Investigating the Sylvatic Transmission and Reservoir Potential of Zika, Dengue, and Chikungunya Viruses of Co-located Humans and Long-tailed Macaques of Thailand and Cambodia
Conditions: Dengue Fever, Zika, Vector-Borne Diseases, Chikungunya
Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)

Consent to participate in a clinical research study
“Investigating the sylvatic transmission and reservoir potential of Zika, dengue, and 
chikungunya viruses of co-located humans and long-tailed macaques in Thailand and 
Cambodia”
Protocol 20-I-N054 ICF Version 2
22 May 2020
Page 1 of 5
Participant Name  ___________________________________________________  Age ___________  
Study Identification Number _______________
KEY INFORMATION
This consent form describes a research study and is designed to help you decide if you would like to 
be a part of the research study.  
You are being asked to take part in a research study. This study is sponsored by the National Center 
for Parasitology, Entomology and Malaria Control (CNM), Ministry of Health, Phnom Penh, Cambodia, 
and the National Institutes of Health (NIH), United States of America. This section provides the 
information we believe is most helpful and important to you in making your decision about 
participating in this study. Additional information that may help you make a decision can be found in 
other sections of the document. Participation in this study is entirely voluntary, and there is no 
penalty or loss of benefits for deciding not to participate. 
We are doing this study to better understand if animals such as monkeys might carry and help spread 
germs to people that cause common illnesses in Cambodia and Thailand, like Zika, dengue, and 
chikungunya. We hope that in the future, we can use this information to improve public health 
programs and conduct more research studies about these diseases.
In this study, we are collecting blood samples from people who live or work near Wat Amphae Phnom 
in Chbar Mon town, and from monkeys in the same area. If you agree to join this study, we will do 
research tests on your blood sample to look for evidence of germs that cause common illnesses. The 
research tests will tell us if you have had these germs at some point in the past, but they will not tell 
us if you have the germs right now. We will not share test results with you. We will compare the 
results of the research tests from humans to those from monkeys to see if they get the same kinds of 
germs.
All of these test results will be protected and stored. Your name or any other personal information 
will be removed before these results are shared with other researchers.
You will not directly benefit by participating in this study. The results will help us better understand if 
monkeys help spread germs in Cambodia. Collecting blood may hurt or cause a little bleeding or 
bruising, but that should go away within a day.
The remaining document will now describe more about the research study. This information should be 
considered before you make your choice. Members of the study team will talk with you about the 
information described in this document. Take the time needed to ask any questions and discuss this 
study with a member of the study team, and with your family, friends, and personal healthcare 
providers.
IRB NUMBER: 20IN054
IRB APPROVAL DATE: 06/12/2020

Consent to participate in a clinical research study
“Investigating the sylvatic transmission and reservoir potential of Zika, dengue, and 
chikungunya viruses of co-located humans and long-tailed macaques in Thailand and 
Cambodia”
Protocol 20-I-N054 ICF Version 2
22 May 2020
Page 2 of 5
BACKGROUND/PURPOSE OF STUDY
The purpose of this study is to better understand if animals such as monkeys might carry and help 
spread germs to people that cause common illnesses in Cambodia, like Zika, dengue, and chikungunya. 
We hope that in the future, we can use this information to improve public health programs and conduct 
more research studies about these diseases.
IDENTIFICATION OF STUDY POPULATION
We will enroll adults who live or work near Wat Amphae Phnom in Chbar Mon town. We anticipate 
enrolling approximately 300 people into this study. 
PROCEDURES EXPLAINED
If you agree to join this study, then we will first ask you some questions about yourself, like your age, 
sex, where you live and work, your health, and your everyday activities.
We will collect a small amount (about 2 teaspoons) of blood from a vein in your arm using a needle. We 
will use this blood for research tests to look for evidence of germs that cause common illnesses in 
people in Cambodia. We will compare the results of the research tests from humans to those from 
monkeys to see if they get the same kinds of germs.
Your participation in this study ends after we collect your blood sample.
ALTERNATIVE TO PARTICIPATION
The alternative to participating in this study is to not participate. Not participating in this study will not 
prevent you from participating in a future study. 
STORED BLOOD AND DATA
Your stored sample and data will be marked with a code and not with your name or any other personal 
information that would identify you. Only researchers linked to this study can get the codes. 
We will store your blood sample and data (information) for a very long time to use for future research 
on diseases that cause illnesses in Cambodia. Your coded study information will be placed in secure 
electronic systems, called databases, for use by other researchers. Researchers must request 
permission to look at information in this system. They may then use the information for future 
research on any topic. This allows the information to be shared broadly for research purposes. You will 
not get any information about future research.
Your coded sample and data might be sent to other scientists that we work with for research. We must 
get approval from the Cambodian and US ethics boards that review this study to share samples and data 
with other researchers. Other information, such as your sex or age, might also be shared, but your name 
will not. Your sample will not be sold. You will not be paid for any products that result from this 
IRB NUMBER: 20IN054
IRB APPROVAL DATE: 06/12/2020

Consent to participate in a clinical research study
“Investigating the sylvatic transmission and reservoir potential of Zika, dengue, and 
chikungunya viruses of co-located humans and long-tailed macaques in Thailand and 
Cambodia”
Protocol 20-I-N054 ICF Version 2
22 May 2020
Page 3 of 5
research. The only risk of allowing us to store your sample or information would be an accidental release 
of your identity.
If you change your mind and decide you do not want us to store your sample or data, then please let us 
know. We will do our best to follow your wishes but cannot promise that we will always be able to 
destroy the sample or data.
DISCUSSION OF FINDINGS
The research tests we do in this study may take many weeks or longer to complete, so we will not return 
the results to you. However, we will share the general results of the study with the provincial and 
national health authorities, but not your name or individual results, so they can better predict what 
diseases they may have to treat in the future.
RISKS/DISCOMFORTS EXPLAINED
Drawing blood may cause discomfort, bleeding, and occasional bruising at the site; rarely, fainting or 
infection may occur. We will clean the arm before taking blood and will use new needles to obtain the 
blood. 
EXPLANATION OF POTENTIAL BENEFITS
You will not directly benefit by being in this study. 
The study team may gain new knowledge about whether animals like monkeys might carry and help 
spread germs that cause common illnesses in Cambodia. We may be able to use this knowledge to 
improve public health programs and help future research about these diseases.
COMPENSATION
To compensate you for the inconvenience of providing a blood sample, you will receive $5 in cash. 
CONFIDENTIALITY
We will keep the study information private. All files with information that could identify you will be kept 
in locked cabinets at our laboratory or offices in Phnom Penh. The sample of blood that is collected from 
you will be marked with a number that tells the study team that it is your blood. The sample will not be 
marked with your name or other identifying information. Only researchers in this study will have access 
to information that could identify you. People responsible for making sure that the research is done 
properly may look at your study records. These might include people or their representatives from the 
Cambodian National Ethics Committee for Health Research, CNM, or NIH. These people will also keep 
your identity private. However, we cannot guarantee absolute confidentiality.
IRB NUMBER: 20IN054
IRB APPROVAL DATE: 06/12/2020

Consent to participate in a clinical research study
“Investigating the sylvatic transmission and reservoir potential of Zika, dengue, and 
chikungunya viruses of co-located humans and long-tailed macaques in Thailand and 
Cambodia”
Protocol 20-I-N054 ICF Version 2
22 May 2020
Page 4 of 5
STATEMENT THAT NEW FINDINGS WILL BE PUBLISHED
The findings of this study may be reported at meetings or in medical journals, but your name will not be 
used in the reports. 
LIST OF CONTACTS
If you have questions or concerns about this study now or at a later date, you may speak with one of our 
staff at the Kampong Speu District Referral Hospital or contact Dr. Suon Seila (Tel: 855 23 996 202), 
Project Manager for the CNM, or Professor Eng Huot (Tel: 012 950 122), Chairman of the National Ethics 
Committee for Health Research, in Phnom Penh. The doctors at the Referral Hospital can help you 
contact Dr. Seila or Professor Huot.
IRB NUMBER: 20IN054
IRB APPROVAL DATE: 06/12/2020

Consent to participate in a clinical research study
“Investigating the sylvatic transmission and reservoir potential of Zika, dengue, and 
chikungunya viruses of co-located humans and long-tailed macaques in Thailand and 
Cambodia”
Protocol 20-I-N054 ICF Version 2
22 May 2020
Page 5 of 5
If you agree to participate in this study, then please put your signature or thumbprint below.
__________
____________________________
_____________
Thumbprint 
    - or -
Signature of Participant
Date 
____________________________
____________________________
_____________
Investigator Name 
Investigator Signature
Date
____________________________
____________________________
_____________
Witness Name
Witness Signature
Date 
IRB NUMBER: 20IN054
IRB APPROVAL DATE: 06/12/2020

 
National Institute of Allergy and Infectious Diseases (NIAID)
National Institutes of Health (NIH)
Protocol Face Sheet
NIH Principal Investigator (PI):
Institute/Branch:
Address:
Phone:
Email:
Jessica Manning, MD, MSc 
NIAID/Laboratory of Malaria and Vector Research (LMVR)
United States (US) Embassy Phnom Penh
Unit 4540, Box 10 
DPO, AE 09975
+855 61 202 473
Jessica.manning@nih.gov 
Cambodian Co-PI:
Institute/Branch:
Phone:
Rekol Huy, MD, PhD
National Malaria Center (CNM), Ministry of Health, Cambodia
+855 23 223 442
Cambodian Co-PI:
Institute/Branch:
Phone:
Rithea Leang, MD, DrPH
National Dengue Control Program, CNM, Ministry of Health, Cambodia
+855 12 523 150
Protocol Number:
20-I-N054
Version Description: 
Version 1.0
Version Date: 
22 May 2020
Protocol Title:
Investigating the sylvatic transmission and reservoir potential of Zika, 
dengue, and chikungunya viruses of co-located humans and long-tailed 
macaques in Thailand and Cambodia 
Abbreviated Title:
eASIA
Institute Name: 
NIAID
Accrual Period:
24 months
Proposed Dates:
15 May 2020 – 15 May 2022
Total Subjects to be Accrued:
350
Ionizing Radiation Use: 
None
Is Tissue Being Collected for 
Research Purposes?
Yes (sera only)
Location of the Study:
Kampong Speu community, Chbar Mon, Kampong Speu, Cambodia
Investigational New 
Drug/Device:
None  
Coordinating Center:
NIAID

 
Table of Contents
STATEMENT OF COMPLIANCE .........................................................................................................4
1
PROTOCOL SUMMARY ..........................................................................................................4
1.1
Synopsis........................................................................................................................4
1.2
Precis ............................................................................................................................5
1.3
Schedule of Activities (SoA)..........................................................................................6
2
INTRODUCTION .....................................................................................................................6
2.1
Study Rationale ............................................................................................................6
2.2
Background...................................................................................................................7
2.3
Risk/Benefit Assessment..............................................................................................8
2.3.1
Known Potential Risks..................................................................................8
2.3.2
Known Potential Benefits ............................................................................9
2.3.3
Assessment of Potential Risks and Benefits ................................................9
3
OBJECTIVES AND ENDPOINTS ...............................................................................................9
4
STUDY DESIGN.....................................................................................................................10
4.1
Site Description ..........................................................................................................10
4.2
Overall Design ............................................................................................................10
4.3
End of Study Definition ..............................................................................................11
5
STUDY POPULATION............................................................................................................11
5.1
Inclusion Criteria ........................................................................................................11
5.2
Exclusion Criteria........................................................................................................11
5.3
Inclusion of Vulnerable Participants ..........................................................................11
5.4
Screen Failures ...........................................................................................................12
5.5
Strategies for Recruitment and Retention.................................................................12
6
PARTICIPANT DISCONTINUATION/WITHDRAWAL..............................................................12
6.1
Participant Discontinuation/Withdrawal from the Study..........................................12
6.2
Lost to Follow-Up .......................................................................................................12
7
STUDY SCHEDULE................................................................................................................13
7.1
Enrollment..................................................................................................................13
7.2
Procedures .................................................................................................................13
7.3
Unexpected or Incidental Medical Conditions of the Participant .............................13
7.4
Return of Research Results ........................................................................................13
8
STUDY ASSESSMENTS AND PROCEDURES...........................................................................14
8.1
Clinical Evaluations.....................................................................................................14
8.2
Study Procedures .......................................................................................................14
8.2.1
Phlebotomy................................................................................................14
8.3
Laboratory Evaluations...............................................................................................14
8.3.1
Specimen Collection, Preparation, Handling, and Shipping......................14
8.4
Safety and Other Assessments...................................................................................15
8.4.1
Adverse Event Definitions..........................................................................15
8.4.2
Adverse Event Management .....................................................................16
8.4.3
Reporting ...................................................................................................17
9
STATISTICAL CONSIDERATIONS...........................................................................................17
9.1
Statistical Hypotheses ................................................................................................17

 
9.2
Sample Size Justification and Analysis Plan ...............................................................18
9.3
Statistical Analysis ......................................................................................................19
9.3.1
Analysis of the Primary Endpoint ..............................................................19
9.3.2
Analysis of the Secondary Endpoint ..........................................................19
10
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS..........................20
10.1
Regulatory, Ethical, and Study Oversight Considerations..........................................20
10.1.1
Informed Consent Process.........................................................................20
10.1.2
Study Discontinuation and Closure ...........................................................21
10.1.3
Confidentiality and Privacy........................................................................21
10.1.4
Future Use of Stored Specimens and Data................................................22
10.1.5
Clinical and Safety Monitoring...................................................................23
10.1.6
Quality Assurance and Quality Control .....................................................24
10.1.7
Data Handling and Record Keeping...........................................................24
10.1.8
Protocol Deviations....................................................................................25
10.1.9
Publication and Data Sharing Policy ..........................................................25
10.2
Abbreviations .............................................................................................................26
11
REFERENCES ........................................................................................................................28

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STATEMENT OF COMPLIANCE
  
The trial will be carried out in accordance with International Council on Harmonisation of Technical 
Requirements for Pharmaceuticals for Human Use (ICH) Good Clinical Practice (GCP) and the following: 

US Code of Federal Regulations (CFR) applicable to clinical studies (45 CFR Part 46) 
NIH-funded investigators and clinical trial site staff who are responsible for the conduct, management, 
or oversight of NIH-funded clinical trials have completed Human Subjects Protection and ICH GCP 
Training.
The protocol, informed consent form (ICF), recruitment materials, and all participant materials will be 
submitted to the NIH Intramural Institutional Review Board (IRB) and Cambodian National Ethics 
Committee for Health Research (NECHR) for review and approval. For Cambodia, approval of both the 
protocol and the consent form must be obtained before any participant is enrolled. Any amendment to 
the protocol will require review and approval by the NIH IRB and NECHR before the changes are 
implemented to the study. In addition, all changes to the consent form will be approved by the NIH IRB 
and NECHR; a determination will be made regarding whether a new consent needs to be obtained from 
participants who provided consent, using a previously approved consent form.
For activities in Thailand, a separate IRB application, protocol, and consent form per Thai standards was 
submitted and approved by the Mahidol University IRB. The macaque sampling in Thailand was 
performed in 2018 and human sampling was performed from September 2019 through March 2020. A 
copy of the Thai IRB approval will be included with this protocol for NECHR. A Materials Transfer 
Agreement will be in place prior to sharing of data and serological materials between Cambodia and 
Thailand portions of the study.
1
PROTOCOL SUMMARY
1.1
SYNOPSIS 
Title:
Investigating the sylvatic transmission and reservoir potential of Zika, 
dengue, and chikungunya viruses of co-located humans and long-tailed 
macaques of Thailand and Cambodia 
Study Description:
This is a biospecimen procurement protocol at one site in Cambodia. For 
Cambodia, specimens will be taken from individuals aged 18 to 55 years 
living or working within 10 km of Wat Amphae Phnom in Kampong Speu, 
Cambodia. Please see Schema and Schedule of Activities, Sections 1.2 and 
1.3. 

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Objectives:
The primary objectives of the study are to:
1.
Describe the seroprevalence of Zika virus (ZIKV), dengue virus 
(DENV), and chikungunya virus (CHIKV) in humans living in 
close proximity to long-tailed macaques in Thailand and 
Cambodia.
2.
Compare the serology patterns against ZIKV, DENV, and CHIKV 
between nonhuman primates (NHPs) and humans living in the 
same areas.
The secondary objectives are to:
1.
Compare serology patterns against ZIKV, DENV, and CHIKV in 
macaques and humans between Thailand and Cambodia.
2.
Compare serology patterns against Aedes aegypti salivary 
gland homogenate proteins in humans and monkeys between 
Thailand and Cambodia.
Endpoints:
The primary endpoints are:
1.
Assessment of seroprevalence via screening enzyme-linked 
immunosorbent assay (ELISA) and/or plaque reduction 
neutralization assay (PRNT) 50 titers for ZIKV, DENV, and CHIKV in 
Cambodian adults.
2.
Assessment of seroprevalence via screening ELISA and/or PRNT50 
titers for ZIKV, DENV, and CHIKV in Cambodian macaques as 
compared to humans.
The secondary endpoints are:
1.
Comparative assessment of seroprevalence via PRNT50 titers for 
ZIKV, DENV, and CHIKV in Cambodian adults and macaques to that 
of Thai adults and macaques.
2.
Assessment of reactivity to salivary gland homogenate of Aedes 
aegypti as detected by ELISA or western blot in human and 
macaque sera.
Study Population:
Total Enrollment:
Healthy adults aged 18 to 55 years (at study entry)
300 subjects
Description of 
Sites/Facilities Enrolling 
Participants:
Chbar Mon town, Kampong Speu, Cambodia
Study Duration:
24 months
Participant Duration:
60 minutes for informed consent, exam, baseline assessments, and blood 
sampling 
1.2
PRECIS
Arboviral epidemics continue to emerge suddenly and spread of disease is unpredictable. The 2015-16 
Zika epidemic resulted in a high case number in Thailand, but not in neighboring Cambodia. It is known 
that nonhuman primates (NHPs) are important reservoirs of arboviruses, but the importance of their 

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epidemiological role in the transmission of arboviruses is not clearly understood. While transmission 
dynamics are complex and require consideration of many variables, primate reservoirs are not routinely 
sampled, particularly in Southeast Asia, because of the level of operational complexity and skill required.
Here, we propose a serological survey for evidence of Zika virus (ZIKV), dengue virus (DENV), and 
chikungunya virus (CHIKV) exposure in long-tailed macaques and human adults who live or work in close 
proximity to these monkeys in Thailand and Cambodia. We hypothesize that ZIKV seroprevalence in 
both humans and macaques will be higher in Thailand than Cambodia. With the current rise of arboviral 
diseases around the world, we hope the results of this study contribute to better understanding of the 
epidemiology and burden of arboviral diseases in this region.
Schema 1: Study Flow Design
SCREEN
Day 0
ENROLL
Visit 1
(Day 0)
EXIT
(DAY 0)
1.3
SCHEDULE OF ACTIVITIES (SOA)
Procedures
Screen (Day 0)
Enroll (Day 0)
Informed Consent
X
 
Review of Eligibility Criteria and 
Screening Medical History
X
Baseline Assessments and Risk Factors
X
Blood Draw for Sera
X
2
INTRODUCTION
2.1
STUDY RATIONALE 
Mosquito-borne diseases such as DENV, CHIKV, and ZIKV have a significant impact on public health, 
particularly in Southeast Asia.1–3 It has been reported that NHPs play an essential role in mosquito-borne 
diseases transmission via the sylvatic cycle of these viruses.4–6 Likewise, recent studies from Africa have 
described the probable role of NHPs as the reservoir and/or amplification hosts of these arboviruses.6,7 
The purpose of this study is to further understand the relationship between humans and NHPs in the 
maintenance and amplification of mosquito-borne viruses in Southeast Asia. The study hypothesis is 
that long-tailed macaques, ubiquitous in populated areas in the Greater Mekong Subregion with 
Perform baseline assessments and blood sampling  
(refer to Section 7.3 for assays).
 
Study exit.
Total N: Screen potential participants by inclusion and exclusion criteria; obtain 
pertinent history; obtain and document informed consent.

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substantial human interaction, play a critical role in mosquito-borne disease transmission in Thailand 
and Cambodia. To test this hypothesis, we will sample humans and macaques co-existing in the same 
areas, typically pagodas, in Thailand and Cambodia.
2.2
BACKGROUND 
While there continue to be reports of DENV and CHIKV circulation in many Southeast Asian countries, 
there is no clear evidence to explain the relatively low reported prevalence of ZIKV infection in some 
parts of Asia, despite recent expansion and explosive outbreaks seen in the Pacific and the Americas.8–10 
Though historical evidence has indicated that ZIKV epidemiology includes a sylvatic cycle involving NHPs, 
recent outbreaks have been centered in urban areas where the primary vector implicated is Aedes 
aegypti. Contrastingly, there is evidence that NHPs play a role in the maintenance of two other 
Aedes-transmitted viruses, DENV and CHIKV.11–13 The role of NHPs in the epidemiology of anthropogenic 
arboviruses is variable, as they may or may not play an important role as reservoir for human 
infections.14 Characterizations of the sylvatic cycle and the transmission trajectories of these arboviruses 
are critical for not only understanding the risk ecology of these pathogens, but for developing 
educational and health policy to control transmission as vaccines for these viruses currently are not 
available. The sylvatic cycle of DENV is complex, as evidence suggests it can go from NHP to human 
populations, as well as from human to NHP populations, increasing the complexity of its 
transmission.11,14 CHIKV and ZIKV were both originally isolated from NHPs in Africa, and recent studies 
from Africa describe the probable role of NHPs as reservoir and/or amplification hosts of these 
arboviruses.4,15–17 However, the current transmission ecology of these viruses in Southeast Asia remains 
under-characterized, meaning there is a gap in our understanding of the fundamental biology of these 
arboviruses in Southeast Asia. Such a gap confounds our ability to respond to and control infections, and 
to dedicate resources and target education programs for interruption of transmission and infection 
control. Though our protocol will evaluate all three of these viruses in NHP and human cohorts, the 
rationale and approach is described below using ZIKV as the prime example.
During the 2015-16 ZIKV epidemic, the Thai Ministry of Public Health reported approximately 700 cases 
of ZIKV (Thai Ministry of Public Health, personal communication), while nearby Cambodia detected 
fewer than 10 cases via reverse transcription polymerase chain reaction in retrospective surveys of over 
13,000 febrile patients by the Naval Medical Research Unit Two (NAMRU-2) and Institut Pasteur from 
2007 to 2016, suggesting transmission is low (personal communication).8,18 This raises the questions: 
Aside from differences in surveillance capacity, why did two neighboring countries with similar 
ecological characteristics experience different transmission intensities of ZIKV? Is there a difference in 
disease prevalence in the NHPs as well as co-existing humans in each country?
To answer these questions, we propose to compare the serology of humans with the most ubiquitous 
NHPs, long-tailed macaques (typically Macaca fascicularis), in Thailand and Cambodia. The arboviral 
serologies of these macaques and nearby human populations from central Thailand (where ZIKV human 
cases were reported during April-August 2017) will be compared with those of macaques from 
Cambodia living near villages where the presence of the Aedes vector(s) is suitable for ZIKV transmission 
to occur. Collection of sera from the macaques from Thailand is complete, and the ongoing human 
sampling is set to be completed in March 2020. As we are interested in the immunoglobulin (Ig) G 
antibody response as an endpoint, the temporal distance is not relevant. 

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We aim to conduct a similar prospective serosurvey in Cambodia, sampling both human and macaque 
populations living in proximity to one another within the same season. Macaques were chosen because 
they are ubiquitous in moderately to heavily human-populated areas around Asia and tend to have 
heavy human interaction in tourist areas. This means that the possibility for transmission is likely, as 
they overlap with the human population. This is relevant not only because the macaque could act as a 
spill-over vector into the human population, but also if there is no ZIKV in Cambodia, it is likely that it 
will be introduced in heavily touristed areas, meaning there is the potential to establish both 
anthroponotic and sylvatic cycles. Cambodian macaque serum samples will be collected separately by 
Thai and Cambodian veterinarians as approved by the Cambodian Ministry of Agriculture, Forestry, and 
Fisheries, specifically the Director General of Animal Health, within a year of this human study in 
Cambodia. 
An arboviral pediatric cohort study (NIH protocol 18-I-N100, “Investigating vector-borne determinants of 
Aedes-transmitted arboviral infections in Cambodia: an observational longitudinal cohort study in 
children”) is already established by NIAID in a peri-urban area of Kampong Speu province, known for 
2 other Aedes-transmitted viruses, DENV and CHIKV (Figure 1). Therefore, we propose to prospectively 
collect sera from long-tailed macaques at Wat Amphae Phnom in Kampong Speu, Cambodia and nearby 
adults for comparison with sera sampling performed in Thai macaques and nearby villagers.  
Figure 1. Cambodia Sampling Map
Left: Blue circle represents Chbar Mon town in Kampong Speu province (in red).  
Right: Red circle represents Wat Amphae Phnom and H designates hospital in Chbar Mon town.
2.3
RISK/BENEFIT ASSESSMENT  
2.3.1
KNOWN POTENTIAL RISKS 
The risk of enrollment in the study is the effect of venipuncture.  
Risks of blood draw include pain, bruising, bleeding, local discomfort, lightheadedness, dizziness or 
possibly fainting and rarely infection or blood clot. The amount of blood drawn will be within the limits 
allowed for adult participants by the local Cambodian authority NECHR, which is 21 mL in a single visit.   

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2.3.2
KNOWN POTENTIAL BENEFITS 
There is no direct benefit to the participant. Results of this study may contribute to better 
understanding of the epidemiology and burden of arboviral diseases in this region and inform public 
health programs in Cambodia. 
2.3.3
ASSESSMENT OF POTENTIAL RISKS AND BENEFITS 
Given the very low risk of a single venipuncture and the indirect benefit of generalizable knowledge, the 
risks and benefits of the study have been appropriately weighted.
3
OBJECTIVES AND ENDPOINTS
OBJECTIVES
ENDPOINTS
JUSTIFICATION FOR ENDPOINTS
Primary
Describe the seroprevalence 
of ZIKV, DENV, and CHIKV in 
humans living in close 
proximity to long-tailed 
macaques in Thailand and 
Cambodia. 
Compare the serology 
patterns against ZIKV, DENV, 
and CHIKV between NHPs 
and humans living in the 
same areas. 
Assessment of seroprevalence via 
screening ELISA and/or PRNT50 
titers for ZIKV, DENV, and CHIKV in 
Cambodian adults.
Assessment of seroprevalence via 
screening ELISA and/or PRNT50 
titers for ZIKV, DENV, and CHIKV in 
Cambodian macaques as 
compared to humans.
PRNT assays are the gold 
standard to detect virus-specific 
antibodies given multiple 
circulating flaviviruses in 
Southeast Asia. Understanding 
the prevalence of these 
Aedes-transmitted viruses, and 
how they differ across the 
Mekong region, is critical to 
understanding the risk to 
Cambodians of future 
epidemics. 
Because primates can be 
amplifying hosts of these 
viruses, it is critical to 
understand the prevalence of 
these Aedes-transmitted viruses 
in macaques as well. 

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OBJECTIVES
ENDPOINTS
JUSTIFICATION FOR ENDPOINTS
Secondary
Compare serology patterns 
against ZIKV, DENV, and 
CHIKV in macaques and 
humans between Thailand 
and Cambodia.
Compare serology patterns 
against Aedes aegypti 
salivary gland homogenate 
proteins in humans and 
monkeys between Thailand 
and Cambodia.
Comparative assessment of 
seroprevalence via PRNT50 titers 
for ZIKV, DENV, and CHIKV in 
Cambodian adults and macaques 
to that of Thai adults and 
macaques.
Assessment of reactivity to 
salivary gland homogenate of 
Aedes aegypti as detected by 
ELISA or western blot in human 
and macaque sera.  
Understanding how the 
prevalence of these 
Aedes-transmitted viruses 
differs across the Mekong 
region is critical for cross-border 
disease detection and 
management, particularly given 
the high level of human 
migration in the Greater 
Mekong Subregion.
Characterizing vector salivary 
protein reactivity profiles 
(mosquitos, ticks, fleas) in 
Cambodians with vector-borne 
disease is the first step to better 
understanding transmission 
patterns, responsible vectors, 
and Cambodians’ risk of 
exposure to these vectors.
4
STUDY DESIGN 
4.1
SITE DESCRIPTION
Located in Cambodia, the main town of Chbar Mon (estimated population approximately 55,000-60,000 
over 10 km2) is located 44 km from Phnom Penh city center. Chbar Mon is the largest operational district 
in Kampong Speu province and is the site of the Kampong Speu District Referral Hospital, a hospital of 
approximately 120 beds with 130 staff of medical doctors, nurses, and lab technicians. NIAID has a field 
house behind the hospital that serves as an office and temporary clinic when needed. 
Wat Amphae Phnom is a pagoda next to a river tributary of the Mekong with 3 different macaque 
troops, numbering over 75 to 100 per troop. Similar to the sites in Thailand, the pagoda is a popular 
tourist destination where locals purchase food from vendors to feed the monkeys and also hosts a local 
marketplace and restaurants (called Resort Amphae Phnom). Over 100 monks also live at the pagoda. 
The closest residences are in the section of town called Taing Toun Le, where NIAID already has many 
children enrolled in a healthy pediatric cohort.
4.2
OVERALL DESIGN
This is a multisite, cross-sectional study to procure biospecimens from individuals aged 18 to 55 years 
who live or work near the monkeys. The NIAID is the data coordinating center and is responsible for 
overall planning, document collection, monitoring, communication, and data management and analysis 

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among all involved institutions. All enrollment and human subjects research activities will take place in 
Cambodia.
4.3
END OF STUDY DEFINITION
A participant is considered to have completed the study if he or she has completed the Day 0 
assessments and blood draw in the Schedule of Activities (SoA), Section 1.3.
5
STUDY POPULATION
5.1
INCLUSION CRITERIA
In order to be eligible to participate in this study, an individual must meet all of the following criteria:
1.
Provision of signed and dated ICF
2.
Able to provide informed consent
3.
Stated willingness to comply with study procedures 
4.
Male or female, aged 18-55 years
5.
Live/work within approximately 10 km of the Wat Amphae Phnom monkey habitat for minimum 
of 2 years
6.
In good general health as evidenced by screening medical history  
7.
Willing to allow biological samples to be stored for future research
5.2
EXCLUSION CRITERIA
1.
Any underlying, chronic, or current medical condition that, in the opinion of the investigator, 
would interfere with participation in the study (e.g., inability or great difficulty in drawing blood)
5.3
INCLUSION OF VULNERABLE PARTICIPANTS
Pregnant women are eligible to screen because excluding pregnant women could potentially bias study 
results. Their exclusion could omit a portion of the study population who may bear a significant burden 
of infection, confounding study results and limiting the effectiveness of epidemiological understanding 
and public health campaigns based on this data. Particularly given the disproportionate impact that ZIKV 
had on women of child-bearing age in the 2015 epidemic, it is important to comprehensively include this 
population. Moreover, excluding this population would significantly limit the number of women eligible, 
leaving them underserved and preventing women from benefiting from the important generalizable 
knowledge this protocol will provide. Thus, the inclusion of pregnant women is essential to the 
development of important biomedical knowledge which cannot be obtained by any other means. 
Additionally, the study procedures (baseline assessment and one-time venipuncture of a small volume 
of blood) do not have any additional risks to pregnant women or fetuses, and the risk to the woman and 
fetus is not greater than minimal.  

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5.4
SCREEN FAILURES
Screen failures are defined as participants who consent to participate in the clinical trial but are not 
subsequently entered into the study. A minimal set of screen failure information is required to ensure 
transparent reporting of screen failure participants, to meet the Consolidated Standards of Reporting 
Trials (CONSORT) publishing requirements and to respond to queries from regulatory authorities. 
Minimal information includes demography, screen failure details, eligibility criteria, and any serious 
adverse event (SAE).  
5.5
STRATEGIES FOR RECRUITMENT AND RETENTION
Advertising and recruitment in this province will mainly be via word-of-mouth using provincial health 
staff and the local village chiefs to communicate to people living and working near Wat Amphae Phnom.  
For this biospecimen procurement protocol, we anticipate having to screen no more than 350 to enroll 
our goal number of 300 participants over the study period. We have no pre-set male:female ratios or 
age structures. 
The anticipated length of individual study participation is limited solely to that time of blood draw and 
baseline assessments. 
Lastly, the typical cost of reimbursement from a blood draw in Cambodia is $5 US (to be paid in 
Cambodian Riel). We will adhere to this guideline for recruitment and reimburse participants in cash. 
6
PARTICIPANT DISCONTINUATION/WITHDRAWAL
6.1
PARTICIPANT DISCONTINUATION/WITHDRAWAL FROM THE STUDY
 
Participants are free to withdraw from participation in the study at any time upon request.   
An investigator may discontinue or withdraw a participant from the study for the following reasons:

Significant study procedure non-compliance (e.g., refuses phlebotomy)

If the participant meets an exclusion criterion (either newly developed or not previously 
recognized) that precludes further study participation  
The reason for participant discontinuation or withdrawal from the study will be recorded on the case 
report form (CRF).  
6.2
LOST TO FOLLOW-UP
This is a cross-sectional study for biospecimen procurement at a single timepoint, so there is no 
follow-up in the study.   

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7
STUDY SCHEDULE
This study will primarily take place in the community space at Wat Amphae Phnom or a nearby pagoda, 
but the Kampong Speu District Referral Hospital is nearby for referral and treatment for any adverse 
events (AEs) related to blood draw. The study schedule is described below, in the study schema 
(Section 1.1), and the SoA table (Section 1.3).  
7.1
ENROLLMENT
The research team will thoroughly discuss the ICF with each eligible individual and obtain consent prior 
to performing any study procedures.   
7.2
PROCEDURES
Screening (Day 0):
The enrollment will take place in or near the pagoda or other appropriate location as has been done for 
prior NIAID studies in Kampong Speu using privacy screens, tables, and chairs that are typically set up 
within the main rooms of the pagoda. The following procedures will be performed: 

Informed consent

Review of inclusion/exclusion criteria
Enrollment (Day 0):

Baseline assessments and risk factors

Blood draw
Any participant who experiences complications due to phlebotomy will be examined by the physician 
onsite or referred to the hospital and followed until complications have resolved and/or referral to the 
necessary medical care has been made. 
7.3
UNEXPECTED OR INCIDENTAL MEDICAL CONDITIONS OF THE PARTICIPANT
If unexpected or incidental medical conditions are diagnosed during the medical evaluation in this 
protocol, the participant will be referred to an appropriate physician and/or hospital and encouraged to 
follow up for treatment of their condition. Standard-of-care treatment may be offered by the study 
team if necessary while the participant is being referred to appropriate outside medical care.
7.4
RETURN OF RESEARCH RESULTS
Research testing will not occur at the same time as the participant is sampled, and results will not be 
returned to the participant. This study investigates past exposure to the viruses under study (as 
evidenced by the presence or absence of antibodies in serum), and individual serostatus would not 
inform the participant’s clinical care at any point in the present or future. Moreover, PRNT assays are 
not a clinically validated test.

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8
STUDY ASSESSMENTS AND PROCEDURES
8.1
CLINICAL EVALUATIONS

Screening (Day 0): Prior to conducting any study-related procedures, informed consent in 
Khmer will be obtained from the participant via in-person interview with an investigator. If 
illiterate, a literate witness will read and sign the informed consent on behalf of the participant, 
and the participant will provide a thumbprint. The participant will be queried regarding a history 
of significant medical disorders and other eligibility criteria. A screening log will be kept to 
document eligibility of all participants.   

Enrollment/Visit 1/Exit (Day 0): Baseline Assessments 
o
Baseline demographics will be collected such as sex, age, and behaviors related to 
vector-borne disease development (e.g., number of domestic water containers), 
including recent travel and extent of interactions with the macaques.
8.2
STUDY PROCEDURES
8.2.1
PHLEBOTOMY
Venipuncture will be performed for approximately up to 10 mL of blood into a serum-separating tube 
(SST). 
8.3
LABORATORY EVALUATIONS
Specific laboratory methods for each assay and instructions for handling and storage of samples will be 
maintained in a manual of procedures (MOP) that includes all the standard operating procedures (SOPs) 
for the study. 
8.3.1
SPECIMEN COLLECTION, PREPARATION, HANDLING, AND SHIPPING
All human and NHP biological samples will be received, processed, aliquoted, and stored at the central 
laboratories of CNM-NIH or Kampong Speu District Referral Hospital according to standard lab 
procedures.
Given that the purpose of the protocol is to build research capacity in Thailand and Cambodia, CNM-NIH 
lab personnel may travel between labs with de-identified samples to learn how to optimally prepare 
their samples in order to bring that knowledge and training back to Cambodia. Similarly, if 
cross-reactivity is determined to be a problem in the PRNT assays, certain exploratory assays (e.g., 
blockade of binding or BOB assays) may be carried out in one lab and not the other, necessitating 
transport of de-identified samples between labs. Samples requiring transport from the clinical collection 
site to the designated central repository or to the main NIH labs in the US will follow designated study 
sample shipping procedures, which will include shipment of samples with no participant identifiers.  

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8.4
SAFETY AND OTHER ASSESSMENTS
8.4.1
ADVERSE EVENT DEFINITIONS
Adverse Event: Any untoward medical occurrence in a human subject, including any abnormal sign (e.g., 
abnormal physical exam or laboratory finding), symptom, or disease, temporally associated with the 
subject’s participation in the research, whether or not considered related to the subject’s participation 
in the research.
Serious Adverse Event: Any AE that

results in death;

is life-threatening (places the subject at immediate risk of death from the event as it occurred);

results in inpatient hospitalization or prolongation of existing hospitalization;

results in a persistent or significant disability/incapacity;

results in a congenital anomaly/birth defect; or

based upon appropriate medical judgment, may jeopardize the subject’s health and may require 
medical or surgical intervention to prevent one of the other outcomes listed in this definition 
(examples of such events include allergic bronchospasm requiring intensive treatment in the 
emergency room or at home, blood dyscrasias or convulsions that do not result in inpatient 
hospitalization, or the development of drug dependency or drug abuse).
Unanticipated Problem Involving Risks to Subjects or Others (UP): Any incident, experience, or 
outcome that meets all of the following criteria:
1.
Unexpected (in terms of nature, severity, or frequency) given
a.
the research procedures that are described in protocol-related documents, such as 
the IRB-approved research protocol and informed consent document; and
b.
the characteristics of the subject population being studied; and
2.
Related or possibly related to participation in the research (possibly related means there is a 
reasonable possibility that the incident, experience, or outcome may have been caused by the 
procedures involved in the research); and
3.
Suggests that the research places subjects or others (which may include research staff, family 
members, or other individuals not directly participating in the research) at a greater risk of 
harm (including physical, psychological, economic, or social harm) related to the research than 
was previously known or expected.
Protocol Deviation: Any change, divergence, or departure from the IRB approved research protocol. 

Major Deviations: Deviations from the IRB-approved protocol that have or may have the 
potential to negatively impact the rights, welfare, or safety of the subject, or to substantially 
negatively impact the scientific integrity or validity of the study.

Minor Deviations: Deviations that do not have the potential to negatively impact the rights, 
safety, or welfare of subjects or others, or the scientific integrity or validity of the study.
Non-compliance: Failure of investigator(s) to follow the applicable laws, regulations, or institutional 
policies governing the protection of human subjects in research, or the requirements or determinations 
of the IRB, whether intentional or not. 

Serious non-compliance: Non-compliance, whether intentional or not, that results in harm or 
otherwise materially compromises the rights, welfare and/or safety of the subject. 

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Non-compliance that materially affects the scientific integrity or validity of the research may be 
considered serious non-compliance, even if it does not result in direct harm to research 
subjects.

Continuing non-compliance: A pattern of recurring non-compliance that either has resulted, or, 
if continued, may result in harm to subjects or otherwise materially compromise the rights, 
welfare and/or safety of subjects, affect the scientific integrity of the study or validity of the 
results. The pattern may comprise repetition of the same non-compliant action(s), or different 
noncompliant events. Such non-compliance may be unintentional (e.g., due to lack of 
understanding, knowledge, or commitment), or intentional (e.g., due to deliberate choice to 
ignore or compromise the requirements of any applicable regulation, organizational policy, or 
determination of the IRB).
8.4.2
ADVERSE EVENT MANAGEMENT 
Subjects entered onto this protocol will only be subject to limited blood sampling. There will be 
expected events as a result of these procedures. The only AEs that will be recorded on this protocol will 
be those related to phlebotomy, except for the expected events, as described below.
Expected Events
The following are mild (Grade 1) to moderate (Grade 2) signs or symptoms that are induced by or 
associated with phlebotomy. If deemed related to phlebotomy by the PI, they will not be recorded as 
AEs in the Research Electronic Data Capture (REDCap) system per protocol, unless deemed by the PI to 
be abnormal or greater than Grade 2.

Bleeding or bruising at venipuncture site
Reactions should be graded in the following manner:
Grade 1
Mild transient reaction; interruption not indicated; intervention not indicated.
Grade 2
Interruption indicated but responds promptly to symptomatic treatment 
(e.g., nonsteroidal anti-inflammatory drugs, narcotics, intravenous fluids); 
prophylactic medications indicated for less than 24 hours.
Grade 3
Prolonged (e.g., not rapidly responsive to symptomatic medication and/or brief 
interruption of infusion); recurrence of symptoms following initial 
improvement; hospitalization indicated for clinical sequelae.
Grade 4
Life-threatening consequences; urgent intervention indicated.
Grade 5
Death.
Information on AEs related to research procedures developing after the procedure will be collected by 
the investigators and entered into a computerized database (REDCap, Section 10.1.6).

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Table 1. Attribution of Adverse Events (AEs)
Relationship 
Attribution 
Description 
Unrelated 
The AE is clearly NOT related 
to the intervention 
Unrelated intervention
Unlikely 
The AE is doubtfully related 
to the intervention 
Possibly 
The AE may be related to the 
intervention 
Probably
The AE is likely related to the 
intervention 
Related intervention
Definitely
The AE is clearly related to 
the intervention 
8.4.3
REPORTING
The PI is responsible for reporting per NIH IRB and NECHR reporting requirements. Reportable events 
will be tracked and submitted to the NIH IRB and NECHR as outlined in NIH Human Research Protections 
Program Policy 801.
 
According to Policy 801, all UPs, major protocol deviations, all non-compliance, new information that 
might affect the willingness of a subject to enroll or remain in the study, and any suspension or 
termination of research activity will be reported within 7 calendar days of investigator awareness. Any 
death of a research subject that is possibly, probably, or definitely related to the research will be 
reported within 24 hours of investigator awareness.
The following events will be reported to the NIH IRB and NECHR in summary at the time of continuing 
review: 

AEs and SAEs that are not UPs, as a narrative summary indicating whether these events were 
within the expected range.

Minor and major protocol deviations.

UPs reported to the NIH IRB/NECHR.

Non-compliance reported to the NIH IRB/NECHR that is not related to a protocol deviation.
The PI will report UPs, major protocol deviations, and deaths to the NIAID clinical director according to 
institutional timelines.
9
STATISTICAL CONSIDERATIONS 
 
9.1
STATISTICAL HYPOTHESES
We hypothesize that seroprevalence as measured via ZIKV PRNT50 titers will be lower in Cambodian 
human adults and macaques compared to Thai human adults and macaques.   

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9.2
SAMPLE SIZE JUSTIFICATION AND ANALYSIS PLAN
Though we will also be assessing DENV and CHIKV in humans and monkeys, the following statistical plan 
is primarily guided by the anticipated ZIKV seroprevalence for two reasons. First, DENV has 
hyperendemic transmission in both Thailand and Cambodia. Therefore, we expect that sample sizes that 
are adequate for ZIKV will also be adequate for dengue. Second, CHIKV is known to have sporadic and 
highly focal transmission in both countries, but there is not enough information to develop reasonable 
assumptions about the expected prevalence. All sites in Thailand and Cambodia have had documented 
ZIKV transmission in the past.3,18
As there are limited data available for the seroprevalence of these arboviruses in macaques in Southeast 
Asia, we based our assumptions about seroprevalence on a field study in Senegal that identified 
seroprevalence of CHIKV in three species of monkeys.19 This study found that the seroprevalence across 
all three species was high, 72% (479/667). There are no studies evaluating ZIKV seroprevalence in 
macaques in Southeast Asia, only scattered reports from Malaysia, Brazil, and Africa that focused 
detection on active viremia, though an African study noted 16% seroprevalence of ZIKV.6,20,21 Preliminary 
analyses from our Thai collaborators show that an initial screen for pan-flavivirus antibodies in the Thai 
macaques is nearly 100% positive (Kob Boonak, Mahidol University, personal communication). Treating 
sampled macaques as mutually independent simple random samples of binary responses for 
seropositivity to a given arbovirus, a sample of 100 monkeys per site will yield an average 95% 
confidence interval (CI) width of less than or equal to 0.2 for seroprevalence at each site, and we will 
have 80% power to detect a 25% relative reduction in seroprevalence relative to a site where 
seroprevalence is 75% using a binomial test of proportions with a Type-1 error rate of 0.05. 
With regards to the sample size in humans, Thailand and Cambodia have both been endemic for dengue 
for many years. Only recently has ZIKV been actively detected in both countries.18,22–24 In Thailand, a 
serosurvey in a sample of 21 humans estimated ZIKV seroprevalence to be 76% (95% CI: 52%, 91%).25 
Another survey of 600 migrant workers from four Southeast Asian countries, 150 of whom were from 
Thailand, estimated overall seroprevalence to be 38.8% and seroprevalence among the Thai cohort to 
be 50.7%.26 However, in Cambodia, the estimated seroprevalence was lower, estimated to be <1% 
definitively with 37.3% equivocal results.8 These equivocal results were based on a potentially 
cross-reactive IgM assay and indicated a recent flavivirus infection with either Japanese encephalitis 
virus (JEV), DENV, or ZIKV. Treating sampled humans as mutually independent simple random samples 
of binary responses for seropositivity, a sample of 300 humans in Cambodia will yield an average 95% CI 
width of less than or equal to 0.052 for presumed seroprevalence centered at 0.05 (Figure 2).  
Our secondary objective is to compare human ZIKV seroprevalence in Cambodia with ZIKV 
seroprevalence in Thailand. Conservatively taking a value of 50% seroprevalence for ZIKV in Thailand 
and 37% seroprevalence in Cambodia, we calculate that a sample size of N=300 Cambodian participants 
and N=300 Thai participants will be sufficient to attain 90% power to reject a null hypothesis of no 
difference in seroprevalence using a binomial test of proportions with a Type-1 error rate of 0.05. 

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Figure 2. Expected precision of seroprevalence estimate versus sample size and true seroprevalence
9.3
STATISTICAL ANALYSIS
9.3.1
ANALYSIS OF THE PRIMARY ENDPOINT
The primary endpoint will be defined as:

Assessment of seroprevalence via screening ELISA and/or PRNT50 titers for ZIKV, DENV, and 
CHIKV in Cambodian adults.

Assessment of seroprevalence via screening ELISA and/or PRNT50 titers for ZIKV, DENV, and 
CHIKV in Cambodian macaques as compared to humans.
PRNT50 titer is a continuous variable (e.g., 0 to 40960) as measured from human and macaque sera at a 
single timepoint. For the purpose of classifying an individual as positive for a particular arbovirus, a 
PRNT50 titer of 50 will be taken to indicate that an individual has seroconverted (based on distribution 
of assay, we can consider <10 as seronegative, 10-50 as indeterminate, and >50 as seroconverted). We 
will estimate seroprevalence rates for humans and macaques, and report summary statistics of 
seroprevalence and titer distributions overall and within meaningful subgroups (e.g., males vs. females, 
by decade of age, by occupation, by bed net use, by intensity of self-reported interaction and duration 
with macaques).
9.3.2
ANALYSIS OF THE SECONDARY ENDPOINT
The secondary endpoints will be defined as 

Comparative assessment of seroprevalence via PRNT50 titers for ZIKV, DENV, and CHIKV in 
Cambodian adults and macaques to that of Thai adults and macaques.

Assessment of reactivity to salivary gland homogenate of Aedes aegypti as detected by 
ELISA or western blot in human and macaque sera.  

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Differences in seroprevalence will be assessed via a two-sample test of binomial proportions, treating 
participants and each study sample as mutually independent of one another. Pairwise comparisons of 
PRNT50 titers as continuous variables will be assessed via Wilcoxon rank sum tests as follows: Thai 
adults versus Cambodian adults, Thai macaques versus Cambodian macaques, and Thai adults and 
macaques versus Cambodian adults and macaques.
For salivary gland reactivity, arbitrary ELISA units as a continuous variable will be assessed and 
categories will be made for high, medium, low, and negligible reactivity to salivary gland homogenate. 
These categories will be compared as: Thai adults versus Cambodian adults, Thai macaques versus 
Cambodian macaques, and Thai adults and macaques versus Cambodian adults and macaques. 
Regression models fit via generalized estimating equations will be used to assess if higher antibody 
reactivity is associated with PRNT50 titer and positive/negative seroprevalence of ZIKV, DENV, or CHIKV.
10
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS
10.1 REGULATORY, ETHICAL, AND STUDY OVERSIGHT CONSIDERATIONS
10.1.1 INFORMED CONSENT PROCESS
10.1.1.1 CONSENT AND OTHER INFORMATIONAL DOCUMENTS PROVIDED TO PARTICIPANTS
ICFs describing in detail the study procedures and risks are given to the participants, and written 
documentation of informed consent is required prior to starting research procedures and evaluations. 
The ICFs in English (to be translated into Khmer for submission for Cambodian ethics review and for use 
in study) are submitted with this protocol.
10.1.1.2 CONSENT PROCEDURES AND DOCUMENTATION
Informed consent is a process where information is presented to enable persons to voluntarily decide 
whether or not to participate as a research subject. It is an ongoing conversation between the human 
research subject and the researchers that begins before consent is given and continues until the end of 
the subject's involvement in the research. Discussions about the research will provide essential 
information about the study in Khmer and include at the very least the purpose, duration, procedures, 
alternatives, and risks and benefits. Potential participants will be given the opportunity to ask questions 
and have them answered. Those who are literate will sign and date the ICF (written in Khmer) prior to 
undergoing any research procedures. In this case, a witness will not sign and date the ICF. If the 
potential participant is illiterate, a thumbprint will be obtained and the date will be documented by the 
investigator. In this case, an impartial witness who is literate and not involved with the study will then 
sign and date the ICF.
Participants may withdraw consent at any time throughout the course of the study. A signed copy of the 
ICF will be given to them for their records. The investigator will document the signing of the ICF in the 
participant’s study record. The rights and welfare of the participants will be protected by emphasizing to 
them that the quality of their medical care will not be adversely affected if they decline to participate in 
this study.

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10.1.2 STUDY DISCONTINUATION AND CLOSURE
This study may be temporarily suspended (paused) or prematurely terminated (halted) if there is 
sufficient reasonable cause. If the PI prematurely terminates or suspends then study, then the PI will 
promptly inform study participants (who have not exited study) and the NIH IRB/NECHR in writing, and 
will provide the reason(s) for the termination or suspension. Study participants will be contacted, as 
applicable, and be informed of changes to study visit schedule. The study may resume once concerns 
about safety, protocol compliance, and data quality are addressed.
10.1.3 CONFIDENTIALITY AND PRIVACY 
Participant confidentiality and privacy is strictly held in trust by the participating investigators and their 
staff. This confidentiality is extended to cover testing of biological samples in addition to the clinical 
information relating to participants. Therefore, the study protocol, documentation, data, and all other 
information generated will be held in strict confidence. No information concerning the study or the data 
will be released to any unauthorized third party without prior written approval of the sponsor. 
All research activities will be conducted in as private a setting as possible. In the community, privacy 
screens will be used for interviews, exams, and phlebotomy.
The study monitor, the Office of Clinical Research Policy and Regulatory Operations (OCRPRO) or their 
authorized representatives , representatives of the IRB, NECHR, or regulatory agencies may inspect all 
documents and records required to be maintained by the investigator. The clinical study site staff will 
permit access to all study records.
The study participant’s contact information will be securely stored at the NIH-CNM laboratory in Phnom 
Penh for internal use during the study. ICFs and enrollment logs will be the only links between the 
unique study identification numbers and participant names. These will be maintained as paper 
documents at the NIH-CNM lab in locked cabinets. Access will be restricted to those investigators 
authorized to access identifiable information. At the end of the study, all records will continue to be 
kept in a secure location for as long a period as dictated by the reviewing IRBs, institutional policies, or 
sponsor requirements. CRFs, ICFs, and source documents will eventually be transported from the study 
site to our offices in Phnom Penh, where they will be retained under lock and key by the investigators 
listed on this protocol and made available for clinical monitoring.
Study participant research data, which are captured on tablets for purposes of statistical analysis and 
scientific reporting, will be transmitted to and stored on a central server in Phnom Penh and/or LMVR at 
NIH main campus. This will not include the participant’s contact or identifying information. Rather, 
individual participants and their research data will be identified by a unique study identification number. 
The study data entry and study management systems used by research staff will be secured and 
password protected. At the end of the study, the study database will be archived at LMVR in 
Rockville, MD. 
To further protect the privacy of study participants, a Certificate of Confidentiality has been issued by 
the NIH. This certificate protects identifiable research information from forced disclosure. It allows the 
investigator and others who have access to research records to refuse to disclose identifying 
information on research participation in any civil, criminal, administrative, legislative, or other 

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proceeding, whether at the federal, state, or local level. By protecting researchers and institutions from 
being compelled to disclose information that would identify research participants, Certificates of 
Confidentiality help achieve the research objectives and promote participation in studies by helping 
assure confidentiality and privacy to participants.
10.1.4 FUTURE USE OF STORED SPECIMENS AND DATA 
Intended Use: Samples, specimens, and data collected under this protocol may be used to study the 
following: 

Development of new diagnostic tests to enable more sensitive and specific tests for 
vector-borne diseases.

Determination of immune response to vector saliva and vector-borne diseases.

Determination of incidence and pathogenesis of co-circulating infections (e.g., dengue, JEV, 
chikungunya, Zika, influenza), as they contribute to this community.

Development of vaccines and therapeutic interventions to prevent or treat vector-borne 
infections.

Isolation or sequencing of viruses (e.g., dengue, chikungunya, Zika), parasites, or bacteria.

Isolation or sequencing related to host immune response or pharmacogenomics.
Storage: All of the stored study research samples are labeled by a code that only the investigators can 
link to the subject. Samples are stored at the Malaria Vector and Research Laboratory (CNM-NIH 
laboratory) at the National Center for Parasitology, Entomology, and Malaria Control, a secure facility 
with limited access, in Phnom Penh, Cambodia. During the high-volume collection, samples may be 
temporarily stored in the Kampong Speu District Referral Hospital main laboratory, which is also a 
secure facility with limited access. In the future, it may be necessary to ship a limited number of samples 
to Mahidol University when Cambodians go to train and learn the immunoassays in the Thai 
laboratories. As with previous CNM-NIH collaborative studies, it may be necessary to ship a limited 
number of samples to NIH for analyses that cannot be performed in Cambodia, and these would be kept 
in a secure facility at the LMVR in Rockville, MD. However, the purpose is to build laboratory capacity in 
Cambodia and a priority will be to process as many samples as possible here in the CNM-NIH laboratory. 
Data will be kept in password-protected computers. Only investigators or their designees will have 
access to the samples and data.
Tracking: Samples and data acquired under this protocol will be tracked using either Microsoft Excel (for 
input into the Biological Specimen Inventory) or REDCap.
Disposition:

In the future, other investigators (both at NIH and outside) may wish to study these samples 
and/or data for research purposes. If the planned research falls within the category of “human 
subjects research,” appropriate NIH IRB and NECHR review and approval will be obtained. This 
includes the NIH or CNM researchers sending out coded and linked samples or data and getting 
results that they can link back to their subjects. 
Loss or Destruction:

Any loss or unanticipated destruction of samples (for example, due to freezer malfunction) or 
data (for example, misplacing a printout of data with identifiers) that meets the definition of a 
reportable event will be reported to the NIH IRB and the NECHR according to NIH Policy 801.

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
Additionally, subjects may decide at any point not to have their samples stored. In this case, the 
PI will destroy all known remaining samples and report what was done to both the subject and 
to the NIH IRB and NECHR. This decision will not affect the individual’s participation in this 
protocol or any other protocols at NIH.

However, withdrawal of consent with regard to bio-sample storage may not be possible after 
the study is completed. If a subject had previously consented to future use and some of their 
blood has already been used for research purposes, then the information from that research 
may still be used even after consent is revoked.
  
10.1.5 CLINICAL AND SAFETY MONITORING
Clinical site monitoring may be conducted to ensure that the rights and wellbeing of participants giving 
samples are protected, that the reported data are accurate, complete, and verifiable, and that the 
conduct of the trial is in compliance with the currently approved protocol/amendment(s), with ICH GCP, 
and with applicable regulatory requirement(s). 
According to ICH GCP section 5.18, clinical protocols are required to be adequately monitored. This 
study monitoring will be conducted according to the “NIAID Intramural Clinical Monitoring Guidelines.” 
Monitors under contract to NIAID/OCRPRO will visit the research site to monitor aspects of the study in 
accordance with the appropriate regulations and the approved protocol. The objectives of a monitoring 
visit will be: (1) to verify the existence of signed ICFs and documentation of the informed consent 
process for each monitored subject; (2) to verify the prompt and accurate recording of all monitored 
data points, and prompt reporting of all SAEs; (3) to compare abstracted information with individual 
subjects’ records and source documents (subjects’ charts, laboratory analyses and test results, 
physicians’ progress notes, nurses’ notes, and any other relevant original subject information); and (4) to 
help ensure investigators are in compliance with the protocol. The monitors also will inspect the clinical 
site regulatory files to ensure that regulatory requirements (Office for Human Research Protections), 
and applicable guidelines (ICH GCP) are being followed. During the monitoring visits, the investigator 
(and/or designee) and other study personnel will be available to discuss the study progress and 
monitoring visit.
During monitoring visits, the PI (and/or designee) and other study personnel will be available to discuss 
the study progress and monitoring visit. The PI will be provided copies of monitoring follow-up letters 
within 20 days of a visit. 
The investigator (and/or designee) will make study documents (e.g., ICF) and pertinent hospital or 
clinical records readily available for inspection by the NIH IRB, NECHR, the site monitors, and the NIAID 
staff for confirmation of the study data. 
A specific protocol monitoring plan will be discussed with the PI and study staff prior to enrollment. The 
plan will outline the frequency of monitoring visits based on such factors as study enrollment, data 
collection status, and regulatory obligations.
The data gathered during this study will be monitored by the PI for safety and compliance with 
protocol-specified requirements.

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10.1.6 QUALITY ASSURANCE AND QUALITY CONTROL
 
Quality control (QC) procedures will be implemented beginning with the data entry system and data QC 
checks that will be run on the database will be generated. Any missing data or data anomalies will be 
communicated to the PI for clarification/resolution.
REDCap will serve as the core data collection component of the data management system. REDCap, 
which has been deployed in approximately 100 countries in support of 244,000 studies, is already in use 
at the site in an ongoing cohort study. It has an extensive range of features, the most important of which 
are the following:

The ability to operate from a web browser on a server or laptop and from Android and Apple 
tablets in disconnected mode and to synchronize data between any of these devices; 

The ability to interface with and receive data from external data management systems and 
adjudicate data imports prior to incorporation into the database;

A lightweight application that requires minimal processing power or memory;

The ability to define and run data quality rules over the duration of the study that can be run on 
both a real-time and ad hoc basis;

Support for updates through multiple mechanisms, including programming directly in the 
system at the site and transmission of updates from the Data Coordinating Center;

Support for multiple languages, both in the user interface and data collection instruments; and

Real-time reports, data summaries, and data exports, including frequencies for outlier 
detection.
Precision and accuracy of actual data collected will be checked by internal procedures at random (5%). 
Data editing and error resolution will be performed monthly. 
Following written SOPs, the monitors will verify that the clinical trial is conducted, data are generated, 
and biological specimens are collected, documented (recorded), and reported in compliance with the 
protocol, ICH GCP, and applicable regulatory requirements. 
The study site will provide direct access to source data/documents, reports for the purpose of 
monitoring and auditing, and inspection by local and regulatory authorities.
10.1.7 DATA HANDLING AND RECORD KEEPING 
10.1.7.1 DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES 
Upon enrollment in the protocol, all subjects will be assigned a unique identifying combination code of 
four to seven numbers depending on assigned protocol number followed by four-digit identification 
number (e.g., 001-0001) as it is a single site study. The identifying codes will serve to link specimens and 
data in CRFs and study databases with individual subjects without  subject names. Study personnel 
involved in data acquisition, entry, and analysis will therefore not have access to names or any other 
identifiers. Standard CRFs containing clinical and laboratory data will be completed by authorized 
individuals on tablets using the aforementioned REDCap that will be locked with a code and uploaded to 
password-protected servers. Relevant subject data will be entered into a hybrid system (REDCap plus 
Datafax as needed, which is already established in the NIAID sites in Cambodia). Electronically captured 

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data will be checked by study investigators and verified by a data manager. The PI is responsible for 
assuring that the data collected are complete, accurate, and recorded in a timely manner. 
Access to subject records and databases for demographic data analysis will be restricted to the 
investigators listed on this protocol and those working under their direct supervision. Access to ICFs, 
which link identifying numbers to names, will be restricted to those investigators authorized to obtain 
consent. 
10.1.7.2 STUDY RECORDS RETENTION 
The PI will retain all study records for a minimum of 7 years in compliance with institutional, IRB, state, 
and federal medical records retention requirements, whichever is longest. The PI will keep all stored 
records confidential to the extent required by federal, state, and local law. Data captured electronically 
via tablets will be backed up nightly to the site’s central server and transmitted on a weekly basis. All 
data will be archived at the end of the study and retained for a period of time consistent with IRB 
requirements.
Should the PI wish to assign the study records to another party and/or move them to another location, 
the PI will provide written notification of such intent to OCRPRO/NIAID with the name of the person 
who will accept responsibility for the transferred records and/or their new location. NIAID will be 
notified in writing and written OCRPRO/NIAID permission shall be obtained by the site prior to 
destruction or relocation of research records.
10.1.8 PROTOCOL DEVIATIONS 
As a result of a protocol deviation (as defined in Section 8.4.1), corrective actions are to be developed by 
the site and implemented promptly. 
These practices are consistent with ICH GCP: 

4.5 Compliance with Protocol, sections 4.5.1, 4.5.2, and 4.5.3. 

5.1 Quality Assurance and Quality Control, section 5.1.1. 

5.20 Noncompliance, sections 5.20.1, and 5.20.2. 
Protocol deviations must be sent to the NIH IRB and NECHR per their policies (Section 8.4.3). The site 
investigator is responsible for knowing and adhering to the reviewing IRB requirements. 
10.1.9 PUBLICATION AND DATA SHARING POLICY
This study will be conducted in accordance with the following publication and data sharing policies and 
regulations:
The NIH Public Access Policy ensures that the public has access to the published results of NIH funded 
research. It requires scientists to submit final peer-reviewed journal manuscripts that arise from NIH 
funds to the digital archive PubMed Central upon acceptance for publication.
This study will comply with the NIH Data Sharing Policy and Policy on the Dissemination of NIH-Funded 
Clinical Trial Information and the Clinical Trials Registration and Results Information Submission rule. As 

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such, this trial will be registered at ClinicalTrials.gov, and results information from this trial will be 
submitted to ClinicalTrials.gov. In addition, every attempt will be made to publish results in 
peer-reviewed journals. Data from this study may be requested from other researchers 5 years after the 
completion of the primary endpoint by contacting Jessica Manning (NIAID).
Any microbial or human data generated in this study will be shared for future research as follows:

De-identified data in an NIH-funded or approved public repository.

De-identified data in another public repository.

De-identified or identified data with approved outside collaborators under appropriate 
agreements.

Data sharing may be complicated or limited in certain cases by contractual obligations or 
agreements with outside collaborators. 
10.2 ABBREVIATIONS
 
AE
Adverse Event
CFR
Code of Federal Regulations
CHIKV
Chikungunya Virus
CI
Confidence Interval
CNM
National Malaria Center
CRF
Case Report Form
DENV
Dengue Virus
ELISA
Enzyme-linked Immunosorbent Assay
GCP
Good Clinical Practice
ICF
Informed Consent Form
ICH
International Council on Harmonisation of Technical Requirements 
for Pharmaceuticals for Human Use
Ig
Immunoglobulin
IRB
Institutional Review Board
JEV
Japanese Encephalitis Virus
LMVR
Laboratory of Malaria and Vector Research
MOP
Manual of Procedures
NECHR
National Ethics Committee for Health Research
NHP
Nonhuman Primate
NIAID
National Institute of Allergy and Infectious Diseases
NIH 
National Institutes of Health
OCRPRO
Office of Clinical Research Policy and Regulatory Operations
PI
Principal Investigator
PRNT
Plaque Reduction Neutralization (Assay)
QC
Quality Control
REDCap
Research Electronic Data Capture
SAE
Serious Adverse Event
SoA
Schedule of Activities
SOP
Standard Operating Procedure
UP
Unanticipated Problem Involving Risks to Subjects or Others
US
United States

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ZIKV
Zika Virus

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11
REFERENCES 
1. Bhatt S, Gething PW, Brady OJ, et al. The global distribution and burden of dengue. Nature 
2013;496(7446):504–7. 
2. Weaver SC, Lecuit M. Chikungunya Virus and the Global Spread of a Mosquito-Borne Disease. N Engl 
J Med 2015;372(13):1231–9. 
3. Ruchusatsawat K, Wongjaroen P, Posanacharoen A, et al. Long-term circulation of Zika virus in 
Thailand: an observational study. Lancet Infect Dis 2019;19(4):439–46. 
4. Althouse BM, Vasilakis N, Sall AA, Diallo M, Weaver SC, Hanley KA. Potential for Zika Virus to 
Establish a Sylvatic Transmission Cycle in the Americas. PLoS Negl Trop Dis 2016;10(12):e0005055. 
5. Wolfe ND, Kilbourn AM, Karesh WB, et al. Sylvatic transmission of arboviruses among Bornean 
orangutans. Am J Trop Med Hyg 2001;64(5):310–6. 
6. Buechler CR, Bailey AL, Weiler AM, et al. Seroprevalence of Zika Virus in Wild African Green 
Monkeys and Baboons. mSphere [Internet] 2017 [cited 2019 Dec 4];2(2). Available from: 
https://msphere.asm.org/content/2/2/e00392-16
7. Nakgoi K, Nitatpattana N, Wajjwalku W, et al. Dengue, Japanese encephalitis and Chikungunya virus 
antibody prevalence among captive monkey (Macaca nemestrina) colonies of Northern Thailand. 
Am J Primatol 2014;76(1):97–102. 
8. Duong V, Ong S, Leang R, et al. Low Circulation of Zika Virus, Cambodia, 2007–2016. Emerg Infect 
Dis 2017;23(2):296–9. 
9. Ho ZJM, Hapuarachchi HC, Barkham T, et al. Outbreak of Zika virus infection in Singapore: an 
epidemiological, entomological, virological, and clinical analysis. Lancet Infect Dis 2017;17(8):813–
21. 
10. Fauci AS, Morens DM. Zika Virus in the Americas — Yet Another Arbovirus Threat. N Engl J Med 
2016;374(7):601–4. 
11. Dubot-Pérès A, Vongphrachanh P, Denny J, et al. An Epidemic of Dengue-1 in a Remote Village in 
Rural Laos. PLoS Negl Trop Dis 2013;7(8):e2360. 
12. Kato F, Ishida Y, Kawagishi T, et al. Natural infection of cynomolgus monkeys with dengue virus 
occurs in epidemic cycles in the Philippines. J Gen Virol 2013;94(Pt 10):2202–7. 
13. Apandi Y, Lau SK, Izmawati N, et al. Identification of Chikungunya virus strains circulating in 
Kelantan, Malaysia in 2009. Southeast Asian J Trop Med Public Health 2010;41(6):1374–80. 
14. Vasilakis N, Holmes EC, Fokam EB, et al. Evolutionary processes among sylvatic dengue type 2 
viruses. J Virol 2007;81(17):9591–5. 

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15. Diallo D, Sall AA, Diagne CT, et al. Zika virus emergence in mosquitoes in southeastern Senegal, 
2011. PloS One 2014;9(10):e109442. 
16. Diagne CT, Diallo D, Faye O, et al. Potential of selected Senegalese Aedes spp. mosquitoes (Diptera: 
Culicidae) to transmit Zika virus. BMC Infect Dis 2015;15:492. 
17. Wang L, Valderramos SG, Wu A, et al. From Mosquitos to Humans: Genetic Evolution of Zika Virus. 
Cell Host Microbe 2016;19(5):561–5. 
18. Heang V, Yasuda CY, Sovann L, et al. Zika Virus Infection, Cambodia, 2010. Emerg Infect Dis 
2012;18(2):349–51. 
19. Althouse BM, Guerbois M, Cummings DAT, et al. Role of monkeys in the sylvatic cycle of 
chikungunya virus in Senegal. Nat Commun 2018;9(1):1046. 
20. Chua CL, Chan YF, Andu ESGS, et al. Little Evidence of Zika Virus Infection in Wild Long-Tailed 
Macaques, Peninsular Malaysia - Volume 25, Number 2—February 2019 - Emerging Infectious 
Diseases journal - CDC. [cited 2019 Dec 4];Available from: 
https://wwwnc.cdc.gov/eid/article/25/2/18-0258_article
21. Terzian ACB, Zini N, Sacchetto L, et al. Evidence of natural Zika virus infection in neotropical non-
human primates in Brazil. Sci Rep 2018;8(1):1–15. 
22. Wongsurawat T, Athipanyasilp N, Jenjaroenpun P, et al. Case of Microcephaly after Congenital 
Infection with Asian Lineage Zika Virus, Thailand. Emerg Infect Dis 2018;24(9):1758–61. 
23. Wiwanitkit V. Zika virus infection among travelers departing from Thailand. Ann Trop Med Public 
Health 2016;9(6):415. 
24. Buathong R, Hermann L, Thaisomboonsuk B, et al. Detection of Zika Virus Infection in Thailand, 
2012-2014. Am J Trop Med Hyg 2015;93(2):380–3. 
25. Wikan N, Suputtamongkol Y, Yoksan S, Smith DR, Auewarakul P. Immunological evidence of Zika 
virus transmission in Thailand. Asian Pac J Trop Med 2016;9(2):141–4. 
26. Perng GC, Ho T-C, Shih H-I, et al. Seroprevalence of Zika and Dengue Virus Antibodies among 
Migrant Workers, Taiwan, 2017 - Volume 25, Number 4—April 2019 - Emerging Infectious Diseases 
journal - CDC. [cited 2019 Nov 27];Available from: https://wwwnc.cdc.gov/eid/article/25/4/18-
1449_article

INSTITUTIONAL REVIEW BOARD OFFICE
Institutional Review Board Office| 6700B Rockledge Dr., Ste. 4300 | Bethesda MD 20817 | Main Line: 301-402-3713
Page 1 of 2
INITIAL APPROVAL
DATE: 
June 12, 2020
TO: 
Jessica E Manning
NIAID - I - Laboratory of Malaria and Vector Research
FROM: 
National Institutes of Health (NIH)
Institutional Review Board (IRB)
RE:                 IRB #: 20IN054
 
iRIS Reference #: 542312
Investigating the sylvatic transmission and reservoir potential of Zika, 
dengue, and chikungunya viruses of co-located humans and long-tailed 
macaques of Thailand and Cambodia 
Approval Date:
06/12/2020
Expiration Date:
N/A
Risk Level:
Minimal Risk under 45 CFR 46 
Review Level:
Expedited (Category 2a, 2b, 7) 
Subjects Approved:
350
This study was reviewed and Approved under the National Institutes of Health’s Federalwide 
Assurance (FWA00005897), in accordance with Federal regulations 45 CFR 
The response to stipulations was reviewed and accepted on 06/12/2020
The following documents are approved with this submission:
Study Application
Version 1.1
Approved
Submission Components Approved
Document Type
Version
Date Approved
Submission-Initial Review Submission Form
Version 1.3
06/12/2020
Consent Form-NIH_20IN054_consentclean_22May2020 Version 1.2
06/12/2020

INSTITUTIONAL REVIEW BOARD OFFICE
Institutional Review Board Office| 6700B Rockledge Dr., Ste. 4300 | Bethesda MD 20817 | Main Line: 301-402-3713
Page 2 of 2
Document-NIH_20-I-
N054_studypersonnelpageclean_10Apr2020
Version 1.1
06/12/2020
Document-NIH_20IN054_protocolclean_22May2020
Version 1.3
06/12/2020
Regulatory Determinations: 
Expedited Review Category: 
Category 2(a): Collection of blood samples by finger stick, heel stick, ear stick, or venipuncture 
from healthy, nonpregnant adults who weigh at least 110 pounds. For these subjects, the amounts 
drawn may not exceed 550 mL in an 8 week period and collection may not occur more 
frequently than 2 times per week
 Category 2(b): Collection of blood samples by finger stick, heel stick, ear stick, or venipuncture 
from other adults and children, considering the age, weight and health of the subjects, the 
collection procedure, the amount of blood to be collected, and the frequency with which it will 
be collected. For these subjects, the amount drawn may not exceed the lesser of 50 ml or 3 ml 
per kg in an 8 week period and collection may not occur more frequently than 2 times per week
Category 7: Research on individual or group characteristics or behavior (including, but not 
limited to, research on perception, cognition, motivation, identity, language, communication, 
cultural beliefs or practices, and social behavior) or research employing survey, interview, oral 
history, focus group, program evaluation, human factors evaluation, or quality assurance 
methodologies 
Pregnant Women/Fetuses/Neonates:
Inclusion of pregnant women approved under 45 CFR 46.204 
Documentation of Informed Consent:
Written consent in accordance with 45 CFR 46.117
Federal regulations and NIH policy require prompt reporting of any unanticipated problems 
involving risks to subjects or others, or serious harm involving subjects, to the IRB. In addition, 
changes in research activities may not be initiated without prior review and approval by the IRB, 
except when necessary to eliminate apparent immediate hazards to subjects.
If you have any questions, contact the IRB Office at 301-402-3713 / email: IRB@od.nih.gov.