaruwan Tubprasert 
Mahidol-Oxford Tropical Medicine Research Unit (MORU) 
Faculty of Tropical Medicine 
Mahidol University 
420/6 Rajvithi Road 
Bangkok 10400 
Thailand  
 
2 BACKGROUND AND RATIONALE 
 
The malaria vaccine, RTS,S/AS01, consists of hepatitis B virus surface antigen virus-like particles 
incorporating a portion of the Plasmodium falciparum-derived circumsporozoite protein and a 
liposome-based adjuvant (AS01) containing two immune enhancers MPL (3’-O-desacyl-4’-
monophosphoryl-lipid A) and QS-21 (Quillaja saponaria Molina, fraction 
21) 1. In a large Phase 3 trial of RTS,S/AS01E at 11 sites in seven sub-Saharan African countries, 
efficacy against clinical malaria in children aged 5–17 months following three primary doses was 
45.1% (CI 41.4 to 48.7), 35.2% (CI 30.5 to 39.5) and 28.3% (CI 23.3 to 32.9) during 20, 32 and 48 
months of follow-up, respectively2. In July 2015, RTS,S/AS01E received a positive scientific opinion 
by the European Medicines Agency for active immunization of children aged 6 weeks to 17 months 
against malaria3.  
 
Other than considering RTS,S/AS01E for inclusion in the expanded programme of immunisations 
(EPI) in sub-Saharan Africa, the vaccine could be used as an innovative and potentially critical 
additional tool in the effort to stop the spread of artemisinin-resistant falciparum malaria in 
Southeast Asia. Multidrug-resistant P. falciparum strains have replaced the susceptible wild type in 
many parts of Cambodia4, where chloroquine, pyrimethamine, and sulphadoxine resistance 
originated, and from where these strains spread to Africa at a cost of millions of children’s lives5, 6. 
With the subsequent development of resistance to artemisinin combination therapy (ACT), the 

 
 
 
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usefulness of ACTs in Cambodia has been compromised7 and malaria incidence in northeast 
Cambodia is again on the rise. These resistant P. falciparum strains have spread across the Greater 
Mekong Subregion (GMS), compromising ACT efficacy, and they are now encroaching on the 
Indian subcontinent, the traditional gateway of malaria resistance to Africa8. There is a large and 
growing sub-Saharan African population that is immunologically naïve to malaria due to the 
dramatic reductions in malaria transmission during the last decade. If artemisinin-resistant P. 
falciparum strains are introduced and spread in sub-Saharan Africa, this could give rise to a surge in 
malaria-related illness and death, as was seen during the spread of chloroquine resistance in the 
1980s and 1990s9. The only way to stop the spread of artemisinin-resistant malaria is through the 
elimination of P. falciparum in the GMS while this is still possible.  
 
Targeted malaria elimination (TME), which comprises appropriate case management by village 
health workers, vector control and mass drug administration, is currently being implemented through 
pilot projects in selected villages in the Greater Mekong Subregion (GMS) and the scale-up of the 
intervention to the regional level are underway. TME is a time-consuming, demanding and difficult 
process requiring several months for regional coverage. Importantly, the elimination of individual P. 
falciparum parasitaemia using anti-malarial drugs is short-term; untreated parasitaemic travellers 
and migrants can readily re-introduce infections into treated villages. There is a concern that TME 
can achieve only a transient reduction in malaria followed by resurgence. Based on mathematical 
modelling, extending the post-TME parasitaemia-free period in the majority of villagers for as short 
as 200 days will substantially increase the chances of achieving the interruption of malaria 
transmission.  
 
The mass administration of antimalarials like DHA/piperaquine can interrupt malaria transmission for 
limited time periods. To achieve longer lasting interruptions it would be critical to prevent re-
infections, and the addition of mass vaccination campaigns integrated in mass drug administration 
campaigns may achieve this goal. 
 
Immunogenicity of RTS,S is greater in older children, and the short term malaria protective effect is 
stronger than the overall effect assessed over 1-2 years. Addition of mass RTS,S/AS01E 
vaccination to the TME arsenal could provide this much needed additional protection.  
 
Prior to the roll out of the combination of antimalarials with a vaccine it is mandatory to assess and 
confirm safety and vaccine immunogenicity.   
 
RTS,S has not been used in combination with antimalarial drugs in the past. There is no practical or 
theoretical reason why the antimalarial drugs dihydroartemisinin/piperaquine and primaquine should 

 
 
 
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have any influence on the immunogenicity or safety of the RTS,S/AS01 vaccine. The only potential 
reason why there could be interference is the observation that the immunogenicity of live rabies 
vaccine is reduced by co-administration with chloroquine. The WHO therefore has warned that the 
concurrent use of chloroquine can reduce the antibody response to intradermal application of cell-
culture rabies vaccines. People who are currently receiving malaria prophylaxis or who are unable 
to complete the entire three-dose rabies vaccine pre-exposure series before starting malarial 
prophylaxis should receive pre-exposure vaccination by the intramuscular route. In the past there 
have been no safety concerns regarding the co-administrations of vaccines with antimalarials. 
 
Currently there are no safety and immunogenicity data for the use of RTS,S/AS01 in Asian 
populations. This trial will generate the required data for the use of this vaccine in Asian populations.  
For integration with the current TME activities, which provide mass drug administrations at months 
M0, M1, and M2, it would be most efficient and practical to provide the vaccine at the same 
intervals. To address a two round intervention (M0, M2) where a three round intervention is not 
feasible, one study arm will look at the immune response generated by only two doses of vaccine 
and antimalarial medications. Recent evidence suggests that a vaccination schedule which includes 
a fractional dose of RTS,S/AS01 (1/5th of the standard dose) could be similarly or more protective 
than a schedule with three standard doses,  while requiring less vaccine and resources10. The 
evidence  demonstrates that a change in immunization schedule that includes a dose reduction of 
the third RTS,S/AS01 vaccination, results in a significant increase in protection against controlled 
human malaria infection (CHMI) without an increase in the absolute antibody concentration after 
vaccination. Qualitative evaluation of immune responses showed that the third dose spacing and 
dose reduction increased somatic hypermutation in immunoglobulin genes and avidity. The trial 
therefore includes study arms which will assess the safety and immunogenicity of fractional dose 
schedules. 
 
In summary: We propose to conduct a safety and immunogenicity trial of RTS,S/AS01 in Thai 
adults. The two major aims of this study are to 1) confirm that the co-administration of antimalarial 
drugs with the malaria vaccine RTS,S/AS01 does not reduce the immunogenicity of the vaccine, 2) 
assess the  safety and immunogenicity of RTS,S/AS01 in Thai adults.  
 
3 OBJECTIVES 
 
The trial has the following objectives: 
 

 
 
 
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 
To assess the safety and immunogenicity of the standard formulation of the RTS,S vaccine 
(RTS,S/AS01E) in Thai adults (Group 3 alone).  
 
To assess the safety and immunogenicity of the adult formulation of the RTS,S vaccine 
(RTS,S/AS01B) in Thai adults (Group 1 alone).  
 
To compare the safety and immunogenicity of a fractional dose RTS,S regime (where the third 
dose is a 1/5th of the standard dose) using the adult formulation (RTS,S/AS01B) to the safety 
and immunogenicity of fractional dose RTS,S regimes using either single or double doses of the 
standard formulation (RTS,S/AS01E), in Thai adults (Group 1 vs Group 2 and Group 1 vs Group 
5).   
 
To compare the safety and immunogenicity of fractional dose regime (where the third dose is a 
1/5th of the standard dose) using a single dose of the standard formulation (RTS,S/AS01E) to 
the safety and immunogenicity of fractional dose RTS,S regime using a double dose of the 
standard formulation (RTS,S/AS01E), in Thai adults (Group 2 vs Group 5).  
 
To compare the serologic response to RTS,S/AS01E vaccine when co-administered with DHA-
PIP + SLD-PQ with RTS,S/AS01E vaccine alone in adults, when RTS,S/AS01E is given in either 
a fractional dose regime (where the third dose is a 1/5th of the standard dose) or a full standard 
dose regime (Group 3 vs. Group 4 and Group 5 vs Group 6). 
 
To compare the serologic response to RTS,S/AS01E vaccine co-administered with DHA-PIP + SLD-
PQ, when RTS,S/AS01E is given in a fractional two-dose regimen (Month 0, standard dose and 
Month 2, fractional (1/5th) dose) with RTS,S/AS01E vaccine co-administered with DHA-PIP + SLD-
PQ, when RTS,S/AS01E is given in a fractional three-dose regimen (Month 0 and Month 1, standard 
doses and Month 2, fractional (1/5th) dose) (Group 6  vs Group 7) 
4 TRIAL DESIGN 
 
4.1 Summary of Trial Design 
 
This is a randomized, open-label, single centre, Phase 2 trial of RTS,S/AS01 in healthy Thai adults.  
 
4.2 Primary Outcome Measures 
 
The primary outcome measures will be: 
 
The safety of the investigational vaccine in each group: 
o Occurrence of serious adverse events (SAEs)  from the date of the first vaccination to 29 
days after the last vaccination, according to the MedRA classification. 
o Occurrence of SAEs during the whole study period, i.e. during a 6 month follow up period 
from the receipt of first vaccination, according to the MedRA classification. 

 
 
 
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 
For groups 1  to 6, the concentration of antibodies against Plasmodium falciparum 
circumsporozoite (anti-CS antibody), one month after the first dose (at Study month 1), one 
month after the second dose (at Study month 2), one month after the third dose (at Study 
Month 3) and six months after the first dose (at Study Month 6). 
 
For group 7, the concentration of antibodies against Plasmodium falciparum circumsporozoite 
(anti-CS antibody), one month after the first dose (at Study month 1), two months after the first 
dose (at Study month 2), one month after the second dose (at Study month 3), and six months 
after the first dose (at Study Month 6). 
 
4.3 Trial Participants 
 
4.3.1 Overall Description of Trial Participants 
 
190 healthy, non-pregnant Thai adults (aged 18 to 55 years, inclusive) will be recruited into the 
study. 
 
4.3.2 Inclusion Criteria 
 
The participant may enter the study if all of the following apply: 
- 
Participant is a healthy male or non-pregnant female, aged 18 to 55 years (inclusive), of Thai 
origin.  
- 
Participant is willing and able to give informed consent to participate in the trial 
- 
Able, in the investigators opinion, and willing to comply with the study requirements and follow-
up. 
 
4.3.3 Exclusion Criteria 
 
The following criteria should be checked at the time of study entry. If ANY exclusion criterion 
applies, the subject must not be included in the study: 
 
- 
Female participant who is pregnant, lactating or planning pregnancy during the course of the 
study. 
- 
Presence of any condition which in the judgment of the investigator would place the participant 
at undue risk or interfere with the results of the study (e.g. serious underlying cardiac, renal, 
hepatic or neurological disease; severe malnutrition; congenital defects or febrile condition). 
- 
Hepatitis B surface antigen (HBsAg) detected in serum. 
- 
Screening ECG demonstrates a QTc interval ≥ 450 ms 

 
 
 
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- 
Seropositive for hepatitis C virus (antibodies to HCV) at screening (unless has taken part in a 
prior hepatitis C vaccine study with confirmed negative HCV antibodies prior to participation in 
that study, and negative HCV RNA PCR at screening for this study).  
- 
Anaemia (Hb < 10 g/dL) 
- 
Positive malaria parasitaemia at screening or baseline (Month 0, Day 0).  
- 
Use of any investigational or non-registered product or investigational use of a registered 
product (drug or vaccine), other than the study vaccines, during the period  from the date of 
screening to the first vaccination, or planned use during the study period. 
- 
Any medical condition that in the judgment of the investigator would make intramuscular (IM) 
injection unsafe. 
- 
Any medical condition that in the judgment of the investigator would make the administration of 
the antimalarial treatment unsafe, such as prior allergic reactions to one or more component of 
the drug regimen: artemisinins, piperaquine or primaquine. 
- 
Contraindications to the use of artemisinins, piperaquine or primaquine or use of medications 
known to have a potentially clinically significant interaction with these medications. 
- 
Chronic administration (defined as more than 14 days in total) of immunosuppressants or other 
immune-modifying drugs during the period starting six months prior to the first vaccine dose. For 
corticosteroids, this will mean prednisone > 20 mg/day (for adult subjects), or equivalent. Inhaled 
and topical steroids are allowed. 
- 
Planned administration/administration of a vaccine not foreseen by the study protocol in the 
period starting seven days before the first dose. 
- 
Concurrently participating in another clinical study, at any time during the study period, in which 
the subject has been or will be exposed to an investigational or a non-investigational 
vaccine/product. 
- 
History of splenectomy. 
- 
Any confirmed or suspected immunosuppressive or immunodeficient condition, including HIV 
infection or based on medical history and physical examination. 
- 
History of anaphylaxis post-vaccination. 
- 
Serious chronic illness. 
- 
Any abnormal baseline laboratory screening tests: ALT, AST, creatinine, haemoglobin, platelet 
count, total WBC, out of normal range as defined in the protocol. 
- 
Hepatomegaly, right upper quadrant abdominal pain or tenderness. 
- 
Personal history of autoimmune disease. 
- 
Administration of immunoglobulins and/or any blood products during the period starting three 
months before the first dose of study vaccine or planned administration during the study period. 
 
4.4 Indications for deferral of vaccination 

 
 
 
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The following events constitute contraindications to administration of RTS,S/AS01 at that point in time. 
If any one of these adverse events (AEs) occurs at the time scheduled for vaccination, the participant 
may be vaccinated at a later date, or withdrawn at the discretion of the investigator.  
 
- 
Acute disease at the time of vaccination (acute disease is defined as the presence of a moderate 
or severe illness with or without fever). All vaccines can be administered to persons with a minor 
illness such as diarrhoea, mild upper respiratory infection with or without low-grade febrile illness, 
i.e. Axillary temperature <37.5°C). 
- 
Axillary temperature of ≥ 37.5°C at time of vaccination. 
- 
Administration of a vaccine not foreseen by the study protocol within 30 days of any dose of 
RTS,S/AS01 with the exception of vaccines against polio, diphtheria, tetanus, pertussis, hepatitis 
B, Haemophilus influenzae type b, BCG, measles, influenza, pneumococcal disease or yellow 
fever which may not be given within one week of vaccination. 
 
4.5 Absolute contraindications to further vaccination 
 
The following AEs constitute absolute contraindications to further administration of RTS,S/AS01. If 
any of these AEs occur during the study, the participant must not receive additional doses of 
RTS,S/AS01, but may continue other study procedures at the discretion of the investigator. It is 
expected that the participant would continue full safety monitoring procedures, as per protocol.  
 
- 
Acute allergic reaction or anaphylactic shock following the administration of vaccine 
investigational product. 
- 
Pregnancy 
- 
Any other findings that the investigator feels would increase the risk of having an adverse 
outcome from participation in the trial. 
 
4.6 Expenses and Benefits 
 
Reasonable compensation (e.g. for transport, parking, and lost working time) for any study visits will 
be reimbursed as appropriate. Subjects will receive compensation of 1,000 Baht for each scheduled 
study visit.   
group 1, 2, 3, 5 group 4, 6 group 7 
screening 
1,000 
1,000 
1,000 
vaccination 
3,000 
3,000 
2,000 
antimalarials day 2 and 3 
6,000 
4,000 
follow  up 
5,000 
5,000 
4,000 

 
 
 
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total 
9,000 
15,000 
11,000 
 
No direct benefit is foreseen from study participation. Meals to be provided to study participants at 
some study visits might be considered as a direct benefit and other possible indirect benefits may 
be possible since subjects will be screened for human immunodeficiency virus (HIV), hepatitis B and 
C and will receive a medical check-up.  Knowledge gained from this study is may assist with the 
development of a vaccine against P.falciparum malaria which could potentially be used to help stop 
the spread of malaria and anti-malarial resistance in the region. 
 
4.7 Potential Risks for Study Participants 
 
4.7.1 Phlebotomy 
 
There may be minor bruising, local tenderness or pre-syncopal symptoms associated with 
venepuncture, which will not be documented as AEs if they occur.  
 
4.7.2 RTS,S/AS01 vaccination 
 
The most frequent adverse reactions observed in previous clinical trials using the RTS,S antigen and 
AS01 adjuvant system include pain, swelling, erythema, and tenderness at the site of injection, and 
systemic symptoms such as low-grade fever and short-term flu-like symptoms: fatigue, myalgia, 
headache, malaise. As with any vaccine, unexpected serious adverse events, including severe 
allergic reactions to the vaccine components, may occur, although this has not been reported in prior 
studies with RTS,S or the adjuvant in adults. In order to mitigate this risk, volunteers will be vaccinated 
in a clinical area where Advanced Life Support trained physicians, equipment and drugs are 
immediately available for the management of any immediate post-vaccination serious adverse 
reactions. Subjects will be observed closely for at least 30 minutes following administration of the 
vaccine. 
Febrile seizures assessed as related to RTS,S/AS01 vaccination have been reported in children, but 
not in adults.  
In the large Phase III study of RTS,S in infants and children in sub-Sahara Africa, an imbalance of 
meningitis cases of any aetiology (i.e. including cases with confirmed aetiology and cases with no 
aetiology found), with no cluster in time-to-onset, has been observed in children 5-17 months of age 
at first dose. Meningitis has not been a safety concern in RTS,S studies in adults.  
Potential immune-mediated disease (pIMD) is a theoretical concern with adjuvanted vaccines. Some 
individuals vaccinated with adjuvant components identical to those that will be used in this study have 
reported autoimmune diseases (AID). A causal association between the adjuvant components and 
occurrence of autoimmune diseases has however not been established, as these can occur in people 

 
 
 
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who get other vaccines, or no vaccines at all. A meta-analysis of a GSK Vaccines adjuvanted vaccine 
showed no increased risk of AID associated to the adjuvant.  
Meningitis and pIMDs are adverse events (AE) of specific interest. 
 
4.7.3 Antimalarial medications 
 
Dihydroartemisinin/piperaquine (DHA-PIP) 
DHA-PIP is the first line treatment for uncomplicated malaria in many malaria endemic countries in 
Asia and Africa and has an extraordinary robust safety profile 11-34. DHA-PIP is also very well tolerated. 
The main reported side effects are gastrointestinal upset (nausea, vomiting, abdominal pain and 
diarrhoea) as well as dizziness, headache and disturbed sleep. Rates of these side effects are 
generally < 10% and often <5% except for dizziness (~12%). There is no evidence that DHA-PIP can 
cause clinically significant QTc prolongation at therapeutic doses. To exclude the possibility that pre-
existing QTc prolongation results in AEs, the QTc of all volunteers will be measured and candidates 
with a QTc>450ms will not be enrolled. 
 
Primaquine (PQ) 
Like all 8-aminoquinolones, primaquine is associated with haemolysis in G6PD deficient individuals 
in a dose-related relationship. To avoid any potential risk for haemolysis, participants will receive just 
a single low dose of primaquine (approximately 0.25mg/kg) on the day of vaccination, at each vaccine 
dose (groups 4, 6, and 7, only). This dose is safe even when administered to individuals with a 
genotype associated with severe G6PD deficiency. Other known side effects with primaquine 
administration include symptoms of gastritis and enteric complaints when administered for 14 days at 
large doses for the treatment of Plasmodium vivax malaria. Such abdominal complaints have not been 
observed when a single low dose primaquine is administered35, 36. 
 
Dosing Schedule 
 
Number of tablets 
Bodyweight 
in kilograms 
(1 tablet contains 
40mg DHA and 
320 mg PIP) 
(1 tablet contains 15mg 
primaquine) 
41 - 50 
2.5 
0.5 
51 - 60 
3 
1.0 
61 - 70 
3.5 
1.0 
71 - 84 
4 
1.5 
85 - 100 
5 
2.0 

 
 
 
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4.8 Study Procedures 
 
Procedures will be performed at the time points indicated in the schedule of procedures (Appendix 
A). Additional procedures or laboratory tests may be performed, at the discretion of the investigators 
if clinically necessary (e.g. follow up repeat haematology or biochemistry laboratory tests in the 
event of clinically significant abnormal results). 
 
4.8.1 Recruitment of volunteers 
 
Volunteers will be recruited using methods traditionally employed by the healthy volunteer unit of the 
Mahidol-Oxford Tropical Medicine Research Unit. The volunteer unit maintains a register of 
candidates who expressed interest in the past to participate in clinical trials. In addition volunteers will 
be recruited via flyers displayed and distributed in the University Hospital and among students 
attending the university. 
 
4.8.2 Informed Consent 
 
The informed consent process:  trained study personnel will explain the purpose of the study 
according to the information sheet prior to any study related procedures being undertaken. The 
participant must personally sign and date the latest approved version of the informed consent form 
before any study specific procedures are performed. In such cases where the participant is illiterate, 
informed consent will be conducted in the presence of an impartial witness and the impartial witness 
would sign and date the informed consent form, while the participant provides their thumbprint. 
 
The information sheet and informed consent form will be explained to the participants detailing no 
less than: the exact nature of the study; the implications and constraints of the protocol; the known 
side effects and any risks involved in taking part. The aims of the study and all tests to be carried 
out will be explained. It will be clearly stated that participation is entirely voluntary and that refusing 
to participate will not involve any penalty or affect the patients’ right to receive standard medical 
care at the healthcare post. It will also be emphasized that if they do consent to participate and are 
enrolled, that they are free to withdraw from the study at any time, for any reason, without any 
penalty or prejudice to future care, and with no obligation to give the reason for withdrawal. The 
volunteers will have the opportunity to question the Investigator, or other independent parties to 
decide whether or not they will participate in the study.  
 
Written informed consent will then be obtained by means of participant dated signature or 
thumbprint and witness dated signature, in the case of an illiterate participant, and dated signature 
of the person who presented and obtained the informed consent.  The person who obtained the 

 
 
 
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consent must be suitably qualified and experienced, and have been authorized to do so by the study 
site Principal Investigator. A copy of the signed Informed Consent and Information Sheet will be 
given to the participants. The original signed form will be kept in the investigator’s site file and 
retained at the study site.  
 
Hospital consent for HIV test will be obtained prior to counselling and HIV test. Pre and post 
counselling for HIV screening, report and treatment for volunteer will be conducted with the support 
of certified staff from the Bangkok Hospital of Tropical Diseases.  In case a participant is found to be 
HIV positive, follow up measures including but not limited to providing counselling and treatment 
according to standard hospital procedure will be arranged through certified staff from the Hospital 
for Tropical Diseases. 
 
4.8.3 Screening and eligibility assessment (Screening visit) 
 
All potential volunteers will have a screening visit, which may take place up to 30 days prior to 
enrolment. Once informed consent is given, a screening number will be assigned in sequential 
order. Screening numbers will be issued consecutively (e.g. RTS-SC-001, RTS-SC-002, RTS-SC-
003,…). This will be recorded in the Case Screening Form, together with the demographic 
information and procedures performed to determine eligibility. Screening procedures indicated in the 
schedule of procedures (Appendix A) will be undertaken. If a screening haematology or 
biochemistry test result is deemed clinically significant it may be repeated to ensure it is not a single 
occurrence. If an abnormal finding at screening is deemed to be clinically significant, the volunteer 
will be informed and appropriate medical care arranged with the permission of the volunteer. In the 
unlikely event that a volunteer is found to have malaria or anaemia the volunteer will be treated 
according to national guidelines and will be excluded from participating in the study.   
 
4.8.4 Enrolment, baseline assessment, regimen allocation, and first vaccination (Month 0 / 
Day 0 visit; Baseline visit) 
 
All inclusion and exclusion criteria will be checked before enrolment in the study. Physical 
examination will be performed. Any new medical issues or symptoms that have arisen will be 
assessed. Blood will be collected for baseline parasite microscopy, haemoglobin and biochemistry. 
Participants with parasitaemia or anaemia will be treated according to national guidelines. Blood will 
be collected and stored for measurement of antibodies against P. falciparum circumsporozoite (anti-
CS antibody) until shipment to the reference laboratory. Urine will be collected from women of child-
bearing age for immediate pregnancy test.  
If interval between screening and enrolment is three days or less, the screening test results 
(parasite microscopy, haemoglobin, biochemistry, and urine pregnancy test) can be used for 

 
 
 
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enrolment evaluation. In such cases, these tests (parasite microscopy, haemoglobin, biochemistry, 
and urine pregnancy test) would not need to be repeated at the baseline (Month 0 / Day 0) visit. 
If all inclusion criteria are fulfilled and none of the exclusion criteria apply, the patient will be enrolled 
into the study and a CRF specific to each participant completed. Regimen allocation and 
administration of the vaccine(s) will be on Day 0.  The randomization lists will be prepared by 
MORU.  
 
Randomization numbers will be generated in blocks, for the 7 intervention arms in a ratio of 
20:20:30:30:30:30:30, as follows: 
- 
RTS,S/AS01B Fractional dose group (Group 1) 
- 
Double RTS,S /AS01E Fractional dose group (Group 2) 
   
- 
RTS,S/AS01E 
Standard dose group (Group 3) 
- 
RTS,S/AS01E + DHA-PIP+PQ  Standard dose group (Group 4)   
   
   
- 
RTS,S/AS01E Fractional dose group (Group 5) 
- 
RTS,S/AS01E + DHA-PIP+PQ  Fractional dose group (Group 6) 
- 
RTS,S/AS01E + DHA-PIP+PQ  Fractional two-dose group (Group 7)  
 
Study participants will be assigned the next available randomization number on the list, and thus will 
be randomly allocated to Group 1, 2, 3, 4, 5, 6 or 7. This is an open-label study and participants and 
clinical investigators will not be blinded to group allocation.  
Subjects will then be vaccinated by intramuscular (IM) needle injection into the deltoid region of the 
arm. Subjects in Groups 4, 6 and 7 will also receive anti-malarial medications. 
 
The study participants will be observed closely for at least 30 minutes following the administration of 
each study vaccine, with appropriate medical treatment readily available in case of an anaphylactic 
reaction.  
An oral thermometer, tape measure and a paper diary card for solicited AEs will be given to each 
participant along with the emergency 24 hour telephone number to contact the on call study 
physician if needed. Diary cards will collect information on the timing and severity of the following 
solicited AEs: 
 
Local solicited AEs 
Systemic solicited AEs 
Pain at injection site 
Fever 
Redness at injection site 
Gastrointestinal symptoms 
(nausea, vomiting, diarrhoea and/or abdominal pain) 
Swelling at injection site 
Fatigue 
 
Headache 
 

 
 
 
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Participants will be instructed on how to self-assess the severity of these AEs. There will also be 
space on the diary card to self-document unsolicited AEs, and whether medication was taken to 
relieve the symptoms. 
 
 
 
 
 
4.8.5 Subsequent vaccination visits (Month 1 / Day 0 and Month 2 / Day 0 visits) 
 
Subsequent vaccination visits will be done according to the schedule of procedures (Appendix A). 
Physical examination will be performed. Any new medical issues or symptoms that have arisen will 
be assessed. Blood will be collected for parasite microscopy. Participants with parasitaemia or 
anaemia will be treated according to national guidelines. Blood will be collected and stored for 
measurement of antibodies against P. falciparum circumsporozoite (anti-CS antibody) until shipment 
to the reference laboratory. Urine will be collected from women of child-bearing age for immediate 
pregnancy test. 
Before vaccination, the on-going eligibility of the volunteer will be reviewed. All participants will attend 
the clinic for vaccination visits, will be observed closely for at least 30 minutes following the 
administration of each study vaccine, and will receive a paper diary card for recording solicited AEs, 
as described above. Information will be recorded in the CRF for subsequent vaccination visits.   
 
4.8.6 Follow up assessments 
 
Follow-up assessments (visits not involving vaccination) will be done according to the schedule of 
procedures (Appendix A). Information will be recorded in the CRF for follow-up visits.  All 
participants will be reviewed according to the schedule, either by attending the clinic or being visited 
at home by a health visitor.  
Diary cards will be reviewed for details of solicited and unsolicited AEs, and any new or 
undocumented medical issues or symptoms that have arisen will also be assessed and recorded in 
the adverse event CRF. Further clinical assessment in the form of detailed history and physical 
examination will be undertaken if appropriate. 
 
4.8.7 Blood tests 
 
Blood will be drawn at the time points indicated in the schedule of procedures (Appendix A) and the 
following laboratory assays performed: 
At screening: 
 
Haematology: haemoglobin [Hb], leukocytes [white blood cells; WBC] and platelets [PLT]. 
 
Biochemistry: alanine aminotransferase [ALT], aspartate aminotransferase [AST] and 
creatinine [CREA]. 

 
 
 
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 
Diagnostic serology: HBsAg, HCV antibodies, HIV antibodies (Counselling will be given 
prior to testing blood for these blood-borne viruses) 
 
Parasite microscopy* 
 
At M0, D0: Parasite microscopy*, Haematology: Hb, WBC, PLT, Biochemistry: ALT, AST, CREA, 
anti-CS antibody; Pharmacokinetics** (piperaquine and primaquine drug levels will be assessed if 
additional data are required) 
At M0, D1: Pharmacokinetics** (piperaquine and primaquine drug levels) 
At M0, D2: Pharmacokinetics** (piperaquine drug levels) 
At M0, D7: Haematology: Hb, WBC, PLT; Biochemistry: ALT, AST, CREA; Pharmacokinetics** 
(piperaquine drug levels) 
At M1, D0: Parasite microscopy*, anti-CS antibody; Pharmacokinetics** (piperaquine drug levels) 
At M1, D1: Pharmacokinetics** (piperaquine and primaquine drug levels) 
At M1, D2: Pharmacokinetics** (piperaquine drug levels) 
At M1, D7: Haematology: Hb, WBC, PLT; Biochemistry: ALT, AST, CREA; Pharmacokinetics** 
(piperaquine drug levels) 
At M2, D0: Parasite microscopy*, anti-CS antibody; Pharmacokinetics** (piperaquine drug levels) 
At M2, D1: Pharmacokinetics** (piperaquine and primaquine drug levels) 
At M2, D2: Pharmacokinetics** (piperaquine drug levels) 
At M2, D7: Haematology: Hb, WBC, PLT; Biochemistry: ALT, AST, CREA; Pharmacokinetics** 
(piperaquine drug levels) 
At M3: Parasite microscopy*, Haematology: Hb, WBC, PLT; Biochemistry: ALT, AST, CREA; anti-
CS antibody 
At M6: Parasite microscopy*, anti-CS antibody 
 
* In the unexpected event that volunteers are found to be parasitaemic during screening, baseline or during vaccination or 
follow-up visits they will be treated according to the most up-to-date government guidelines. If at screening or baseline, 
these volunteers will be excluded from  participation in the study. If at Month 1 or Month 2 vaccination days, these volunteers 
will be withdrawn from further study vaccination.  
** Samples for pharmacokinetics will only be taken for subjects in Groups 4 and 6. Additional drug level assessment for 
Primaquine will be done if additional data are required  
 
Samples collected for screening assays including haematology, biochemistry, diagnostic serology 
and parasite microscopy will be tested at Bangkok Hospital for Tropical Disease Laboratory, Faculty 
of Tropical Medicine, Mahidol University. 
   

 
 
 
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Samples collected for drug levels assessment (piperaquine and primaquine) will be tested at the 
Department of Clinical Pharmacology Laboratories, Faculty of Tropical Medicine, Mahidol 
University. 
   
Samples collected for assessment of antibody responses will be processed at the site and  serum 
samples will be stored at -20C or below until shipment to a biorepository sample management 
laboratory (Precision) and will then be shipped to  the Walter Reed Army Institute of Research 
(WRAIR) for testing. The following assays will be conducted at the WRAIR laboratories in Silver 
Spring, United States:  
 
Component 
Method 
Kit / 
Manufacturer 
Unit 
Cut-off 
Laboratory 
Plasmodium falciparum. Circumsporozoite 
Protein.(NANP)6 Ab.IgG  
ELISA 
In house 
EPT or 
ug/ml 
100 
WRAIR 
Plasmodium falciparum. Circumsporozoide 
Protein.(NANP)6 Ab.IgG Avidity  
ELISA 
In house 
Avidity 
index 
Not 
applicable 
WRAIR 
Plasmodium falciparum. anti-C-Term 
Circumsporozoide Ab.IgG  
ELISA 
In house 
EPT  
100  
WRAIR 
Plasmodium falciparum. anti-C-Term 
Circumsporozoide Ab.IgG avidity  
ELISA 
In house 
Avidity 
Index  
Not 
applicable 
WRAIR 
Plasmodium falciparum. Circumsporozoite Full length 
(N+C-Terminal)  
ELISA  
In house 
EPT 
100 
WRAIR 
P falciparum. anti-full length CSP Ab.IgG avidity 
ELISA  
In house 
Avidity 
Index  
Not 
applicable 
WRAIR 
ELISA: Enzyme-linked immunosorbent assay; EPT: endpoint titer; IgG: Immunoglobulin G; WRAIR: Walter Reed Army Institute of 
Research 
 
These assays allow the characterisation of B cell responses elicited by RTS,S/AS01, quantification 
of anti-CSP titers and avidity index (NANP repeat region, C-terminus, and full length). This will 
enable bridging back to earlier trials with RTS,S/AS01. 
 
With the volunteers’ informed consent, any leftover serum will be frozen for up to 5 years for future 
immunological analysis of malaria-specific responses. This may include human DNA and RNA 
analysis to search for correlates of vaccine immunogenicity and efficacy. 
 
4.8.8 Drug levels 
 
The study investigates two questions regarding the potential interactions between antimalarial drugs 
and vaccines.  
1) Does the co-administration of antimalarial drugs with vaccines influence vaccine antibody levels 
2) Does the co-administration of antimalarial drugs with vaccines influence drug levels  
The second question will be addressed for piperaquine and primaquine. Piperaquine levels will be 
assessed during each round (M0, M1, and M2) on Day 0, 1, 2, and 7 (M0D0 drug level will be 

 
 
 
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assessed if additional data are required). Primaquine levels will be assessed during each round 
24hrs after drug administration. Additional drug level assessment for Primaquine will be done if 
additional data are required. 
The drug levels will be assessed in the 60 participants who receive vaccine and drugs (groups 4 
and 6). The drug levels will be compared to historic controls. 
 
4.9 Definition of Start and End of Trial 
 
The start of the trial is defined as the date of the first vaccination of the first participant. The end of 
trial is the date of the last visit of the last participant, which would be a maximum of 6 months after 
recruitment and first vaccination of the last participant.  
 
4.10 Participant withdrawal from the study 
 
Each participant has the right to withdraw from the study at any time and for any reason, and is not 
obliged to give his or her reasons for doing so.  Participants who are withdrawn because of AEs 
must be clearly distinguished from participants who are withdrawn for other reasons. For all 
withdrawals due to SAE/AEs, appropriate follow-up visits or medical care will be arranged, with the 
agreement of the participant, until the SAE/AE has resolved and stabilized  
 
From an analysis perspective, a ‘withdrawal’ from the study is any participant who did not come 
back for the concluding visit or was not available for the concluding contact foreseen in the protocol. 
A participant qualifies as a ‘withdrawal’ from the study when no study procedure has occurred, no 
follow-up has been performed and no further information has been collected for this participant from 
the date of withdrawal/last contact. Investigators will make an attempt to contact those participants 
who do not return for scheduled visits or follow-up.  
 
In addition participant may be withdrawn from the study by the investigator at any time, if it is in the 
best interests of the participant’s health and well-being, or for any of the following reasons: 
• 
Ineligibility (either arising during the study or retrospectively, having been overlooked at 
screening). 
• 
Significant protocol deviation. 
• 
Participant non-compliance with study requirements. 
• 
An AE, which requires discontinuation of the study involvement or results in inability to 
continue to comply with study procedures. 
 

 
 
 
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If a participant withdraws from the study, blood samples collected before their withdrawal from the 
trial will be used/stored unless the participant specifically requests otherwise. Data collected prior to 
the withdrawal of a participant will be used. 
 
In all cases of participant withdrawal or discontinuation, excepting those of complete consent 
withdrawal, long-term safety data collection will continue as appropriate if subjects have received 
one or more vaccine doses. 
 
4.11 Participant withdrawal from the study agent 
 
Participants withdrawn from the study agent are those who do not receive the complete number of 
vaccine doses. A participant withdrawn from the study agent may not necessarily be withdrawn from 
the study, as further procedures or follow-up may be performed (safety or immunogenicity) if 
planned in the study protocol. Information relative to premature discontinuation of the study agent 
will be documented in the CRF. The investigator will document whether the decision to discontinue 
further vaccination was made by the participant or the investigator and which of the following 
possible reasons was responsible for withdrawal: 
 
- 
serious adverse event, 
- 
non-serious adverse event, 
- 
other (specify). 
 
Subjects with positive microscopy result indicating malaria on vaccination days at Month 1 or Month 
2 will be treated according to national guidelines and the volunteer will be withdrawn from further 
vaccination.  
 
4.12 Pregnancy 
 
Participants are informed that the safety of the vaccine in pregnancy is unknown. Female study 
participants are asked to use appropriate contraceptive methods to prevent pregnancy while they 
receive vaccinations.  Appropriate contraceptive methods include: 
- Established use of oral, injected or implanted hormonal contraceptives 
- Intrauterine Device or Intrauterine System 
- Barrier methods (condoms or diaphragm with additional spermicide) 
- Male sterilisation (with appropriate post-vasectomy documentation of absence of sperm in the 
ejaculate) 

 
 
 
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- True abstinence, when this is in line with the preferred and usual lifestyle of the subject. Periodic 
abstinence (e.g., calendar, ovulation, symptothermal, post-ovulation methods) and withdrawal are not 
acceptable methods of contraception. 
Female participants will be tested for pregnancy immediately prior to each vaccination. 
Should a participant become pregnant during the trial, she will be followed up as other volunteers and 
in addition will be followed until pregnancy outcome, with the participant’s permission. We will not 
routinely perform venepuncture on such participants. 
 
4.13 Source Data 
 
Source documents are original documents, data, and records from which participants’ CRF data are 
obtained. These include, but are not limited to, hospital records (from which medical history and 
previous and concurrent medication may be summarized into the CRF), clinical and office charts, 
registration logbook, laboratory and pharmacy records, diaries, radiographs, referral notes and 
correspondence. 
 
All documents will be stored safely in confidential conditions. On all study-specific documents, other 
than the signed consent, the participant will be referred to by the study participant number/code, not 
by name. 
 
5 TREATMENT OF TRIAL PARTICIPANTS 
5.1 Description and administration of the study agents 
 
5.1.1 Vaccines 
 
The candidate RTS,S/AS01 vaccine to be used has been developed and manufactured by GSK 
Vaccines. The Quality Control Standards and Requirements for each candidate vaccine are described 
in separate Quality Assurance documents (e.g. release protocols, certificate of analysis) and the 
required approvals have been obtained. The vaccines are labelled and packed according to applicable 
regulatory requirements. 
 
RTS,S/AS01E   
 
RTS,S/AS01E is the standard formulation of the vaccine. The RTS,S antigen is presented as a 
lyophilized pellet with sucrose as cryoprotectant, which is reconstituted in the liquid adjuvant, 
AS01E. Once prepared, a standard dose of RTS,S/AS01E contains approximately 25µg of 
RTS,S antigen, in 0.5mL of liquid adjuvant containing 25µg MPL and 25µg QS-21.  In this 

 
 
 
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study, the commercial presentation of RTS,S/AS01E will be used, i.e. a two-doses glass vial 
of lyophilized RTS,S antigen (50μg) to be reconstituted with a two-doses glass vial of AS01E 
Adjuvant System (1.0 ml). The final product for administration will be prepared by 
reconstitution of the lyophilized antigen with the liquid adjuvant. From the reconstituted 
vaccine vial: 
 
0.5 ml will be withdrawn to administer RTS,S/AS01E standard doses, or 
 
0.1 ml will be withdrawn to administered RTS,S/AS01E fractional doses (1/5th dose), 
or 
 
1.0 ml will be withdrawn to administer RTS,S/AS01E double doses, or 
 
0.2 ml will be withdrawn to administered double dose of RTS,S/AS01E fractional 
doses (1/5th dose). 
All vials of vaccine provided in this study are intended for single use only. 
 
RTS,S/AS01B  (0.5 mL dose) 
RTS,S/AS01B is the adult formulation of the vaccine. The RTS,S antigen is presented as a 
lyophilized pellet with sucrose as cryoprotectant, which is reconstituted in the liquid adjuvant, 
AS01B. Once prepared, a standard dose of RTS,S/AS01B contains approximately 50µg of 
RTS,S antigen, in 0.5mL of liquid adjuvant containing 50µg MPL and 50µg QS-21.  In this 
study, the clinical presentation of RTS,S/AS01B will be used, i.e. a monodose glass vial of 
lyophilized RTS,S antigen (50μg) to be reconstituted with a mono-dose glass vial of AS01B 
Adjuvant System (0.5 ml). The final product for administration will be prepared by 
reconstitution of the lyophilized antigen with the liquid adjuvant. From the reconstituted 
vaccine vial: 
 
0.5 ml will be withdrawn to administer RTS,S/AS01B standard doses, or 
 
0.1 ml will be withdrawn to administered RTS,S/AS01B fractional doses (1/5th dose). 
All vials of vaccine provided in this study are intended for single use only. 
 
Administration of RTS,S/AS01 
The procedure for administration is as follows. Disinfect the top of vaccine vial and adjuvant vial with 
alcohol swabs and let dry. Withdraw the contents of the adjuvant vial in a syringe and inject adjuvant 
into the vial of lyophilized antigen. The pellet is then dissolved by gently shaking the vial. Wait for 1 
minute to ensure complete dissolution of vial contents before withdrawing the correct volume (see 
above). The reconstituted vaccine should be administered by slow IM injection, using a fresh 25G 
needle with length of 1 inch (25 mm), preferably into the non-dominant arm. Vaccine should be 
injected within 4 hours of reconstitution (storage at +2°C to +8°C). The study participants will be 
observed closely for at least 30 minutes following the administration of study vaccine, with appropriate 
medical treatment readily available in case of an anaphylactic reaction. 

 
 
 
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5.1.2 Anti-malarial therapy 
Participants in Groups 4 and 6 will receive three rounds of antimalarial drugs - each round starting on 
the day of vaccination (Day 0) at Study Months 0, 1 and 2. Participants in Group 7 will receive two 
rounds of antimalarial drugs – each round starting on the day of vaccination (Day 0) at Study months 
0 and 2.  Each round consists of three daily doses of co-formulated dihydroartemisinin/piperaquine 
on Day 0, 1, and 2 (i.e. the day of vaccination and each day for 2 days after). 
Dihydroartemisinin/piperaquine 
tablets 
(Guilin 
Pharmaceutical 
Company 
or 
Sigma 
Tau 
Pharmaceuticals) for adult patients each contain 40mg dihydroartemisinin and 320mg piperaquine 
with a therapeutic dose range between 2–10 mg/kg/day dihydroartemisinin and 16–26 mg/kg/dose 
piperaquine. In addition each participant will receive a single low dose primaquine on the day of 
vaccination (Day 0). One single low dose primaquine of approximately 0.25mg/kg (Thai Government 
Pharmaceutical Organisation) will be administered. This drug regimen has been used in mass drug 
administrations in more than 10,000 participants which have established that this antimalarial drug 
regimen is safe and effective. 
In the unexpected event that volunteers are found to be infected with malaria during screening, 
baseline or during follow-up examination they will be treated according to the most up-to-date 
government guidelines. 
 
5.2 Storage of vaccines and anti-malarial medications 
The RTS,S/AS01 vaccines must be stored according to the manufacturer’s recommendations at +2°C 
to +8°C. Any temperature deviation outside the range 0 to 8°C must be reported to the GSK Vaccines 
as soon as detected. Following an exposure to such a temperature deviation, vaccines will not be 
used until approval has been given by GSK Vaccines. In case of temperature deviation between 0 
and 2°C/32 to 36°F the impacted study vaccines can still be administered, but the site must take 
adequate actions to go back to the defined range +2 to +8°C/36 to 46°F and avoid re-occurrence of 
such a temperature deviation. 
Study anti-malarial medications must be stored at room temperature below 30 degrees Celsius. 
All vaccines and study medications will be stored in a safe and locked place, with no access to 
unauthorized personnel. Only trained, authorized study staff will have access to the vaccines and 
study medications. Storage temperatures will be monitored daily, according to SOPs at the 
investigator’s site. In addition, for vaccine storage refrigerator(s), an alarm system and a back-up 
refrigerator will be available in case of power failure/breakdown. All movements of the study vaccines 
will be documented and cold boxes, with temperature monitoring, will be used to transfer vaccines to 
the area where it will be administered. Vaccine and study medication accountability, storage, and 
handling will be in accordance with local SOPs.  
This study will not be blinded; i.e. it is an open-label study.  
 

 
 
 
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6 SAFETY REPORTING 
6.1 SAFETY 
The investigator or site staff is/are responsible for the detection, documentation and reporting of 
events meeting the criteria and definition of an AE or SAE as provided in this protocol. Each subject 
will be instructed to contact the investigator immediately should the subject manifest any signs or 
symptoms they perceive as serious. 
 
REPORTING PROCEDURES FOR SERIOUS AEs  
In order to comply with current regulations on serious adverse event reporting to regulatory 
authorities, the event will be documented accurately and notification deadlines respected.  
SAEs will be reported to a safety group (specified members of the study team) and medical monitor 
immediately (within 24 hours) of the investigators being aware of their occurrence.  This safety group 
includes the Principal Investigator, who acts on behalf of the sponsor for notification of SAEs. 
SAEs will also be reported to ethics committees and the regulatory authority, in accordance with 
reporting requirements and according to required timelines.  
 
6.2 Safety definitions 
6.3 Definition of an adverse event 
An AE is any untoward medical occurrence in a clinical investigation subject, temporally associated 
with the use of a medicinal product, whether or not considered related to the medicinal product. An 
AE can therefore be any unfavourable and unintended sign (including an abnormal laboratory finding), 
symptom, or disease (new or exacerbated) temporally associated with the use of a medicinal product. 
For marketed medicinal products, this also includes failure to produce expected benefits (i.e. lack of 
efficacy), abuse or misuse.  
 
Examples of an AE include: 
 
Significant or unexpected worsening or exacerbation of the condition/indication under study. 
 
Exacerbation of a chronic or intermittent pre-existing condition including either an increase in 
frequency and/or intensity of the condition. 
 
New conditions detected or diagnosed after investigational vaccines administration even though 
they may have been present prior to the start of the study. 
 
Signs, symptoms, or the clinical sequelae of a suspected interaction. 
 
Signs, symptoms, or the clinical sequelae of a suspected overdose of either investigational 
vaccines/ antimalarial medications or a concurrent medication (overdose per se should not be 
reported as an AE/SAE). 
 
Signs, symptoms temporally associated with vaccines/antimalarial drug administration. 

 
 
 
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 
Pre- or post-treatment events that occur as a result of protocol-mandated procedures (i.e. 
invasive procedures, modification of subject’s previous therapeutic regimen). 
 
Examples of an AE DO NOT include: 
 
Medical or surgical procedures (e.g. endoscopy, appendectomy); the condition that leads to the 
procedure is an AE/SAE. 
 
Situations where an untoward medical occurrence did not occur (e.g. social and/or convenience 
admission to a hospital, admission for routine examination). 
 
Anticipated day-to-day fluctuations of pre-existing disease(s) or condition(s) present or detected 
at the start of the study that do not worsen.  
 
Pre-existing conditions or signs and/or symptoms present in a subject prior to the first study 
vaccination. These events will be recorded in the medical history section of the CRF. 
 
6.4 Definition of a serious adverse event  
A SAE is any untoward medical occurrence that: 
a. 
Results in death, 
b. 
Is life-threatening, 
Note: The term ‘life-threatening’ in the definition of ‘serious’ refers to an event in which the 
subject was at risk of death at the time of the event. It does not refer to an event, which 
hypothetically might have caused death, had it been more severe. 
c. 
Requires hospitalization or prolongation of existing hospitalization, 
Note: In general, hospitalization signifies that the subject has been admitted at the hospital or 
emergency ward for observation and/or treatment that would not have been appropriate in the 
physician’s office or in an out-patient setting. Complications that occur during hospitalization are 
also considered AEs. If a complication prolongs hospitalization or fulfils any other serious 
criteria, the event will also be considered serious. When in doubt as to whether ‘hospitalization’ 
occurred or was necessary, the AE should be considered serious. 
Hospitalization for elective treatment of a pre-existing condition (known or diagnosed prior to 
informed consent signature) that did not worsen from baseline is NOT considered an AE. 
d. 
Results in disability/incapacity, OR 
Note: The term disability means a substantial disruption of a person’s ability to conduct normal 
life functions. This definition is not intended to include experiences of relatively minor medical 
significance such as uncomplicated headache, nausea, vomiting, diarrhoea, influenza like 
illness, and accidental trauma (e.g. sprained ankle) which may interfere or prevent everyday life 
functions but do not constitute a substantial disruption. 
e. 
Is a congenital anomaly/birth defect in the offspring of a study subject. 
f. 
Spontaneous pregnancy loss  

 
 
 
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g. 
Medical or scientific judgment should be exercised in deciding whether reporting is appropriate 
in other situations, such as important medical events that may not be immediately life-
threatening or result in death or hospitalization but may jeopardize the subject or may require 
medical or surgical intervention to prevent one of the other outcomes listed in the above 
definition. These should also be considered serious. Examples of such events are invasive or 
malignant cancers, intensive treatment in an emergency room or at home for allergic 
bronchospasm, blood dyscrasias or convulsions that do not result in hospitalization. 
 
6.5 Solicited adverse events 
6.6 Solicited local (injection-site) adverse events 
The following local (injection-site) AEs will be solicited: 
 
All age groups 
Pain at injection site 
Redness at injection site 
Swelling at injection site 
 
6.7 Solicited general adverse events 
The following general AEs will be solicited: 
 
Adult 
Fatigue 
Fever 
Gastrointestinal symptoms † 
Headache 
† Gastrointestinal symptoms include nausea, 
vomiting, diarrhoea and/or abdominal pain. 
Note: Temperature will be recorded in the evening. Should additional temperature measurements be performed 
at other times of day, the highest temperature will be recorded in the CRF. 
 
6.8 Clinical laboratory parameters and other abnormal assessments qualifying as 
adverse events or serious adverse events  
In absence of diagnosis, abnormal laboratory findings (e.g. clinical chemistry, haematology, 
urinalysis) or other abnormal assessments that are judged by the investigator to be clinically 
significant will be recorded as AE or SAE if they meet the definition of an AE or SAE. Clinically 
significant abnormal laboratory findings or other abnormal assessments that are present at baseline 
and significantly worsen following the start of the study will also be reported as AEs or SAEs. 
The investigator will exercise his or her medical and scientific judgment in deciding whether an 
abnormal laboratory finding or other abnormal assessment is clinically significant. 
 
 
 

 
 
 
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6.9 Adverse events of specific interest 
AEs of specific interest for safety monitoring include meningitis and potential Immune-Mediated 
Diseases pIMDs. 
 
6.10 Potential immune-mediated diseases (pIMD) 
pIMDs are a subset of AEs that include autoimmune diseases and other inflammatory and/or 
neurologic disorders of interest which may or may not have an autoimmune aetiology. AEs that need 
to be recorded and reported as pIMDs include those listed below. However, the investigator will 
exercise his/her medical and scientific judgment in deciding whether other diseases have an 
autoimmune origin (i.e. pathophysiology involving systemic or organ-specific pathogenic 
autoantibodies) and should also be recorded as a pIMD. 
 
List of potential immune-mediated diseases:  
Neuroinflammatory disorders 
Musculoskeletal disorders 
Skin disorders 
 
Cranial nerve disorders, 
including paralyses/paresis 
(e.g. Bell’s palsy)  
 
Optic neuritis 
 
Multiple sclerosis 
 
Transverse myelitis 
 
Guillain-Barré syndrome, 
including Miller Fisher 
syndrome and other variants 
 
Acute disseminated 
encephalomyelitis, including 
site specific variants: e.g. 
non-infectious encephalitis, 
encephalomyelitis, myelitis, 
myeloradiculoneuritis 
 
Myasthenia gravis, including 
Lambert-Eaton myasthenic 
syndrome  
 
Immune-mediated peripheral 
neuropathies and 
plexopathies, (including 
chronic inflammatory 
demyelinating 
polyneuropathy, multifocal 
motor neuropathy and 
polyneuropathies associated 
with monoclonal 
gammopathy). 
 
Narcolepsy 
 
Systemic lupus 
erythematosus and 
associated conditions 
 
Systemic scleroderma 
(Systemic sclerosis), 
including diffuse systemic 
form and CREST 
syndrome 
Idiopathic inflammatory 
myopathies, including 
dermatomyositis  
 
Polymyositis  
 
Antisynthetase syndrome 
 
Rheumatoid arthritis, and 
associated conditions 
including juvenile chronic 
arthritis and Still’s disease 
 
Polymyalgia rheumatica 
 
Spondyloarthritis, 
including ankylosing 
spondylitis, reactive 
arthritis (Reiter's 
Syndrome) and 
undifferentiated 
spondyloarthritis  
 
Psoriatic arthropathy 
 
Relapsing polychondritis 
 
Mixed connective tissue 
disorder 
 
Psoriasis 
 
Vitiligo 
 
Erythema nodosum 
 
Autoimmune bullous 
skin diseases 
(including 
pemphigus, 
pemphigoid and 
dermatitis 
herpetiformis) 
 
Alopecia areata 
 
Lichen planus 
 
Sweet’s syndrome 
 
Localised 
Scleroderma 
(Morphoea) 
Vasculitides 
Blood disorders 
Others 
 
Large vessels vasculitis 
including: giant cell arteritis 
such as Takayasu's 
arteritis and temporal 
arteritis.  
 
Medium sized and/or small 
vessels vasculitis 
including: polyarteritis 
nodosa, Kawasaki's 
 
Autoimmune 
hemolytic anemia 
 
Autoimmune 
thrombocytopenia 
 
Antiphospholipid 
syndrome 
 
Pernicious anemia 
 
Autoimmune 
glomerulonephritis (including 
IgA nephropathy, 
glomerulonephritis rapidly 
progressive, membranous 
glomerulonephritis, 
membranoproliferative 
glomerulonephritis, and 

 
 
 
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disease, microscopic 
polyangiitis, Wegener's 
granulomatosis, Churg–
Strauss syndrome (allergic 
granulomatous angiitis), 
Buerger’s disease 
(thromboangiitis 
obliterans), necrotizing 
vasculitis and anti-
neutrophil cytoplasmic 
antibody (ANCA) positive 
vasculitis (type 
unspecified), Henoch-
Schonlein purpura, 
Behcet's syndrome, 
leukocytoclastic vasculitis. 
 
Autoimmune 
aplastic anaemia 
 
Autoimmune 
neutropenia  
 
Autoimmune 
pancytopenia 
mesangioproliferative 
glomerulonephritis) 
 
Ocular autoimmune diseases 
(including autoimmune uveitis 
and autoimmune retinopathy) 
 
Autoimmune 
myocarditis/cardiomyopathyS
arcoidosis 
 
Stevens-Johnson syndrome 
 
Sjögren’s syndrome 
 
Idiopathic pulmonary fibrosis 
 
Goodpasture syndrome 
 
Raynaud’s phenomenon 
Liver disorders 
Gastrointestinal disorders 
Endocrine disorders 
 
Autoimmune 
hepatitis 
 
Primary biliary 
cirrhosis 
 
Primary sclerosing 
cholangitis 
 
Autoimmune 
cholangitis 
 
Inflammatory Bowel 
disease, including 
Crohn’s disease, 
ulcerative colitis, 
microscopic colitis, 
ulcerative proctitis  
 
Celiac disease 
 
Autoimmune pancreatitis 
 
Autoimmune thyroiditis 
(including Hashimoto 
thyroiditis) 
 
Grave's or Basedow’s disease 
 
Diabetes mellitus type I 
 
Addison’s disease 
 
Polyglandular autoimmune 
syndrome 
 
Autoimmune hypophysitis 
When there is enough evidence to make any of the above diagnoses, the AE must be reported as a 
pIMD. Symptoms, signs or conditions which might (or might not) represent the above diagnoses, 
should be recorded and reported as AEs but not as pIMDs until the final or definitive diagnosis has 
been determined, and alternative diagnoses have been eliminated or shown to be less likely.  
 
6.11 Meningitis 
For the further evaluation of the safety signal of meningitis in the investigational vaccine groups all 
cases of meningitis occurring during the study will be reported as a SAE. 
 
6.12 Events or outcomes not qualifying as adverse events or serious adverse events  
6.13 Pregnancy 
Female volunteers who are pregnant or intend to become pregnant will not be enrolled. Female 
subjects who become unexpectedly pregnant during of vaccination period (M0 to M2) must not receive 
additional doses of study vaccines but may continue other study procedures at the discretion of the 
investigator. While pregnancy itself is not considered an AE or SAE, any adverse pregnancy outcome 
or complication or elective termination of a pregnancy for medical reasons will be recorded and 
reported as an AE or a SAE. 
 
The following should always be considered as SAE  
 
Spontaneous pregnancy loss, including: 
 
spontaneous abortion, (spontaneous pregnancy loss before/at 22 weeks of gestation) 
 
ectopic and molar pregnancy 

 
 
 
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 
stillbirth (intrauterine death of foetus after 22 weeks of gestation). 
 
Any early neonatal death (i.e. death of a live born infant occurring within the first 7 days of life).  
 
Any congenital anomaly or birth defect  identified in the offspring of a study subject (either 
during pregnancy, at birth or later) regardless of whether the foetus is delivered dead or alive. 
This includes anomalies identified by prenatal ultrasound, amniocentesis or examination of the 
products of conception after elective or spontaneous abortion. 
Furthermore, any SAE occurring as a result of a post-study pregnancy AND considered by the 
investigator to be reasonably related to the investigational vaccines will be reported. While the 
investigator is not obligated to actively seek this information from former study participants, he/she 
may learn of a pregnancy through spontaneous reporting. 
 
6.14 Detecting and recording adverse events and serious adverse events 
 
6.15 Recording adverse events, serious adverse events and pregnancies 
All AEs must be recorded into the appropriate section of the CRF, irrespective of intensity or whether 
or not they are considered vaccination-related. 
 
6.16 Post-Study adverse events and serious adverse events 
Investigators are not obligated to actively seek AEs or SAEs in former study participants. However, if 
the investigator learns of any SAE at any time after a subject has been discharged from the study, 
and he/she considers the event reasonably related to the investigational vaccines, the investigator 
will promptly notify the Study Contact for Reporting SAEs. 
 
6.17 Active questioning to detect adverse events and serious adverse events 
As a consistent method of collecting AEs, the subject should be asked a non-leading question such 
as: 
‘Have you felt different in any way since receiving the vaccines or since the previous visit?’ 
When an AE/SAE occurs, it is the responsibility of the investigator to review all documentation (e.g. 
hospital progress notes, laboratory and diagnostics reports) relative to the event. The investigator will 
attempt to establish a diagnosis pertaining to the event based on signs, symptoms, and/or other 
clinical information. In such cases, the diagnosis should be documented as the AE/SAE and not the 
individual signs/symptoms. 
 
6.18 Assessment of intensity 
The intensity of the following solicited AEs will be assessed as described:  

 
 
 
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Intensity scales for solicited symptoms in adults 
Adults 
Adverse Event 
Intensity grade 
Parameter 
Pain at injection site 
0 
None 
 
1 
Mild: Any pain neither interfering with nor 
preventing normal every day activities. 
 
2 
Moderate: Painful when limb is moved and 
interferes with every day activities. 
 
3 
Severe: Significant pain at rest. Prevents 
normal every day activities. 
Redness at injection site 
Record greatest surface diameter in mm 
Swelling at injection site 
Record greatest surface diameter in mm 
Fever* 
 
Record temperature in °C/°F 
Headache 
0 
Normal 
 
1 
Mild: Headache that is easily tolerated 
 
2 
Moderate: Headache that interferes with 
normal activity 
 
3 
Severe: Headache that prevents normal 
activity 
Fatigue 
0 
Normal 
 
1 
Mild: Fatigue that is easily tolerated 
 
2 
Moderate: Fatigue that interferes with normal 
activity 
 
3 
Severe: Fatigue that prevents normal activity 
Gastrointestinal symptoms 
0 
Normal 
(nausea, vomiting, diarrhoea 
and/or abdominal pain) 
1 
Mild: Gastrointestinal symptoms that are easily 
tolerated 
 
2 
Moderate: Gastrointestinal symptoms that 
interfere with normal activity 
 
3 
Severe: Gastrointestinal symptoms that 
prevent normal activity 
*Fever is defined as temperature  37.5°C / 99.5°F for oral, axillary or tympanic route, or  38.0°C / 100.4°F 
for rectal route. The preferred route for recording temperature in this study will be oral. 
The maximum intensity of local injection site redness and swelling will be scored as follows: 
0 
: 
0 mm 
1 
: 
> 0 to ≤ 50 mm 
2 
: 
> 50 mm to ≤ 100 mm 
3 
: 
> 100 mm 
The maximum intensity of fever will be scored as follows: 
0 
: 
< 37.5°C (< 99.5°F) 
1 
: 
≥ 37.5°C (≥ 99.5°F) to ≤ 38.0°C (100.4°F) 
2 
: 
> 38.0°C (> 100.4°F) to ≤ 39.0°C (102.1°F) 
3 
: 
> 39.0°C (102.1°F) 
The investigator will assess the maximum intensity that occurred over the duration of the event for all 
unsolicited AEs (including SAEs) recorded during the study. The assessment will be based on the 
investigator’s clinical judgment. 
 
The intensity should be assigned to one of the following categories: 

 
 
 
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1 (mild) 
= 
An AE which is easily tolerated by the subject, causing minimal 
discomfort and not interfering with everyday activities. 
2 (moderate) 
= 
An AE which is sufficiently discomforting to interfere with normal 
everyday activities. 
3 (severe) 
= 
An AE which prevents normal, everyday activities. In adults, such 
an AE would, for example, prevent attendance at work/school and 
would necessitate the administration of corrective therapy. 
An AE that is assessed as Grade 3 (severe) should not be confused with a SAE. Grade 
3 is a category used for rating the intensity of an event; and both AEs and SAEs can be 
assessed as Grade 3.  
 
The normal ranges and toxicity 
grading for laboratory safety 
parameters used in this study: 
Adverse event 
Intensity grade 
Intensity* 
Haemoglobin (males) 
Normal range  
12.5 - 17.0 g/dl 
 
1 
< 12.5 but  11.0 g/dl 
 
2 
< 11.0 but  10.0 g/dl 
 
3 
< 10.0 g/dl 
Haemoglobin (females) 
Normal range  
11.5 - 15.0 g/dl 
 
1 
< 11.5 but  10.5 g/dl 
 
2 
< 10.5 but  9.5 g/dl 
 
3 
< 9.5 g/dl 
Increase in leukocytes  
Normal range 
3200 - 10799 cells/mm3 
(WBC) 
1 
10800 - 15000 cells/mm3 
 
2 
15001 - 20000 cells/mm3 
 
3 
> 20001 cells/mm3 
Decrease in leukocytes  
Normal range 
3200 - 10800 cells/mm3 
(WBC) 
1 
2500 - 3199 cells/mm3 
 
2 
1500 - 2499 cells/mm3 
 
3 
< 1500 cells/mm3 
Decrease in platelets 
Normal 
140000 - 400000 cells/mm3 
 
1 
125000 - 139000 cells/mm3 
 
2 
100000 - 124000 cells/mm3 
 
3 
< 100000 cells/mm3 
Alanine Aminotransferase  Normal range 
Below ULN (60 U/l for males; 40 U/l for females  
 
1 
1.1 - 2.5 x ULN 
 
2 
2.6 – 5 x ULN 
 
3 
> 5 x ULN 
Aspartate 
Aminotransferase  
Normal range 
Below ULN (40 U/l for males; 35 U/l for females 
 
 
1.1 - 2.5 x ULN 
 
 
2.6 – 5 x ULN 
 
 
> 5 x ULN 
Creatinine (males) 
Normal range  
0.5 - 1.39 mg/dl 
 
1 
1.4 - 1.79 mg/dl 
 
2 
1.8 - 2.0 mg/dl 
 
3 
> 2.0 mg/dl 
Creatinine (females) 
Normal range 
0.5 - 1.29 mg/dl 
 
1 
1.3 – 1.69 mg/dl 
 
2 
1.7 – 1.9 mg/dl 
 
3 
>1.9 mg/dl 
ULN: upper limit of normal range 

 
 
 
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The normal ranges and toxicity 
grading for laboratory safety 
parameters used in this study: 
Adverse event 
Intensity grade 
Intensity* 
  
6.19 Assessment of causality 
The investigator is obligated to assess the relationship between investigational vaccines and study 
antimalarial medications and the occurrence of each AE/SAE. The investigator will use clinical 
judgment to determine the relationship. Alternative plausible causes, such as natural history of the 
underlying diseases, concomitant therapy, other risk factors, and the temporal relationship of the 
event to the investigational vaccines and study antimalarial medications will be considered and 
investigated. The investigator will also consult the IB and/or Summary of Product Characteristics to 
determine his/her assessment. 
There may be situations when a SAE has occurred and the investigator has minimal information. 
However, it is very important that the investigator always makes an assessment of causality. The 
investigator may change his/her opinion of causality in light of follow-up information and update the 
SAE information accordingly. The causality assessment is one of the criteria used when determining 
regulatory reporting requirements. 
In case of concomitant administration of vaccine and study antimalarial medication, it may not be 
possible to determine the causal relationship of general AEs to the individual vaccine or medication 
administered. All solicited local (injection site) reactions will be considered causally related to 
vaccination. Causality of all other AEs should be assessed by the investigator using the following 
question: 
 
Is there a reasonable possibility that the AE may have been caused by the investigational vaccine or 
study antimalarial medications? 
 
YES 
: 
There is a reasonable possibility that the vaccines or study 
antimalarial medications contributed to the AE. 
NO 
: 
There is no reasonable possibility that the AE is causally related to 
the administration of the study vaccines or study antimalarial 
medications. There are other, more likely causes and administration 
of the study vaccines and study antimalarial medications is not 
suspected to have contributed to the AE. 
If an event meets the criteria to be determined as ‘serious’, additional examinations/tests will be 
performed by the investigator in order to determine ALL possible contributing factors for each SAE. 
 
 

 
 
 
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Possible contributing factors include: 
 
Medical history. 
 
Other medication. 
 
Protocol required procedure. 
 
Other procedure not required by the protocol. 
 
Lack of efficacy of the vaccines, if applicable. 
 
Erroneous administration. 
 
Other cause (specify). 
 
6.20 Assessment of outcomes 
The investigator will assess the outcome of all AEs (including SAEs) recorded during the study as: 
 
Recovered/resolved. 
 
Recovering/resolving. 
 
Not recovered/not resolved. 
 
Recovered with sequelae/resolved with sequelae. 
 
Fatal (SAEs only). 
 
6.21 Safety (ANALYSIS) 
 
Safety and reactogenicity of the investigational vaccine for each vaccination schedule: 
 
Occurrence of solicited local and general AEs within seven days (day of vaccination and 
six subsequent days) after each vaccination. 
 
Occurrence of unsolicited AEs from the date of the first vaccination to 29 days after the last 
vaccination, according to the Medical Dictionary for Regulatory Activities (MedDRA) 
classification. 
 
Occurrence of SAEs (all, fatal, related to investigational vaccine) within 30 days (day of 
vaccination and 29 subsequent days) after each vaccination, according to the MedDRA 
classification.  
 
Occurrence of SAEs (all, fatal, related to investigational vaccine) during the whole study 
period according to the MedDRA classification. 
 
Occurrence of AEs and SAEs leading to withdrawal from further vaccination from Dose 1 
(Day 0) up to study conclusion (Day 180), according to the MedDRA classification, for each 
vaccinated subjects. 
 
Occurrence of pIMDs from Dose 1 (Day 0) up to study conclusion (Day 180), according to 
the MedDRA classification, for each vaccinated subjects. 
 
Occurrence of meningitis from Dose 1 (Day 0) up to study conclusion (Day 180), according 
to the MedDRA classification, for each vaccinated subjects. 
 

 
 
 
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6.22 Analysis of safety 
 
The percentage of subjects with at least one local AEs with at least one general AE (solicited and 
unsolicited) and with any AE during the 7-day or total follow-up period up to 29 days after the last 
vaccine dose and overall will be tabulated with exact 95% CI. The percentage of doses followed by 
at least one local AE (solicited and unsolicited), by at least one general AE (solicited and unsolicited) 
and by any AE during the 7-day or the total follow up period up to 29days after the last vaccine  will 
be tabulated with exact 95% CI. The same computations will be done for Grade 3 AEs, for any AEs 
considered related to vaccination and for any Grade 3 AEs considered related to vaccination. 
The percentage of subjects reporting each individual solicited local AE (any grade and Grade 3) and 
solicited general AE (any grade, Grade 3, any related, Grade 3 related, resulting in medically attended 
visit) during the 7-day follow-up period (Day 0-6) after each vaccine dose and overall will be tabulated 
for each group. Similarly, the percentage of doses followed by each individual solicited local and 
general AE will be tabulated, overall vaccination course, with exact 95% CI. 
For fever, the number and percentage of subjects reporting fever by half degree (°C) cumulative 
increments during the first seven days (Day 0-6) after each vaccine dose and overall will be tabulated. 
Similar tabulations will be performed for any fever with a causal relationship to vaccination and Grade 
3 (> 39.5°C) causally related fever. 
The percentage of subjects reporting unsolicited AEs from the date of the first vaccine dose up to 29 
days after the last vaccine dose and after the sporozoite challenge will be tabulated by group and by 
MedDRA preferred term with exact 95% CI. Similar tabulation will be done for Grade 3 unsolicited 
AEs, for any causally related unsolicited AEs and for Grade 3 causally related unsolicited AEs. 
The percentage of subjects reporting SAEs and pregnancies will be described in detail. 
The percentage of vaccinated subjects reporting AEs of specific interest (meningitis and pIMDs) will 
be described in detail. 
Biochemistry (ALT, AST and creatinine) and haematological (haemoglobin, WBC and platelets) 
laboratory values will be presented according to toxicity grading scales and tabulated by group. 
 
7 HOLDING RULES AND SAFETY MONITORING 
7.1. 
No group holding rules will be pre-defined considering the evidence for a favourable safety 
profile of this candidate vaccine in Phase III infant evaluation.  
7.2. Individual subject holding rules. Individual study participants who present at least one of the 
following stopping rules for individual subjects will be withdrawn from further vaccination: 
a) Local reactions: upon investigator discretion. 
b) Systemic solicited adverse events: The subject develops a Grade 3 systemic solicited 
adverse event beginning within 2 days after vaccination (day of vaccination and one 
subsequent day) and persisting at Grade 3 for >2 consecutive days. 
c) Unsolicited adverse events: The subject has any Grade 3 adverse event considered related 
to vaccination, persisting at Grade 3 for >2 consecutive days. 

 
 
 
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d) The subject has a serious adverse event considered related to vaccination. 
e) The subject has an acute allergic reaction or anaphylactic shock following the administration 
of vaccine investigational product. 
f) Laboratory adverse events: The subject has any Grade 3 laboratory adverse event 
considered related to vaccination. 
7.3.  
Safety Oversight 
 7.3.1.  Medical Monitor 
A Medical Monitor, representing the Sponsor will be appointed for oversight of safety in this clinical 
study. The Medical Monitor will be responsible for safety assessments as outlined below. The  monitor 
will review the study prior to initiation and will be available to advise the Investigators on study-related 
medical issues and to act as a representative for the welfare of the subjects. The monitor does not 
have direct involvement in the conduct of the study and does not have other interests with any 
collaborating pharmaceutical firms or their competitors. All serious adverse events and any AEs that 
fulfil the criteria for pausing or halting will be reported to the medical monitor within 24 hours of 
becoming aware of the event. The monitor is responsible for the review of the safety data and 
communicate with the PI and/or the DSMB, as appropriate.. The Medical Monitor may also provide 
recommendation for continuation, modification, or termination of the study, if there is urgent need. 
 
7.3.2.  Data and Safety Monitoring Board 
The DSMB will review the study prior to initiation; review the interim safety data reports; and review 
all SAEs at the end of the study. The Board may convene additional reviews if deemed necessary, on 
review of the safety data, as sent, periodically by the Medical monitor. All SAEs will be reported by 
the PI to the DSMB at the same time they are submitted to the IRB. The PI will notify the Board at the 
time pausing or halting criteria are met and obtain a recommendation concerning continuation, 
modification, or termination of the study. The PI will submit the written DSMB summary reports with 
recommendations to the IRB(s). 
 
8 STATISTICAL ANALYSIS 
 
8.1 Endpoints 
 
We will assess the RTS,S recipients with regards to:  
- 
Safety: the occurrence of AEs and SAEs (please see safety section)  
- 
Immunogenicity: serum anti-CS antibody titre responses and anti-CS antibody avidity.  
 
 
 

 
 
 
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8.2 The Number of Participants 
 
The sample size calculations are based on the objective of comparing the serologic response to 
RTS,S/AS01E vaccine co-administered with DHA-PIP + SLD-PQ with RTS,S/AS01E or 
RTS,S/AS01B vaccine alone in adults. This is a phase II trial.  Sample sizes for phase II trials are 
usually small, as safety is still of paramount importance. Valid sample sizes for comparing sample 
sizes between two groups are usually obtained using exact test methods such as the Fisher’s exact 
test power calculations. This is done using simulations as sample size formulas are not well 
developed. To estimate the sample size we use a four-fold increase in anti –CS antibody titre as an 
assumed correlate of protection. For the sample size calculation, we assume that the background 
rate of response in the reference groups will be 5% and the true rate of anti-CS antibody response 
in the vaccine groups is 80%. We wish to exclude, for the vaccine, a one-tailed lower 95% CI for the 
reference-vaccine group difference of lower than 30%. The study aims to detect this difference with 
90% power (because the detectable difference is big) and testing at 5% significance level. With 
these assumptions, and using the method of Blackwelder[37] for precision-based sample size 
calculations, a total of 20 participants per group would be needed for arms 1 and 2 because the 
anticipated difference is too big. However, for arms 3 to 7 (Table 3 below), we will need more 
participants per group because a smaller detectable effect is anticipated. Using the Fisher’s exact 
test power simulations, a difference in serologic response of 30% (say 65% vs 95%) gives 
approximately 80% power with a sample size of 30 participants in each group testing at 5% 
significance level. Therefore the total sample size for all the 7 arms will be 190 participants. 
 
The size of study groups is relatively small hence it is imperative to minimise potential losses. 
Whenever possible an attempt will be made to replace study participates should a participant be 
withdrawn or choose to withdraw. The stata command for obtaining the Fishers exact test power 
simulations is: power two proportions 0.65 0.95, test(fisher) n1(30) n2(30). This has been performed 
in Stata 14. 
 
 
 
 
 
 
 
 
 

 
 
 
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The required sample sizes are summarized as follows: 
 
Table 3: Sample size and vaccine vials required for each arm  
 
Group 
# 
participants 
Vaccine 
Dose 
M0 
Dose 
M1 
Dose 
M2 
Antimalarial 
vaccine vials 
required 
1 
20 
RTS,S/AS01B 
Single 
standard 
dose 
(0.5mL) 
Single 
standard 
dose 
(0.5mL) 
Fx dose 
(0.1mL) 
 
60 
2 
20 
RTS,S /AS01E 
Double 
standard 
dose 
(1.0mL) 
Double 
standard 
dose 
(1.0mL) 
Double Fx 
dose 
(0.2mL) 
 
60 
3 
30 
RTS,S/AS01E 
Single 
standard 
dose 
(0.5mL) 
Single 
standard 
dose 
(0.5mL) 
Single 
standard 
dose 
(0.5mL) 
 
90 
4 
30 
RTS,S/AS01E 
Single 
standard 
dose 
(0.5mL) 
Single 
standard 
dose 
(0.5mL) 
Single 
standard 
dose 
(0.5mL) 
DHA-PIP+PQ 
90 
5 
30 
RTS,S/AS01E 
Single 
standard 
dose 
(0.5mL) 
Single 
standard 
dose 
(0.5mL) 
Fx dose 
(0.1mL) 
 
90 
6 
30 
 
RTS,S/AS01E 
Single 
standard 
dose 
(0.5mL) 
Single 
standard 
dose 
(0.5mL) 
Fx dose 
(0.1mL) 
DHA-PIP+PQ 
90 
7 
30 
RTS,S/AS01E 
Single 
standard 
dose 
(0.5mL) 
 
Fx dose 
(0.1mL) 
DHA-PIP+PQ 
60 
Total 
190 
 
 
 
 
 
540 
Fx dose= fractional dose 
 
RTS,S/AS01B = adult formulation containing 50µg of RTS,S and 50μg MPL and 50μg QS-21 in the 
standard dose of 0.5mL. 
RTS,S/AS01E = standard formulation containing 25µg of RTS,S and 25μg MPL and 25μg QS-21 in 
the standard dose of 0.5mL. 
DHA-PIP = dihydroartemisinin-piperaquine 
 
PQ = single low dose primaquine 
Fx dose = fractional dose i.e. 1/5th of standard dose of RTS,S/AS01B or RTS,S/AS01E 

 
 
 
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8.3 Inclusion in Analysis 
 
All patients who received at least one dose of vaccine will be included in the safety analyses. 
Patients lost to follow-up before the completion of the follow-up period assessments will be 
censored at the last day seen.  
 
Immunology analyses 
Given the incidence of malaria in the study area, it is highly unlikely that any volunteer will become 
infected with any Plasmodium species during the trial. However, to exclude the remote possibility 
that a participant becomes infected we will screen participants for malaria at screening, Month 0, 
Month 1, Month 2, Month 3, and Month 6. The malaria screen consists of a blood film which is read 
immediately in the hospital laboratory. The result will be available in <30 min. Subjects positive for 
malaria at screening or Month 0 are excluded from participation in the study and will not be enrolled 
or vaccinated. Subjects positive for malaria at Month 1 or Month 2 will be withdrawn from further 
vaccinations. In the remote scenario that a volunteer becomes parasitaemic during the study results 
obtained from that point in time onward will be confounded by the immune response to the natural 
infection. Immunology results obtained during and after an episode of parasitaemia will be excluded 
from the immunology analysis. The results can be included in the safety analysis. 
 
8.4 Overall plan 
 
Both intention-to-treat and per-protocol analyses will be carried out. 
 
- 
In the intention-to-treat analysis, every participant randomized in the study (who receive the 
correct or incorrect study agent, one or more doses, and complete or incomplete doses) will be 
analysed, except if he/she did not receive any dose of the study vaccine or if no post-
randomization data was collected for this participant.  
 
- 
The per-protocol analysis will compare participants according to the study agent actually 
received and will include only those participants who satisfied the inclusion/exclusion criteria, 
followed the protocol, and received three complete, correct doses. The following non-compliant 
participants will be excluded: 
o Participants included without meeting at least one inclusion criterion 
o Participants included despite meeting at least one exclusion criterion 
o Participants found non-compliant with the blood sampling schedule 
o Participants vaccinated with the wrong study agent (non-compliance with the 
randomization code) 

 
 
 
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o Participants excluded from the intention-to-treat analysis. 
No interim analysis is planned. 
 
8.5 Analysis of baseline characteristics 
 
The demographic characteristics of enrolled participants will be compared by study group. 
 
8.6 Analysis of immunogenicity 
 
The serum anti-CS antibody titre and avidity responses for each treatment arm will be compared to 
the titre before vaccine administration as follows: 
 
For group 1 to 6: 
- 
Number (%) in each study group with >4-fold rise in titre from baseline to: 
o One month after first dose 
o One month after second dose 
o One  month after the third dose 
o Six months after the first dose 
- 
The geometric mean-fold rise in each study group from baseline to: 
o One month after first dose 
o One month after second dose 
o One month after the third dose 
o Six months after the first dose. 
 
For group 7: 
- 
Number (%) in study group with >4-fold rise in titre from baseline to: 
o One month after first dose 
o Two months after first dose 
o One  month after the second dose 
o Six months after the first dose 
- 
The geometric mean-fold rise in study group from baseline to: 
o One month after first dose 
o Two months after first dose 
o One month after the second dose 
o Six months after the first dose. 
 

 
 
 
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9 DIRECT ACCESS TO SOURCE DATA/DOCUMENTS 
Direct access to all trial related source data/documents will be granted to authorized representatives 
from the sponsor, PATH Malaria Vaccine Initiative, GSK, Research Ethics Committees (RECs),  and 
the regulatory authorities to permit trial-related monitoring, audits and inspections. 
 
10 QUALITY CONTROL AND QUALITY ASSURANCE PROCEDURES 
The study will be conducted in accordance with the current approved protocol, ICH GCP, relevant 
regulations and standard operating procedures. Data will be evaluated for compliance with the 
protocol and accuracy in relation to source documents. Following written standard operating 
procedures, the monitors will verify that the clinical trial is conducted and data are generated, 
documented and reported in compliance with the protocol.  
 
11 ETHICS 
Ethical approval will be sought prior to commencing the study through the relevant Research Ethics 
Committees. Indemnity for the trial will be provided by the University of Oxford. SAEs will be 
reported to the medical monitor, DSMB, ethics committees and the Sponsor. GCP training will be 
provided to all staff/investigators who have no valid training certificate prior to commencing the 
studies. 
 
11.1 Declaration of Helsinki 
 
The Investigators at each site will ensure that this study is conducted in accordance with the 
principles of the Declaration of Helsinki. 
 
11.2 ICH Guidelines for Good Clinical Practice 
The trial will adhere to the Research Governance policies of the University of Oxford and the ICH 
GCP. 
 
11.3 Approvals 
The protocol, informed consent form, participant information sheet, and other written participant 
information / materials will be submitted to appropriate Research Ethics Committees (RECs), and 
regulatory authorities for written approval. The Principal Investigator will submit and, where 
necessary, obtain approval from the above parties for all amendments to the original approved 
documents.  
 

 
 
 
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11.4 Participant Confidentiality 
The trial staff will ensure that the participants’ anonymity is maintained.  The participants will be 
identified only by participants ID number on the CRF and in any electronic databases.  All 
documents will be stored securely and only accessible to trial staff and authorized personnel. Only 
the sponsor representative, investigators, the clinical monitor, authorized individuals from the PATH 
Malaria Vaccine Initiative, GSK, the ethical committee(s) and the regulatory authorities will have 
access to the records.  Data will be anonymized as soon as it is practical to do so.  
With subject’s consent, subject’s clinical data and results from blood analyses stored in our 
database may be shared with PATH Malaria Vaccine Initiative, GSK, other researchers to use in the 
future. However, the other researchers will not be given any information that could identify the 
subject. 
 
12 DATA HANDLING AND RECORD KEEPING 
 
All study data will be stored under lock and key. The investigators will maintain and retain 
appropriate medical and research records and essential documents for this trial in compliance with 
ICH E6 GCP and regulatory and institutional requirements for the protection of confidentiality of 
volunteers. Only authorized, trained study staff will have access to study records. The participants 
will be identified by a study specific participants ID number and/or code in any database.  The 
participants’ names and any other identifying details will NOT be included in any study data 
electronic file.  
 
The principal Investigator will be responsible for data management and for delegating the receiving, 
entering, cleaning, querying, analysing and storing all data that accrues from the study. The study 
staff will enter the data into the volunteers’ CRFs, which will be in a paper and/or electronic format. 
This includes safety data, laboratory data (both clinical and immunological) and outcome data. Data 
will be managed and stored in MACRO® database, a GCP-compliant electronic data capture 
system. 
 
The investigators will permit authorized representatives of the sponsor, ethical committee(s), 
regulatory agencies, authorized individuals from PATH Malaria Vaccine Initiative, GSK and the 
monitors to examine (and when required by applicable law, to copy) clinical records for the purposes 
of quality assurance reviews, audits and evaluation of the study safety and progress. 
 
 
 
 

 
 
 
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13 INSURANCE 
The University of Oxford has a specialist insurance policy in place: - Newline Underwriting 
Management Ltd, at Lloyd’s of London – which would operate in the event of any Participant 
suffering harm as a result of their involvement in the research. 
 
14 PUBLICATION POLICY 
All Investigators will be involved in reviewing drafts of the manuscripts, abstracts, press releases 
and any other publications arising from the study. Authorship will be determined in accordance with 
the ICMJE guidelines and other contributors will be acknowledged. 
 
 

 
 
 
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15 APPENDIX A: SUMMARY OF STUDY ARMS AND PROCEDURES  
 
RB = Standard dose RTS,S/AS01B: 50µg RTS,S + standard dose AS01B (0.5ml containing 50µg MPL 
+ 50µg QS21) 
RE = Standard dose RTS,S/AS01E: 25µg RTS,S + standard dose AS01E (0.5ml containing 25µg MPL 
+ 25µg QS21) 
rB = Fractional dose RTS,S/AS01B (1/5th dose): 10µg RTS,S + 1/5 standard dose AS01B (0.1ml 
containing 10µg MPL + 10µg QS21)  
rE = Fractional dose RTS,S/AS01E (1/5th dose): 2.5µg RTS,S + 1/5 standard dose AS01E (0.1ml 
containing 2.5µg MPL + 2.5µg QS21)  
2x = Double dose of RE (i.e. 1.0ml) or rE (i.e. 0.2ml), as indicated. 
DHA-PIP = Dihydroartemisinin/piperaquine (for 3 days; day of vaccination and two subsequent days) 
PQ = Primaquine (single low dose on day of vaccination) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Month 
Group 1 (n=20) 
 
RBRBrB 
Group 2 
(n=20) 
 
2xRE2xRE2xrE 
Group 3 (n=30) 
 
RERERE 
Group 4 (n=30) 
 
RERERE + DHA-
PIP + PQ 
Group 5 (n=30) 
 
RERErE 
Group 6 (n=30) 
 
RERErE + DHA-
PIP+ PQ 
Group 7(n=30) 
 
RErE + DHA-PIP 
+ PQ 
0 
RTS,S/AS01B 
Standard dose 
(0.5mL) 
RTS,S/AS01E 
Double 
Standard dose 
(1.0mL) 
RTS,S/AS01E 
Standard dose 
(0.5mL) 
RTS,S/AS01E 
Standard dose 
(0.5mL) 
+ 
DHA-PIP+PQ 
RTS,S/AS01E 
Standard dose 
(0.5mL) 
RTS,S/AS01E 
Standard dose 
(0.5mL) 
+ 
DHA-PIP+PQ 
RTS,S/AS01E 
Standard dose 
(0.5mL) 
+ 
DHA-PIP+PQ 
1 
RTS,S/AS01B 
Standard dose 
(0.5mL) 
RTS,S/AS01E 
Double 
Standard dose 
(1.0mL) 
RTS,S/AS01E 
Standard dose 
(0.5mL) 
RTS,S/AS01E 
Standard dose 
(0.5mL) 
+ 
DHA-PIP+PQ 
RTS,S/AS01E 
Standard dose 
(0.5mL) 
RTS,S/AS01E 
Standard dose 
(0.5mL) 
+ 
DHA-PIP+PQ 
No intervention 
in M1 
2 
RTS,S/AS01B 
1/5 Standard 
dose 
(0.1mL) 
RTS,S/AS01E 
Double 1/5 
Standard dose 
(0.2mL) 
RTS,S/AS01E 
Standard dose 
(0.5mL) 
RTS,S/AS01E 
Standard dose 
(0.5mL) 
+ 
DHA-PIP+PQ 
RTS,S/AS01E 
1/5 Standard 
dose 
(0.1mL) 
RTS,S/AS01E 
1/5 Standard 
dose 
(0.1mL) 
+ 
DHA-PIP+PQ  
RTS,S/AS01E 
1/5 Standard 
dose 
(0.1mL) 
+ 
DHA-PIP+PQ 

 
 
 
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Study procedures 
 
 
 
 
 
 
Month 
Scr 
M0 
M1 
M2 
M3 
M6a 
Day of month 
 
0f 
1b 
2b 
7 
0 
1b 
2b 
7 
0 
1b 
2b 
7 
0 
0 
Informed Consent 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inclusion / Exclusion criteria 
x 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
Vaccination 
 
x 
 
 
 
x* 
 
 
 
x 
 
 
 
 
 
DHA/piperaquine**  
 
x 
x b 
x b 
 
x* 
x b 
x b 
 
x 
x b 
x b 
 
 
 
PQ single low dose primaquine** 
 
x 
 
 
 
x* 
 
 
 
x 
 
 
 
 
 
History of fever, current axillary 
temperature*** 
x 
x 
x b 
x b 
x 
x 
x b 
x b 
x 
x 
x b 
x b 
x 
x 
x 
Full medical history, vital signs, 
physical examination 
x 
x 
 
 
 
x 
 
 
 
x 
 
 
 
 
 
Ask about any concomitant medication 
x 
x 
x b 
x b 
x 
x 
x b 
x b 
x 
x 
x b 
x b 
x 
x 
x 
Assessment of any adverse event(s) 
 
x 
x b 
x b 
x 
x 
x b 
x b 
x 
x 
x b 
x b 
x 
x 
x 
Assess for any withdrawal criteria 
 
x 
x b 
x b 
x 
x 
x b 
x b 
x 
x 
x b 
x b 
x 
x 
x 
Blood 
sample 
(mL) 
Parasite microscopy**** 
 
 
2 
 
 
2 
 
 
 
0.5 
 
 
 
0.5 
 
 
 
 
 
2 
0.5 
Haematology 
Hb, WBC, PLT 
 
 
2 
 
 
 
2 
 
 
 
2 
 
Biochemistry 
ALT, AST, CREA 
3 
3 
 
 
3 
 
 
 
3 
 
 
 
3 
3 
 
HBsAg, HCV, HIV 
1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immunology panel c 
 
10 
 
 
 
10 
 
 
 
10 
 
 
 
10 
10 
Piperaquine  & Primaquine 
levels***** 
 
1g 
1e 
1d 
1d 
1d 
1e 
1d 
1d 
1d 
1e 
1d 
1d 
 
 
Blood volume per visit (mL) 
6 
16 
1 
1 
6 
11.5 
1 
1 
6 
11.5 
1 
1 
6 
15 
10.5 
Maximum cumulative blood 
volume (mL) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
94.5 
Electrocardiogram (ECG) 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine pregnancy test 
x 
x 
 
 
 
X 
 
 
 
x 
 
 
 
 
 
 
 
* Procedures are not applicable for study group 7 
** Only for study groups 4, 6 and 7, where applicable 
*** Axillary temperature will be record from D0-D7 after 
each vaccination 
a) first day of M6 
b) Visits on days 1 and 2 post-vaccination are only 
applicable for study groups 4, 6, and 7 in Months 0 and 2, 
and for study groups 4 and 6 in Month 1. 
c) the immunology panel consists of six assays to be 
processed at WRAIR: 

 
 
 
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**** Parasite microscopy for purposes of indicating 
whether volunteer has been exposed, and not as an 
assessment of protection. 
***** Piperaquine and Primaquine levels for group 4 and 6 
only. Additional drug level assessment for Primaquine will 
be done if additional data are required. 
 
Plasmodium  falciparum. Circumsporozoite 
Protein. (NANP)6 Ab.IgG  
 
Plasmodium  falciparum. Circumsporozoide 
Protein. (NANP)6 Ab.IgG Avidity  
 
Plasmodium falciparum. anti-C-Term 
Circumsporozoide Ab.IgG  
 
Plasmodium falciparum. anti-C-Term 
Circumsporozoide Ab.IgG avidity  
 
Plasmodium falciparum. Circumsporozoite Full 
length (N+C-Terminal)  
 
P falciparum. anti-full length CSP Ab.IgG avidity 
d) Drug level only for Piperaquine 
e) Drug level for Piperaquine and Primaquine 
f) If interval between screening and M0D0 is 3 days or less, 
screening lab results (haematology, biochemistry, 
parasite microscopy, and urine pregnancy test) can be 
used for enrolment (M0D0) 
g) Drug level for Piperaquine and/or Primaquine will be 
assessed if additional data are required 
 
 
Summary of participant visits 
 
Grou
p  
Number 
of visit 
Visit timepoints 
 
 
Scr 
M0 
M1 
M2 
M3 
M6 
 
 
 
D0 
D1 
D2 
D7 
D0 
D1 
D2 
D7 
D0 
D1 
D2 
D7 
D0 
D0 
1 
9 
x 
x 
 
 
x 
x 
 
 
x 
x 
 
 
x 
x 
x 
2 
9 
x 
x 
 
 
x 
x 
 
 
x 
x 
 
 
x 
x 
x 
3 
9 
x 
x 
 
 
x 
x 
 
 
x 
x 
 
 
x 
x 
x 
4 
15 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
5 
9 
x 
x 
 
 
x 
x 
 
 
x 
x 
 
 
x 
x 
x 
6 
15 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
7 
13 
x 
x 
x 
x 
x 
x 
 
 
x 
x 
x 
x 
x 
x 
x 
 
All the study procedure will be performed by research team including research doctor, research 
nurse and research physician at healthy volunteer unit at Faculty of Tropical Medicine, Mahidol 
University.  
Intervals between study visits 
 
Interval 
Optimal length of 
interval 
Allowed interval 
Screening to Month 0 / Day 0 (1st vaccination) 
0 to 30 days 
- 
Month 0 / Day 0 (1st vaccination) to Month 1 / Day 0 (2nd 
vaccination) 
28 days 
+/ - 7 days 
Month 1 / Day 0 (2nd vaccination) to Month 2 / Day 0 (3rd 
vaccination) 
28 days 
+/ - 7 days 
Month 2 / Day 0 (3rd vaccination) to Month 3 / Day 0 
28 days 
+/ - 7 days 
Month 3 / Day 0 to Month 6 / Day 0 
84 days 
+/ - 14 days 
  
16 REFERENCES 
 

 
 
 
Protocol v. 5.0 dated 2/11/2017  
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Page 53 of 55 
 
1. Kaslow DC, Biernaux S. RTS,S: Toward a first landmark on the Malaria Vaccine Technology 
Roadmap. Vaccine 2015; 33(52): 7425-32. 
2. Rts SCTP. Efficacy and safety of RTS,S/AS01 malaria vaccine with or without a booster dose in 
infants and children in Africa: final results of a phase 3, individually randomised, controlled trial. 
Lancet 2015; 386(9988): 31-45. 
3. What next for the malaria RTS,S vaccine candidate? Lancet 2015; 386(10005): 1708. 
4. Ashley EA, Dhorda M, Fairhurst RM, et al. Spread of artemisinin resistance in Plasmodium 
falciparum malaria. The New England journal of medicine 2014; 371(5): 411-23. 
5. Mita T, Tanabe K. Evolution of Plasmodium falciparum drug resistance: implications for the 
development and containment of artemisinin resistance. Japanese journal of infectious diseases 
2012; 65(6): 465-75. 
6. Mita T, Tanabe K, Kita K. Spread and evolution of Plasmodium falciparum drug resistance. 
Parasitology international 2009; 58(3): 201-9. 
7. Leang R, Taylor WR, Bouth DM, et al. Evidence of Plasmodium falciparum Malaria Multidrug 
Resistance to Artemisinin and Piperaquine in Western Cambodia: Dihydroartemisinin-
Piperaquine Open-Label Multicenter Clinical Assessment. Antimicrobial agents and 
chemotherapy 2015; 59(8): 4719-26. 
8. Tun KM, Imwong M, Lwin KM, et al. Spread of artemisinin-resistant Plasmodium falciparum in 
Myanmar: a cross-sectional survey of the K13 molecular marker. The Lancet Infectious diseases 
2015; 15(4): 415-21. 
9. Trape JF, Pison G, Preziosi MP, et al. Impact of chloroquine resistance on malaria mortality. 
Comptes rendus de l'Academie des sciences Serie III, Sciences de la vie 1998; 321(8): 689-97. 
10. Regules JA, Cicatelli SB, Bennett JW, et al. Fractional Third and Fourth Dose of RTS,S/AS01 
Malaria Candidate Vaccine: A Phase 2a Controlled Human Malaria Parasite Infection and 
Immunogenicity Study. The Journal of infectious diseases 2016; 214(5): 762-71. 
11. Adjei A, Narh-Bana S, Amu A, et al. Treatment outcomes in a safety observational study of 
dihydroartemisinin/piperaquine (Eurartesim((R))) in the treatment of uncomplicated malaria at 
public health facilities in four African countries. Malaria journal 2016; 15: 43. 
12. Matangila JR, Mitashi P, Inocencio da Luz RA, Lutumba PT, Van Geertruyden JP. Efficacy and 
safety of intermittent preventive treatment for malaria in schoolchildren: a systematic review. 
Malaria journal 2015; 14: 450. 
13. Kheng S, Muth S, Taylor WR, et al. Tolerability and safety of weekly primaquine against relapse 
of Plasmodium vivax in Cambodians with glucose-6-phosphate dehydrogenase deficiency. BMC 
medicine 2015; 13: 203. 
14. Benjamin JM, Moore BR, Salman S, et al. Population pharmacokinetics, tolerability, and safety 
of dihydroartemisinin-piperaquine and sulfadoxine-pyrimethamine-piperaquine in pregnant and 
nonpregnant Papua New Guinean women. Antimicrobial agents and chemotherapy 2015; 59(7): 
4260-71. 
15. Baiden R, Oduro A, Halidou T, et al. Prospective observational study to evaluate the clinical 
safety of the fixed-dose artemisinin-based combination Eurartesim(R) 
(dihydroartemisinin/piperaquine), in public health facilities in Burkina Faso, Mozambique, Ghana, 
and Tanzania. Malaria journal 2015; 14: 160. 
16. Nji AM, Ali IM, Moyeh MN, et al. Randomized non-inferiority and safety trial of dihydroartemisin-
piperaquine and artesunate-amodiaquine versus artemether-lumefantrine in the treatment of 
uncomplicated Plasmodium falciparum malaria in Cameroonian children. Malaria journal 2015; 
14: 27. 
17. Bigira V, Kapisi J, Clark TD, et al. Protective efficacy and safety of three antimalarial regimens 
for the prevention of malaria in young Ugandan children: a randomized controlled trial. PLoS 
medicine 2014; 11(8): e1001689. 
18. Moore BR, Benjamin JM, Salman S, et al. Effect of coadministered fat on the tolerability, safety, 
and pharmacokinetic properties of dihydroartemisinin-piperaquine in Papua New Guinean 
children with uncomplicated malaria. Antimicrobial agents and chemotherapy 2014; 58(10): 
5784-94. 
19. Ogutu BR, Onyango KO, Koskei N, et al. Efficacy and safety of artemether-lumefantrine and 
dihydroartemisinin-piperaquine in the treatment of uncomplicated Plasmodium falciparum 

 
 
 
Protocol v. 5.0 dated 2/11/2017  
                        CONFIDENTIAL 
Page 54 of 55 
 
malaria in Kenyan children aged less than five years: results of an open-label, randomized, 
single-centre study. Malaria journal 2014; 13: 33. 
20. Sylla K, Abiola A, Tine RC, et al. Monitoring the efficacy and safety of three artemisinin based-
combinations therapies in Senegal: results from two years surveillance. BMC infectious diseases 
2013; 13: 598. 
21. Naing C, Mak JW, Aung K, Wong JY. Efficacy and safety of dihydroartemisinin-piperaquine for 
treatment of uncomplicated Plasmodium falciparum malaria in endemic countries: meta-analysis 
of randomised controlled studies. Transactions of the Royal Society of Tropical Medicine and 
Hygiene 2013; 107(2): 65-73. 
22. Gargano N, Ubben D, Tommasini S, et al. Therapeutic efficacy and safety of dihydroartemisinin-
piperaquine versus artesunate-mefloquine in uncomplicated Plasmodium falciparum malaria in 
India. Malaria journal 2012; 11: 233. 
23. Tjitra E, Hasugian AR, Siswantoro H, et al. Efficacy and safety of artemisinin-naphthoquine 
versus dihydroartemisinin-piperaquine in adult patients with uncomplicated malaria: a multi-
centre study in Indonesia. Malaria journal 2012; 11: 153. 
24. Nambozi M, Van Geertruyden JP, Hachizovu S, et al. Safety and efficacy of dihydroartemisinin-
piperaquine versus artemether-lumefantrine in the treatment of uncomplicated Plasmodium 
falciparum malaria in Zambian children. Malaria journal 2011; 10: 50. 
25. Mayxay M, Keomany S, Khanthavong M, et al. A phase III, randomized, non-inferiority trial to 
assess the efficacy and safety of dihydroartemisinin-piperaquine in comparison with artesunate-
mefloquine in patients with uncomplicated Plasmodium falciparum malaria in southern Laos. The 
American journal of tropical medicine and hygiene 2010; 83(6): 1221-9. 
26. Nankabirwa J, Cundill B, Clarke S, et al. Efficacy, safety, and tolerability of three regimens for 
prevention of malaria: a randomized, placebo-controlled trial in Ugandan schoolchildren. PloS 
one 2010; 5(10): e13438. 
27. Bojang K, Akor F, Bittaye O, et al. A randomised trial to compare the safety, tolerability and 
efficacy of three drug combinations for intermittent preventive treatment in children. PloS one 
2010; 5(6): e11225. 
28. Katrak S, Gasasira A, Arinaitwe E, et al. Safety and tolerability of artemether-lumefantrine 
versus dihydroartemisinin-piperaquine for malaria in young HIV-infected and uninfected children. 
Malaria journal 2009; 8: 272. 
29. Zwang J, Ashley EA, Karema C, et al. Safety and efficacy of dihydroartemisinin-piperaquine in 
falciparum malaria: a prospective multi-centre individual patient data analysis. PloS one 2009; 
4(7): e6358. 
30. Mytton OT, Ashley EA, Peto L, et al. Electrocardiographic safety evaluation of dihydroartemisinin 
piperaquine in the treatment of uncomplicated falciparum malaria. The American journal of 
tropical medicine and hygiene 2007; 77(3): 447-50. 
31. Myint HY, Ashley EA, Day NP, Nosten F, White NJ. Efficacy and safety of dihydroartemisinin-
piperaquine. Transactions of the Royal Society of Tropical Medicine and Hygiene 2007; 101(9): 
858-66. 
32. Karema C, Fanello CI, van Overmeir C, et al. Safety and efficacy of 
dihydroartemisinin/piperaquine (Artekin) for the treatment of uncomplicated Plasmodium 
falciparum malaria in Rwandan children. Transactions of the Royal Society of Tropical Medicine 
and Hygiene 2006; 100(12): 1105-11. 
33. Karunajeewa H, Lim C, Hung TY, et al. Safety evaluation of fixed combination piperaquine plus 
dihydroartemisinin (Artekin) in Cambodian children and adults with malaria. British journal of 
clinical pharmacology 2004; 57(1): 93-9. 
34. Denis MB, Davis TM, Hewitt S, et al. Efficacy and safety of dihydroartemisinin-piperaquine 
(Artekin) in Cambodian children and adults with uncomplicated falciparum malaria. Clinical 
infectious diseases : an official publication of the Infectious Diseases Society of America 2002; 
35(12): 1469-76. 
35. Eziefula AC, Bousema T, Yeung S, et al. Single dose primaquine for clearance of Plasmodium 
falciparum gametocytes in children with uncomplicated malaria in Uganda: a randomised, 
controlled, double-blind, dose-ranging trial. The Lancet Infectious diseases 2014; 14(2): 130-9. 

 
 
 
Protocol v. 5.0 dated 2/11/2017  
                        CONFIDENTIAL 
Page 55 of 55 
 
36. White NJ, Qiao LG, Qi G, Luzzatto L. Rationale for recommending a lower dose of primaquine 
as a Plasmodium falciparum gametocytocide in populations where G6PD deficiency is common. 
Malaria journal 2012; 11: 418. 
37. Blackwelder WC. Showing a treatment is good because it is not bad: when does "noninferiority" 
imply effectiveness? Controlled clinical trials 2002; 23(1): 52-4.