Immunologic Responses to a Live Attenuated Oral Cholera Vaccine
Phase: PHASE2
Conditions: Cholera
Sponsor: Emory University

Study Protocol 
 
 
Immunologic Responses to a Live Attenuated Oral Cholera Vaccine 
 
Protocol Date: March 4, 2025 
 
NCT03251495 

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Immunologic Responses to a Live Attenuated Oral Cholera Vaccine 
Protocol Number: Cholera 1 
Sponsored by:
National Institute of Allergy and Infectious Diseases (NIAID)
1 R01 AI137127-01
Clinical Trial Principal Investigator:
Nadine Rouphael, MD
Draft or Version Number: 
11
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i
Statement of Compliance
The trial will be carried out in accordance with Good Clinical Practices (GCP) as 
required by the following:

United States Code of Federal Regulations (CFR) applicable to clinical studies 
(45 CFR Part 46; 21 CFR Part 50, 21 CFR Part 54, 21 CFR Part 56, and 21 CFR 
Part 312);
Compliance with these standards provides public assurance that the rights, safety and 
wellbeing of study subjects are protected, consistent with the principles that have their 
origin in the Declaration of Helsinki.
All key personnel (all individuals responsible for the design and conduct of this trial) 
have completed Human Subjects Protection Training.

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SIGNATURE PAGE
The signature below constitutes the approval of this protocol and the attachments, and provides 
the necessary assurances that this trial will be conducted according to all stipulations of the 
protocol, including all statements regarding confidentiality, and according to local legal and 
regulatory requirements and applicable US federal regulations.
Site Investigator:
Signed:
Date:
Nadine Rouphael, MD, FIDSA
Hope Clinic of the Emory Vaccine Center
Professor of Medicine
Division of Infectious Diseases
Emory University School of Medicine

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Table of Contents
Statement of Compliance ...............................................................................................................i
Signature Page ..............................................................................................................................ii
Table of Contents......................................................................................................................iii-iv
Protocol Summary .....................................................................................................................v-vi
Key Roles ......................................................................................................................................3
1
Background Information and Scientific Rationale.................................................................4
1.1Background Information...................................................................................................4
1.2 Scientific Rationale .........................................................................................................6
1.3 Potential Risks and Benefits...........................................................................................6
1.3.1
Potential Risks ..............................................................................................6
1.3.2
Known Potential Benefits ..............................................................................8
2
Objectives.............................................................................................................................9
2.1 Study Objectives.............................................................................................................9
2.2 Study Outcome Measures ..............................................................................................9
3
Study Design ......................................................................................................................11
4
Study Population.................................................................................................................12
4.1 Selection of the Study Population.................................................................................12
4.2 Inclusion/Exclusion Criteria...........................................................................................12
5.0 Recruitment…………………………………………………………………………………...14
5
Study Procedures/Evaluations............................................................................................15
5.1 Study Procedures .........................................................................................................15
5.1.1
Laboratory Evaluations/Assays...................................................................15
5.1.2
Special Assays or Procedures ....................................................................15
5.1.3
Specimen Collection, Preparation, Handling and Analyses........................16
6
Study Schedule...................................................................................................................17
6.1 Screening and Enrollment/Baseline Visit......................................................................17
6.1.1
Screening Visit Day 00 (Optional) (Day -45 to -7 days) ..............................17
6.1.2
Visit 0a (screening+7) for group 1 and 2.....................................................17
6.1.3
Enrollment Day 01.......................................................................................17
6.2 Follow-up and Final Visits.............................................................................................18
6.2.1
Visit 02 Day 08, Visit 03 Day 11, Visit 04 Day 15........................................18
6.2.2
Visit 05 Day 29............................................................................................19
6.2.3
Visit 06 Day 90............................................................................................19
6.2.4
Visit 05a (EGD +7 days) and Visit 06a (EGD day+7 days).........................20
6.2.5
Visit 07 Day 365..........................................................................................20
6.3 Early Termination Visit (if needed)................................................................................20
7
Statistical Considerations ...................................................................................................21
8
Quality Control and Quality Assurance...............................................................................22
9
Ethics/Protection of Human Subjects .................................................................................23

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9.1 Ethical Standard ...........................................................................................................23
9.2 Institutional Review Board ............................................................................................23
9.3 Informed Consent Process ...........................................................................................23
9.4 Exclusion of Women, Minorities, and Children (Special Populations) ..........................24
9.5 Subject Confidentiality ..................................................................................................24
9.6 Future Use of Stored Specimens..................................................................................24
10
Literature References .........................................................................................................25
SUPPLEMENTS/APPENDICES
A: Study Schedule………………………………………………………………………………….......28
B: Adverse Events Grading……………………………………………………….…………………...30

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Protocol Summary
Title: 
            
Immunologic Responses to a Live Attenuated Oral Cholera              
                                               Vaccine 
Population:
50 subjects, 18 to 49 years old, who are in good health and meet 
the eligibility criteria
Clinical Sites:
The Hope Clinic of the Emory Vaccine Center, Emory University
                                               Emory GI Clinic/Ambulatory Surgery Center
Study Duration:
5 years
Subject Duration:
Approximately 13 months
Description of Agent:
One dose delivered orally of the FDA-approved live attenuated 
cholera vaccine (Vaxchora)
Objectives:
Primary:

To evaluate the antibody response to the cholera vaccine in healthy subjects.
Secondary:

To evaluate B cell responses in healthy subjects receiving the live attenuated cholera 
vaccine.

To evaluate the safety and reactogenicity in healthy subjects receiving the live attenuated 
cholera vaccine.
Exploratory:

To evaluate mucosal cell responses in a subset of the healthy subjects receiving the live 
attenuated cholera vaccine.
Endpoints: 
Primary:

Level of antibody titers at day 1 (pre-vaccination) and day 29 in serum.
Secondary:

Levels of plasmablasts at days 1, 8 and 29 

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
Levels of  activated B cells at days 1, 8 and 29

Levels of  memory B cells at days 1 and 29. 

Correlation between antibody titers and the level of plasmablasts, activated B cells, and 
memory B cells.

Production and characterization of monoclonal antibodies against V. cholerae at day 8 in a 
subset of subjects.

Solicited and unsolicited adverse events in healthy subjects receiving cholera vaccine at day 
8 and day 29 respectively.

Serious adverse events in healthy subjects receiving cholera vaccine for the duration of the 
study. 
Exploratory:

Levels of plasma cells, activated B cells and T cells in small intestinal biopsy samples at day 
29 (n=15) or day 90 (n=5). 

Correlation between systemic and mucosal immune responses.

Production and characterization of monoclonal antibodies against V. cholerae from a 
protected mucosal site. 

Levels of antibody titers at days 90 and 365. 

Levels of plasmablasts at days 11 and 15 in a subset of subjects. 

Levels of activated B cells at days 11 and 15 in a subset of subjects.

Levels of T cells at days 1 and 29 in a subset of subjects.

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KEY ROLES
Principal Investigator:
Nadine Rouphael, MD, FIDSA
Division of Infectious Diseases 
Emory University
The Hope Clinic of the Emory Vaccine Center 
 
Co-Principal Investigator:
Steven Keilin, MD
Division of Digestive Diseases,
Emory University School of Medicine, 
Co-investigator/ Research Project 
Principal Investigator: 
Jens Wrammert, PhD
Department of Microbiology and Immunology, 
School of Medicine, Emory University, 
 
Institution:
Emory University

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1
BACKGROUND INFORMATION AND SCIENTIFIC 
RATIONALE
1.1
Background Information
Vibrio cholerae causes an acute diarrheal disease responsible for more than 100,000 deaths 
and affects an estimated 3 to 5 million people annually [1-3]. Recent epidemics in Haiti and 
Africa illustrate the continued reach of this pathogen [4]. Across the globe, one billion people 
lack access to safe drinking water and are vulnerable to cholera. The increasing disease 
burden, and emergence of more virulent strains, suggest that more aggressive approaches to 
preventing cholera are needed [5-7]. This includes renewed efforts to understand the 
mechanism of protective immunity against cholera and to improve the protective efficacy of 
current cholera vaccines.
V. cholerae infection and the need for improved vaccines. V. cholerae is a non-invasive 
pathogen, and thus represents an excellent model to study the induction and maintenance of 
mucosal immunity. V. cholerae colonizes the surface of the small intestine and expresses 
cholera toxin (CT). The enzymatic activity of CT leads to the profound secretory diarrhea that 
characterizes cholera [8]. There are currently two WHO prequalified, inactivated whole cell 
cholera vaccines commercially available, Dukoral and Shanchol. Since 2010, the WHO 
recommends the use of these vaccines [1], combined with other strategies, in cholera endemic 
areas, but to date this has been poorly implemented. A major reason for this is that the vaccines 
have significant immunological and practical limitations. Although the vaccines induce protective 
immunity, the efficacy is moderate and protection wanes rapidly, with poor protective efficacy in 
children [9-11]. In contrast, natural infection with V. cholerae induces 90-100% protection 
against re-infection, for up to ten years [12-14]. Yet it remains poorly understood why 
infection confers long-lived protection and current vaccines do not. A live attenuated 
cholera vaccine, Vaxchora, was approved in the US by the FDA  [15]. In contrast to the 
inactivated whole cell vaccines, this novel vaccine only requires a single dose, making it more 
practical for travelers to cholera affected areas. In a human challenge study, a protective 
efficacy of 90% at day 10 and 80% at day 90 was demonstrated [16]. Interestingly, the 4 out of 
33 volunteers that had measureable disease after challenge, displayed markedly less diarrhea, 
and shed three logs less bacteria in stool, arguing that they were partially protected. This is an 
important development, as with the ever-expanding travel by the population of developed 
countries, exposure to this severe human pathogen in one of the 69 cholera-endemic countries 
in Africa, Asia and the Carribean is likely to increase. Finally, it is currently unknown if this 
vaccine would provide more long-lived protection than that afforded by the inactivated whole 
killed vaccines that show little protection already two years after vaccination.
Both live attenuated and cholera vaccines induce early antibody and plasmablast responses 
that are similar in magnitude to that of natural infection [14, 17-21]. However, the magnitude of 
the plasmablast response does not necessarily correlate with the induction or maintenance of 
long-term protection, at least in endemic areas[18, 22], suggesting that there is a need to better 

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understand these early immune responses and define what critical parameters predict a 
productive B cell response to cholera. We hypothesize that there are critical aspects of the 
acute plasmablast response induced by V. cholerae infection, in terms of homing potential to the 
intestinal mucosa and immunoglobulin isotype, repertoire and antigenic specificity/functional 
characteristics that dictate the protective efficacy and the duration of humoral immune 
responses, both systemically and in the intestinal mucosa. 
V. cholerae as a model system to understand mucosal humoral immunity in humans. 
Understanding human mucosal immunity and regulation of homing to mucosal tissues is of key 
importance, not only for V. cholerae, but for many other mucosal infections, such as influenza 
and HIV. For example, the discovery of broadly neutralizing monoclonal antibodies (mAb) 
against HIV [23], underscores the importance of clinical studies aimed at understanding humoral 
immunity at the mucosal barrier. It is necessary to understand mechanisms that determine 
mucosal homing and long-term survival of plasmacells in this compartment. Although animal 
models are essential to understand many mechanistic aspects of immunity, cholera is not 
recapitulated well in any model tested to date. Thus, the most informative approach is to study 
this pathogen directly in humans. In this proposal, we demonstrate that the study of cholera in 
humans offers a strong platform for understanding the induction and longevity of humoral 
immunity, against a pathogen of great importance for human health. In addition, while an 
infectious episode provides up to ten years of protection from infection, serum antibody titers 
rapidly wane to undetectable levels, underscoring the importance of studying mucosal immune 
responses at the site of action for protective immunity against cholera. 
Over the last decade we have worked closely with our collaborators at MGH in Boston and at 
ICDDR’b in Bangladesh, to characterize acute systemic and mucosal B cell responses in V. 
cholerae infected patients in a cholera-endemic area in Bangladesh [24-26]. Our colleagues 
there have studied both blood borne [24, 26]  and mucosal [20] (EGD) immune responses to 
both natural infection and against other, non-live vaccines. The studies proposed herein will 
expand and complement those studies and allow the direct comparison of infection driven 
immune responses in an endemic and a naïve setting.
In this study, we attempt to better understand the immune responses to the live-attenuated 
cholera vaccine (Vaxchora) in healthy naïve subjects. Single cell expression cloning will 
generate a panel of monoclonal antibodies from these patients to further dissect the antibody 
responses induced by this vaccine. In addition to providing insight into the biology of vaccine 
induced immune responses, this analysis may also generate reagents with potential diagnostic 
or even therapeutic potential. Finally, we attempt to better understand the mucosal immune 
response to the live-attenuated cholera vaccine (Vaxchora) in a subset of subjects. 

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1.2
Scientific Rationale
The immune response to cholera varies between natural infection and vaccination in terms of 
magnitude, quality and longevity. Here we attempt to better understand the immune response to 
cholera vaccination in healthy subjects who are naïve to cholera vaccination and/or infection. As 
protection against V. cholerae is thought to occur at the mucosal surface in the small 
intestine, we propose to analyze local, mucosal immunity induced by vaccination with 
the live attenuated cholera vaccine, Vaxchora. This analysis will provide key insight into 
the dynamics of protective immunity against cholera, and also significantly enhance our 
understanding of mucosal immunity in general, which is of importance for many other 
mucosal infections, such as rotavirus, shigella, and HIV infections.
1.3
Potential Risks and Benefits
The study utilizes an FDA-approved live cholera vaccine, Vaxchora. See package insert for full 
risks and benefits of the vaccine [27].  
1.3.1 Potential Risks
The potential risks to all subjects are those associated with oral administration of the live 
cholera vaccine, possible reactions to the vaccine, and with having blood drawn.  
The potential risks of receiving the live cholera vaccine include but are not limited to: tiredness 
(30%), headache (28%), abdominal pain (18%), nausea/vomiting (17%), lack of appetite (16%), 
diarrhea (4%), and fever (0.6%) [28]. If any participant develops severe watery diarrhea we will 
clinically assess the patient and facilitate access to treatment 
Clinical trials found no related serious adverse reactions to the Vaxchora vaccine. Rarely, a 
subject may experience an allergic reaction, which produces rash, hives, or difficulty breathing. 
Vaccine products have been shown to be shed in stool for at least one week following 
administration, posing a potential risk. Subjects will be instructed to be diligent with hand 
washing and avoid contact with infants and immunosuppressed patients as per the vaccine 
package insert.
Blood sample collection involves transient discomfort and may cause fainting, which is managed 
by having the subject lie down prior. The blood draw site may bruise, and this can be 
ameliorated by holding pressure to this site following the blood draw. The sites of blood draw 
are potential sites of infection, but this risk is made very unlikely by the use of sterile technique. 
For the subset of patients (n=30) for which an upper endoscopy biopsy (EGD) is performed, 
additional risks involve those associated with the EGD procedure. Risks of the EGD procedure 
include complications related to: sedation, endoscopy, and the biopsy extraction. In a large 
survey from 1974 that was based on 200,000 upper endoscopies, the overall complication rate 
was 0.13%, and the mortality rate was 0.004%. Subsequent studies have estimated 

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complication rates of 0.15% overall and 0.0002% for diagnostic endoscopy without therapeutic 
maneuvers [29-32]. The risk for the healthy cohort proposed herein are likely less, as the 
numbers above include patients with advanced age, cardiopulmonary disease, anemia or 
obesity. Since our cohort is a healthy patient population, we expect our complication rates to be 
lower. 
The most frequent and serious complications of procedural sedation are cardiopulmonary, with 
risk factors being: advanced age, underlying comorbid illness (especially pulmonary disease), 
sleep apnea, obesity, anemia, and dementia. The frequency of cardiopulmonary events is 
associated with increasing American Society of Anesthesiologists scores. Some adverse events 
due to oversedation include: aspiration, hypoventilation, hypotension, hypoxemia, airway 
obstruction, vasovagal episodes, and arrhythmias. The overall incidence of cardiopulmonary 
complications is low. In a prospective survey of 14,149 upper endoscopies and a retrospective 
study of 21,011 endoscopic procedures, the rates of early cardiopulmonary events were 2 to 5.4 
per 1000 cases and mortality rates were 0.3 to 0.5 per 1000 cases, including cases of 
pneumonia, pulmonary embolism, aspiration, and myocardial infarct [33, 34].
Bleeding rarely occurs following diagnostic upper endoscopy. While the risk may be increased 
in patients with thrombocytopenia or coagulopathies, diagnostic upper endoscopy is generally 
thought to be safe in patients with platelet counts as low as 20,000 [32]. The risk is increased 
with use of anticoagulants and antiplatelet medications.
Upper endoscopy is associated with perforation of the esophagus, stomach and small bowel. It 
is more common when therapeutic maneuvers are carried out and in patients with esophageal 
diverticula. The estimated risk of esophageal perforation varies with the procedure being 
performed [35].
● Diagnostic endoscopy with a flexible endoscope: 0.03%
● Diagnostic endoscopy with a rigid endoscope: 0.11%
● Stricture dilation: 0.09 to 2.2%
● Sclerotherapy: 1 to 5%
● Pneumatic dilation for achalasia: 2 to 6%
The risk of infection related to gastrointestinal endoscopy is low, though there have been cases 
of hepatitis B, hepatitis C, and bacterial transmission related to breaches in protocols for proper 
endoscope disinfection, including an outbreak of carbapenem-resistant Enterobacteriaceae 
associated with improper processing of side-viewing duodenoscopes [36].

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1.3.2 Known Potential Benefits
While individuals are generally not at risk for acquiring cholera in the United States, the vaccine 
can offer protection to subjects if traveling to endemic countries, where individuals who receive 
this vaccine are likely to receive some level of protection from future V. cholerae exposure. The 
benefit for the study is predominantly scientific, allowing a better understanding of the immune 
response, in both the blood and in the mucosal tissues, to this particular vaccine. 

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2
OBJECTIVES
2.1
Study Objectives
Primary:

To evaluate the antibody response to the cholera vaccine in healthy subjects.
Secondary:

To evaluate B cell responses in healthy subjects receiving cholera vaccine.

To evaluate the safety and reactogenicity in healthy subjects receiving cholera vaccine.
Exploratory:

To evaluate mucosal cell responses in a subset of the healthy subjects receiving cholera 
vaccine.
2.2
Study Outcome Measures
Primary:

Level of antibody titers at day 1 (pre-vaccination) and day 29 in serum.
Secondary:

Levels of plasmablasts at days 1, 8 and 29

Levels of activated B cells at days 1, 8 and 29

Levels of memory B cells at days 1 and 29 .

Correlation between antibody titers and the level of plasmablasts, activated B cells, and 
memory B cells.

Production and characterization of monoclonal antibodies at day 8 against V. cholerae in a 
subset of subjects.

Solicited and unsolicited adverse events in healthy subjects receiving cholera vaccine at day 
8 and day 29 respectively.

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
Serious adverse events in healthy subjects receiving cholera vaccine for the duration of the 
study 
Exploratory:

Levels of plasmacells, activated B cells and T cells in small intestinal biopsy samples at day 
29 (n=15) or day 90 (n=5).

Correlation between systemic and mucosal immune responses.

Production and characterization of monoclonal antibodies against V. cholerae from a 
protected mucosal site. 

Levels of antibody titers at days 90 and 365. 

Levels of plasmablasts at days 11 and 15 in a subset of subjects. 

Levels of activated B cells at days 11 and 15 in a subset of subjects.

Levels of T cells at days 1 and 29 in a subset of subjects.

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3
STUDY DESIGN
This study will be a prospective study, with 50 subjects total, who are between ages 18 and 49 
years of age, in good health and meet all eligibility criteria. Each subject will make a total of 7 
visits to the Hope Clinic. Subjects will be recruited from the Atlanta metro area. (See appendix). 
30 of the subjects will also have two different visits at the GI suite during which small intestinal 
biopsies will be obtained: one at screening (-45 to -7 days) and the other post vaccination 
(Group 1 at Day 29 -7 days/ +14 days and Group 2 at day 90 +14 days) by EGD, and will have 
an additional follow-up phone call 7 days after the procedure. Subjects will be recruited from the 
Atlanta metro area.

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4
STUDY POPULATION
4.1
Selection of the Study Population 
The target sample size will be 50 subjects who will receive the Vaxchora live cholera 
vaccine, of whom 30 will undergo two procedures for small intestinal biopsies (6-12 
biopsies per EGD procedure in total): one at screening and the other post vaccination 
(Group 1 at Day 29 and Group 2 at day 90) by an EGD. With the exception of the 
inclusion/exclusion criteria, there will be no intentional recruitment of particular ethnic or 
racial groups. Subjects will be screened for eligibility according to the inclusion/exclusion 
criteria by history. Informed consent will be obtained for study participation.
4.2
Inclusion/Exclusion Criteria
Subjects eligible to participate shall meet all of the following inclusion criteria:
1.
Capable of informed consent and provision of written informed consent before 
any study procedures.
2.
Capable of attending all study visits according to the study schedule.
3.
Males or females between the ages of 18 and 49 years of age (inclusive).
4.
Are in good health, as determined by medical history and targeted physical exam 
related to this history.
5.
Female subjects of childbearing* age must have a negative urine pregnancy test 
before study vaccination and must use two forms of contraception** to avoid 
pregnancy within one month of Vaxchora administration.
* Not sterilized via tubal ligation, bilateral oophorectomy, hysterectomy, or successful Essure® placement
(permanent, non-surgical, non-hormonal sterilization) with documented radiological confirmation test at least
90 days after the procedure, and still menstruating or <1 year of the last menses if menopausal..
**Includes, but is not limited to, non-male sexual relationships, abstinence from sexual intercourse with a
male partner, monogamous relationship with vasectomized partner who has been vasectomized for 180
days or more prior to the subject receiving the first study vaccination, barrier methods such as condoms or
diaphragms with spermicide or foam, effective intrauterine devices, NuvaRing®, and licensed hormonal
methods such as implants, injectables, or oral contraceptives (“the pill).
Subjects eligible to participate shall not meet any of the following exclusion criteria:
1.
Have an acute illness within 72 hours before vaccination.

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2.
Have any acute or chronic medical condition that, in the opinion of the principal 
investigator, would make vaccination unsafe or interfere with the evaluation of immune 
response to study vaccination.
3.
Have a suppressed immune system as a result of illness, immunosuppressive medication, 
chemotherapy, or radiation therapy within 3 years prior to study vaccination.
4.
Have taken oral or parenteral corticosteroids of any dose within 30 days before study 
vaccination.
5.
Reside with individuals under the age of 2 or with an immunocompromised individuals.
6.
Have a known history of autoimmune disease. 
7.
Have a history of Guillain-Barre Syndrome.
8.
Have plans to receive any vaccine from 28 days prior to study vaccination until Day 29.
9.
Has previously received a cholera vaccine or have a known history of V. Cholerae.
10. Have donated blood or blood products within 56 days before study vaccination, plan to 
donate blood at any time during the 56-day duration of subject study participation, or plan 
to donate blood within 56 days after the last blood draw.
11. Have known hypersensitivity or allergy to any component of the vaccine or history of 
anaphylaxis with a vaccine or vaccine component.
12. Have allergy to tetracycline and/or ciprofloxacin.
13. Are pregnant or breastfeeding or plan to within one month of vaccination.
14. Travelled to a cholera endemic area and had traveler’s diarrhea in the previous 5 years.
15. Have abnormal stool pattern (fewer than 3 stools/ week or greater than 2 stools/ day) or 
regular use of laxatives in the last 6 months.
16. Have current or recent antibiotic use in the past 14 days.
17. Are 
healthcare 
workers 
who 
have 
direct 
contact 
with 
patients 
who 
are 
immunocompromised, have unstable medical conditions, or are under the age of 2.
18. Are childcare caregivers who have direct contact with children who are 2 years or younger.
19. Are employed in the food industry.
20. Have received any vaccine within the previous 21 days.
21. History of bleeding disorders or current use of warfarin, aspirin, heparin, nonsteroidal 
anti-inflammatory drugs (NSAIDs) or other blood thinner/ anticoagulant medications in 
the past week for subjects undergoing intestinal biopsies.
22. Use of benzodiazepines or narcotics for subjects undergoing intestinal biopsies 4 weeks 
prior to the procedure

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23. Any contraindications to endoscopy/concerns of the anesthesiologist for subjects who 
agree for EGD/biopsies.
24. BMI > 35 kg/m2
25. Have a diagnosis of any small bowel disease. This includes but is not limited to 
inflammatory bowel disease (e.g., Crohn’s disease, ulcerative colitis, indeterminate 
colitis, or microscopic colitis), small bowel obstruction, celiac disease, h/o small bowel 
resection, small bowel lymphoma, Whipple’s disease, primary Intestinal 
lymphangiectasis, abdominal radiation.
26. Current medications for the treatment of Gastroesophageal reflux disease (GERD) or 
dyspepsia
27. History of Helicobacter pylori (H. pylori) infection
5.0 Recruitment
Recruitment for the study will be done using various recruitment platforms and methods 
described below:
Posting and distributing IRB approved flyers around the community:

IRB approved flyers will be posted in and around the community. The flyers will be 
distributed using methods including but not limited to:
o
Approved flyers will be posted on billboards.
o
Posting and handing flyers to the public in locations such as Malls, Airports, 
parks, recreation centers, restaurants etc.

Posting IRB approved Ads on Shuttles and buses – Emory University buses/shuttles, 
Georgia Tech shuttles/buses, MARTA buses and bus stops

The Hope Clinic team will take part in community events throughout Atlanta where 
study staff will talk to attendees about research studies being done at the Hope 
Clinic, including this study. 
The study team will ensure that in locations where required, permission from relevant 
authorities will be sought before distributing or posting the flyers.
Social media and paid advertising: 

Posting ads on different social media platforms such as Facebook, Instagram, 
Twitter, Snapchat, TikTok etc. and dating apps containing a link to the Hope Clinic 
Volunteer Form.

The Emory Hope Clinic website (A short description of the study will be put on the 
Hope Clinic website using the same language as the ads). 

IRB approved Ad banners may also be placed on streaming platforms including but 
not limited to Netflix, Hulu, Disney+ etc. 

We may also partner with cable companies such as AT&T, Xfinity etc. to post paid 
ads. The ads may be posted in the form of texts, email or banner on cable TV. 

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Recruiting via email:

Email blasts of IRB approved email language will be sent out on various listservs e.g., 
Emory Vaccine Dinner Club, Emory Vaccine Center, CDC etc.

Email blasts to student listservs including Emory University, Georgia State University, 
Georgia Tech and UGA. The study team will seek approval from the respective 
universities registrars and verify the method in which the email blast will be sent out 
(listservs or individual email). 
Registries

We may also use registries as a recruitment platform for this protocol. Various volunteer 
registries may be utilized. After potential candidates have been identified from the 
registry, they may be contacted by their indicated method of contact (email, mailing 
address or phone/texting) and invited to be screened under this protocol.
Contacting past and present study subjects

Current and past  Hope Clinic subjects (i.e. who have agreed to be contacted in past 
informed consent forms) may be contacted by calling and emailing. Potential new 
subjects who will self-refer from recruitment advertisements will be included. All 
recruitment materials will be IRB approved prior to use. IRB approved advertisements 
may be placed in local media platforms. 
Verbal/written consent is first obtained and then subjects will be interviewed to assess if they 
meet the inclusion and exclusion criteria. They will be enrolled and undergo the screening 
procedures indicated unless it is discovered that they are not eligible to continue.

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5
STUDY PROCEDURES/EVALUATIONS
5.1
Study Procedures
Medical history will be obtained by interview of study subjects on Day 1 (Visit 1) prior to 
the study vaccination. Subjects will be asked about a known history of significant 
medical disorders, cancer, immunodeficiency, allergies, psychiatric illness, substance 
use, and autoimmune diseases.
Medications history will include a review of all current medications and any medications 
taken in the last 30 days before study vaccination. Medications included in this history 
will include prescription medication, over-the-counter medication, vitamins, supplements, 
and prohibited treatments listed in the above Inclusion/Exclusion Criteria section, such 
as antibiotics within the last 14 days and vaccines.
On Day 1 (Visit 1) and before the study vaccination, a targeted physical examination 
may be performed by the investigator, who is licensed to make medical diagnoses. At 
visits 2-7, a targeted physical examination may be performed based on interim health 
history.  
Vital signs (oral temperature, pulse rate, and blood pressure) will be measured at all 
study visits. 
Height and weight will be measured on Day 1 (Visit 1) before study vaccination 
Subjects will be observed in the clinic for at least 20 minutes after study vaccination on 
Day 1 (Visit 1). 
5.1.1 Laboratory Evaluations/Assays
Urine pregnancy tests will be performed by the site laboratory on the same day as and 
prior to study vaccination (Day 1). Results must be negative and known prior to study 
vaccination.
5.1.2 Special Assays or Procedures
The immunologic assays will be performed at Dr. Wrammert’s Laboratory on the Emory 
University main campus.

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5.1.3 Specimen Collection, Preparation, Handling and Analyses
Blood will be collected at each of the seven study visits as per the Study Schedule in 
Appendix A.

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6
STUDY SCHEDULE
6.1
Screening and Enrollment/Baseline Visit 
6.1.1 Screening Visit Day 00 (As needed) (Day -45 to -7 days)
Study subjects will be given a description of the study and have an opportunity to have 
their questions and concerns addressed by the study principal investigator or designee.
Subjects will be given the informed consent form to read and discuss with study staff, 
and if they wish to enroll will sign the document before any study vaccination, 
procedures, or lab draws are performed.
A medical history and targeted physical exam, if necessary, as outlined in the Study 
Procedures section will be conducted in order to assess for compliance with study 
inclusion and exclusion criteria. 
A list of any medications taken by subjects in the past 30 days and those to be taken for 
28 days after vaccinations will be documented on the appropriate study form.
A urine pregnancy test will be conducted for female subjects, and a negative result will 
be required and be documented on the appropriate study form prior to any study 
interventions.
Vital signs, including pulse rate, blood pressure, oral temperature, and height and weight 
will be measured and documented on the appropriate study form.
Group 1 and Group 2 subjects: a procedure for small intestinal biopsies using 
esophagogastroduodenoscopy will be performed by a gastrointestinal specialist at 
Emory GI suite. Visit will take 4 hours.
6.1.2 Visit 0a (screening+7) for groups 1 and 2
Groups 1 and 2: a follow-up phone call is made 7 days post procedure to assess for any 
adverse events from the EGD procedure.
6.1.3 Enrollment Day 01
Study subjects will be given a description of the study and have an opportunity to have 
their questions and concerns addressed by the study principal investigator or designee.

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Subjects will be given the informed consent form to read and discuss with study staff (if 
no screening visit has been done), and if they wish to enroll will sign the document 
before any study vaccination, procedures, or lab draws are performed.
A medical history and targeted physical exam, if necessary, as outlined in the Study 
Procedures section will be conducted in order to assess for compliance with study 
inclusion and exclusion criteria. 
A list of any medications taken by subjects in the past 30 days and those to be taken for 
28 days after vaccinations will be documented on the appropriate study form.
A urine pregnancy test will be conducted for female subjects, and a negative result will 
be required and be documented on the appropriate study form prior to any study 
interventions.
Vital signs, including pulse rate, blood pressure, oral temperature, and height and weight 
will be measured and documented on the appropriate study form.
Blood will be collected for baseline study labs as outlined in the Study Procedures 
section.
A single dose of the FDA-approved oral live cholera vaccine (Vaxchora) will be 
administered. Eating and drinking should be avoided for one hour before and after 
vaccine administration. Subjects will be asked to remain at the clinic for 20 minutes to 
monitor for any reactions or adverse events. Any reactions or adverse events will be 
documented on the appropriate study form. Subject will be instructed to use adequate 
hand hygiene to avoid fecal-oral transmission of the vaccine to others. 
Subjects will be informed to contact the study clinic should they experience any 
concerning reactions to the vaccine, and they will be asked to visit the clinic for 
evaluation should the principal investigator or designee deem the reaction in need of 
evaluation.
6.2
Follow-up and Final Visits
6.2.1 Visit 02 Day 08 Visit 03 Day 11, Visit 04 Day 15 
Interim medical history and targeted physical exam, if necessary, will be conducted.
Medications taken during the interim from the previous visit and any adverse or serious 
adverse events will be documented on the appropriate study form.

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Vital signs, including pulse rate, blood pressure, and oral temperature will be measured 
and documented on the appropriate study form.
Blood will be collected for immunogenicity analysis.
A review of the memory aid will be done at Visit 02.
Certain follow up visits  (D11 and D15) will not be required by PI discretion.
6.2.2 Visit 05 Day 29
Interim medical history and targeted physical exam, if necessary, will be conducted.
Medications taken during the interim from the previous visit and any adverse or serious 
adverse events will be documented on the appropriate study form.
Vital signs, including pulse rate, blood pressure, and oral temperature will be measured 
and documented on the appropriate study form.
Blood will be collected for immunogenicity analysis.
Group 1 (n=15): a small intestinal biopsy using esophagogastroduodenoscopy will be 
performed by a gastrointestinal specialist at Emory GI suite. Visit will take 4 hours. The 
window for this visit is – 7 days/ + 14 days
6.2.3 Visit 06 Day 90 
Interim medical history and targeted physical exam, if necessary, will be conducted.
Any serious adverse event will be documented on the appropriate study form.
Vital signs, including pulse rate, blood pressure, and oral temperature will be measured 
and documented on the appropriate study form.
Blood will be collected for immunogenicity analysis
Group 2 (n=5): a small intestinal biopsy using esophagogastroduodenoscopy will be 
performed by a gastrointestinal specialist at Emory GI suite. Visit will take 4 hours. The 
window for this visit is + 14 days. Visit 05a (EGD +7 days) and Visit 06a (EGD day+7 
days)
Group 1 and 2: a follow-up phone call is to be made 7 days post-procedure to 
assess for any adverse events from the procedure. Visit 07 Day 365

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Interim medical history and targeted physical exam, if necessary, will be conducted.
Any serious adverse event will be documented on the appropriate study form.
Vital signs, including pulse rate, blood pressure, and oral temperature will be measured 
and documented on the appropriate study form.
Blood will be collected for immunogenicity analysis
6.3 Early Termination Visit (if needed)
The following will be performed at any early termination visit, if necessary, for subjects 
who withdraw or who are withdrawn from the study:
Interim medical history and targeted physical exam, if necessary, will be conducted.
A review of the memory aid will be conducted (if visit occurs within 7 days of 
vaccination). 
Medications taken during the interim from the previous visit will be documented on the 
appropriate study form (if prior to D29). 
Vital signs, including pulse rate, blood pressure, and oral temperature will be measured 
and documented on the appropriate study form.
Any adverse (prior to D29) or serious adverse events will be documented on the 
appropriate study form. 
Blood will be collected for immunogenicity analysis. 

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7
STATISTICAL CONSIDERATIONS
The goal of this study is to study the immune responses to the live attenuated cholera 
vaccine Vaxchora in healthy, cholera infection/vaccination naïve subjects by analysis of 
the blood and mucosal tissue samples from the small intestine. 
Our aim is to include a total of 50 participants who will receive the live attenuated oral 
cholera vaccine (Vaxchora), of which 30 participants will undergo 2 procedures for small 
intestinal biopsy via EGD by a gastrointestinal specialist at Emory University Hospital.
The biostatistician will perform descriptive statistics to describe the immune responses to 
cholera vaccine. As a faculty in the Department of Pediatrics, Dr. Wrammert has access 
to an excellent Statistical Core that is provided free of charge.

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8
QUALITY CONTROL AND QUALITY ASSURANCE
The study will undergo internal quality control and quality assurance per the Hope Clinic 
standard operating procedures.  

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9
ETHICS/PROTECTION OF HUMAN SUBJECTS
9.1
Ethical Standard
The site principal investigator will ensure that this trial is conducted in full conformity with 
the principles of the Belmont Report: Ethical Principles and Guidelines for the Protection 
of Human Subjects of Research of the National Commission for the Protection of Human 
Subjects of Biomedical and Behavioral Research (April 18, 1979) and codified in 45 CFR 
46, 21 CFR 50 and 56; 62 Federal Regulations 25691 (1997), if applicable. 
9.2
Institutional Review Board
Prior to enrollment of subjects into this trial, the approved protocol and informed consent 
form will be reviewed and approved by the Emory IRB. The responsible official for the 
IRB will sign the IRB letter of approval of the protocol prior to the start of this study. 
9.3
Informed Consent Process
The site principal investigator and designee will choose subjects in accordance with the 
eligibility criteria detailed in Section 4. Before any study procedures are performed, 
subjects must sign an informed consent form that complies with the requirements of 21 
CFR Part 50 and 45 CFR 46 and the local IRB.
Informed consent is a process that is initiated prior to an individual agreeing to participate 
in a study and continuing throughout the individual’s study participation. Before any study 
procedures are performed, subjects will receive a comprehensive explanation of the 
proposed study procedures and study interventions/products, including the nature and 
risks of the trial, alternate therapies, any known adverse effects, and the other elements 
that are part of obtaining proper informed consent. Subjects will also receive a detailed 
explanation of the proposed use and disclosure of their protected health information, 
including specifically their serum samples. Subjects will be allowed sufficient time to 
consider participation in the study, after having the nature and risks of the trial explained 
to them, and have the opportunity to discuss the trial with their family, friends or legally 
authorized representative or think about it prior to agreeing to participate. 
Informed consent forms describing in detail the study interventions/products, study 
procedures, risks and possible benefits are given to subjects. The informed consent form 
must not include any exculpatory statements. Informed consent forms will be IRB-
approved and subjects will be asked to read and review the appropriate document. Upon 
reviewing the appropriate document, the site principal investigator (or designee) will 
explain the research study to subjects and answer any questions that may arise. Subjects 
must sign the informed consent form, and written documentation of the informed consent 
process is required prior to starting any study procedures/interventions being done 
specifically for the trial, including administering study product. 

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Study personnel may employ IRB-approved recruitment efforts prior to obtaining the 
subjects consent; however, before any study procedures are performed to determine 
protocol eligibility an informed consent form must be signed. Subjects will be given a copy 
of all informed consent forms that they sign.
This submission seeks approval for two new study flyers intended for print and social 
media use. Specifically, the flyers will be disseminated, once IRB-approved, in the 
community, on Emory University Campuses and electronically via listservs and on 
electronic notification boards. The flyers may also be posted on social media platforms 
such as Facebook, Instagram, Twitter and craigslist via an official Emory University 
Facebook account and Instagram Emory Get Involved account.
By signing the informed consent form, subjects agree to complete all evaluations required 
by the trial, unless the subject withdraws voluntarily, or is withdrawn or terminated from 
the trial for any reason. 
The rights and welfare of subjects will be protected by emphasizing to subjects that the 
quality of their medical care will not be adversely affected if they decline to participate in 
or withdraw from this trial.
9.4
Exclusion of Women, Minorities, and Children (Special 
Populations)
This trial will be inclusive of all adults who meet the Subject Inclusion/Exclusion Criteria, 
regardless of religion, sex, or ethnic background.
9.5
Subject Confidentiality
Subjects will have code numbers and will not be identified by name. Subject 
confidentiality is strictly held in trust by principal investigator and the Hope Clinic 
personnel directly involved in the study. This confidentiality is extended to cover testing of 
biological samples, in addition to the clinical information relating to participating subjects. 
The study protocol, documentation, data, and all other information generated will be held 
in strict confidence.
9.6
Future Use of Stored Specimens
Subjects will be asked for permission to keep any remaining samples for possible use in 
future research studies, such as examining additional immunological assessments or 
testing for antibodies against other viruses or bacteria. The samples will not be sold or 
used directly for production of any commercial product. Human genetic tests will be 
performed on samples. Each sample will be labeled with a unique tracking number to 
protect subject’s confidentiality. There are no benefits to subjects in the collection, 
storage and subsequent research use of specimens. Reports about future research done 
with subject’s samples will NOT be kept in their health records.

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Subjects may be given the option to decide if they want their samples to be used for 
future research or have their samples destroyed at the end of the study. The subject’s 
decision can be changed at any time prior to the end of the study by notifying the study 
doctors or nurses in writing. However, if the subject originally consents to future use and 
subsequently changes his/her decision, any data from a previously collected sample may 
still be used for this research.

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10
LITERATURE REFERENCES
1.
Cholera vaccines: WHO position paper. Wkly Epidemiol Rec, 2010. 85(13): p. 117-28.
2.
Kaper, J.B., J.G. Morris, Jr., and M.M. Levine, Cholera. Clin Microbiol Rev, 1995. 8(1): p. 
48-86.
3.
Pasetti, M.F. and M.M. Levine, Insights from natural infection-derived immunity to 
cholera instruct vaccine efforts. Clin Vaccine Immunol, 2012. 19(11): p. 1707-11.
4.
Harris, J.B., et al., Cholera's western front. Lancet, 2010. 376(9757): p. 1961-5.
5.
Farmer, P., et al., Meeting cholera's challenge to Haiti and the world: a joint statement 
on cholera prevention and care. PLoS Negl Trop Dis, 2011. 5(5): p. e1145.
6.
Ryan, E.T., Eyes on the prize: lessons from the cholera wars for modern scientists, 
physicians, and public health officials. Am J Trop Med Hyg, 2013. 89(4): p. 610-4.
7.
Weil, A.A., et al., Memory T-cell responses to Vibrio cholerae O1 infection. Infect Immun, 
2009. 77(11): p. 5090-6.
8.
Harris, J.B., L.C. Ivers, and M.J. Ferraro, Case records of the Massachusetts General 
Hospital. Case 19-2011. A 4-year-old Haitian boy with vomiting and diarrhea. N Engl J 
Med, 2011. 364(25): p. 2452-61.
9.
Clemens, J.D., et al., Field trial of oral cholera vaccines in Bangladesh: results from 
three-year follow-up. Lancet, 1990. 335(8684): p. 270-3.
10.
Deen, J.L., et al., The high burden of cholera in children: comparison of incidence from 
endemic areas in Asia and Africa. PLoS Negl Trop Dis, 2008. 2(2): p. e173.
11.
Sur, D., et al., Efficacy and safety of a modified killed-whole-cell oral cholera vaccine in 
India: an interim analysis of a cluster-randomised, double-blind, placebo-controlled trial. 
Lancet, 2009. 374(9702): p. 1694-702.
12.
Glass, R.I., et al., Endemic cholera in rural Bangladesh, 1966-1980. Am J Epidemiol, 
1982. 116(6): p. 959-70.
13.
Koelle, K., et al., Refractory periods and climate forcing in cholera dynamics. Nature, 
2005. 436(7051): p. 696-700.
14.
Levine, M.M., et al., Duration of infection-derived immunity to cholera. J Infect Dis, 1981. 
143(6): p. 818-20.
15.
Levine, M.M., et al., PaxVax CVD 103-HgR single-dose live oral cholera vaccine. Expert 
Rev Vaccines, 2017. 16(3): p. 197-213.
16.
Chen, W.H., et al., Single-dose Live Oral Cholera Vaccine CVD 103-HgR Protects 
Against Human Experimental Infection With Vibrio cholerae O1 El Tor. Clin Infect Dis, 
2016. 62(11): p. 1329-1335.
17.
Levine, M.M., et al., Safety, immunogenicity, and efficacy of recombinant live oral 
cholera vaccines, CVD 103 and CVD 103-HgR. Lancet, 1988. 2(8609): p. 467-70.
18.
Sack, D.A., et al., Antibody responses after immunization with killed oral cholera 
vaccines during the 1985 vaccine field trial in Bangladesh. J Infect Dis, 1991. 164(2): p. 
407-11.
19.
Sack, D.A., et al., Evaluation of Peru-15, a new live oral vaccine for cholera, in 
volunteers. J Infect Dis, 1997. 176(1): p. 201-5.
20.
Shamsuzzaman, S., et al., Robust gut associated vaccine-specific antibody-secreting 
cell responses are detected at the mucosal surface of Bangladeshi subjects after 
immunization with an oral killed bivalent V. cholerae O1/O139 whole cell cholera 
vaccine: comparison with other mucosal and systemic responses. Vaccine, 2009. 27(9): 
p. 1386-92.

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21.
Svennerholm, A.M., et al., Mucosal antitoxic and antibacterial immunity after cholera 
disease and after immunization with a combined B subunit-whole cell vaccine. J Infect 
Dis, 1984. 149(6): p. 884-93.
22.
Clemens, J.D., et al., Field trial of oral cholera vaccines in Bangladesh: serum vibriocidal 
and antitoxic antibodies as markers of the risk of cholera. J Infect Dis, 1991. 163(6): p. 
1235-42.
23.
Burton, D.R., et al., A Blueprint for HIV Vaccine Discovery. Cell Host Microbe, 2012. 
12(4): p. 396-407.
24.
Harris, A.M., et al., Antigen-specific memory B-cell responses to Vibrio cholerae O1 
infection in Bangladesh. Infect Immun, 2009. 77(9): p. 3850-6.
25.
Kauffman, R.C., et al., Single-Cell Analysis of the Plasmablast Response to Vibrio 
cholerae Demonstrates Expansion of Cross-Reactive Memory B Cells. MBio, 2016. 7(6).
26.
Rahman, A., et al., Antibody-secreting cell responses after Vibrio cholerae O1 infection 
and oral cholera vaccination in adults in Bangladesh. Clin Vaccine Immunol, 2013. 
20(10): p. 1592-8.
27.
 Vaxchora [package insert]. PaxVax, Inc., Redwood City, CA; 2016.
28.
Asakura, H., et al., Pathologic findings from intestinal biopsy specimens in human 
cholera. Am J Dig Dis, 1973. 18(4): p. 271-8.
29.
Wolfsen, H.C., et al., Complications of endoscopy of the upper gastrointestinal tract: a 
single-center experience. Mayo Clin Proc, 2004. 79(10): p. 1264-7.
30.
Committee, A.S.o.P., et al., Adverse events of upper GI endoscopy. Gastrointest 
Endosc, 2012. 76(4): p. 707-18.
31.
Geraci, G., et al., [Complications of elective esophago-gastro-duodenoscopy (EGDS). 
Personal experience and literature review]. G Chir, 2009. 30(11-12): p. 502-6.
32.
Silvis, S.E., et al., Endoscopic complications. Results of the 1974 American Society for 
Gastrointestinal Endoscopy Survey. JAMA, 1976. 235(9): p. 928-30.
33.
Sharma, V.K., et al., A national study of cardiopulmonary unplanned events after GI 
endoscopy. Gastrointest Endosc, 2007. 66(1): p. 27-34.
34.
Quine, M.A., et al., Prospective audit of upper gastrointestinal endoscopy in two regions 
of England: safety, staffing, and sedation methods. Gut, 1995. 36(3): p. 462-7.
35.
Chirica, M., et al., Esophageal perforations. J Visc Surg, 2010. 147(3): p. e117-28.
36.
Epstein, L., et al., New Delhi metallo-beta-lactamase-producing carbapenem-resistant 
Escherichia coli associated with exposure to duodenoscopes. JAMA, 2014. 312(14): p. 
1447-55.
37.
Faigel, D.O., et al., Preparation of patients for GI endoscopy. Gastrointest Endosc, 2003. 
57(4): p. 446-50.
38.
American Society of Anesthesiologists, C., Practice guidelines for preoperative fasting 
and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: 
application to healthy patients undergoing elective procedures: an updated report by the 
American Society of Anesthesiologists Committee on Standards and Practice 
Parameters. Anesthesiology, 2011. 114(3): p. 495-511.
39.
Pasha, S.F., et al., Routine laboratory testing before endoscopic procedures. 
Gastrointestinal Endoscopy, 2014. 80(1): p. 28-33.

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SUPPLEMENTS/APPENDICES
Study Visit 
Number
Screen 
(D00)
(V0a)
V01
V02
V03
V04
V05
(V05a)
V06
(V06a)
V07
Study Day +/- 
Window (days)
-45/-7
D00+7
D1
D8+1
D11
optional
D15
optional
D29
-7/+14
EGD+7
D90
-4/+7
EGD+
7
D365
+/-14
Obtain Informed 
Consent#
X*
X*+
Review Eligibility 
Criteria
X*
X*
Medical History+
X*
X
X*
X
X
X
X
X
X
X
X
Concomitant 
Medications
X*%
X
X*%
X
X
X
X
Vital Signs
 (Oral 
Temperature, 
Pulse Rate, and 
BP)
X*&$
X*&$
X$
X$
X$
Height and 
Weight
X*
X*
Targeted Physical 
Examination
X*
X*
 
 
 
 
Urine Pregnancy 
Test
X*@
X*@
X*@
Study Vaccination
X
20-minute 
Evaluation Period 
After Study 
Vaccination
X
Venous Blood 
Collection for 
Study Assays
X
X
X
X
X
X
X
X
Small intestinal 
biopsy via EGD
X!
X=
X=

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Memory Aid 
review
X
Post-procedural
phone call^
X
X
X
Adverse events
X
X
X
X
X
X
X
Serious adverse 
events
X
X
X
X
X
X
X
X
X
X
X
#Prior to study procedures
*Prior to study vaccination.
+Not required if done at the screening visit
%All current medications and medications taken within 30 days prior to day 1 of the study.
&Vital signs assessed on Day 1 (Visit 1) before the study vaccination will be considered as baseline.
$Subjects must not eat or drink anything hot or cold, or smoke within 10 minutes prior to taking oral temperature.
() Targeted physical examination if indicated based on review of complete or interim medical history.
@Must be performed on all female subjects of childbearing potential within 24 hours prior to each study vaccination and results must be negative and known prior 
to each study vaccination.
+Complete medical history by interview of subjects to be obtained on Day 0 (Visit 01) prior to the first study vaccination and interim medical history by interview of 
subjects to be obtained at follow-up visits after study vaccination.
!Only for participants agreeing to EGD i.e. Group 1 and 2
= Group 1 (n=25) will undergo small intestinal biopsy on D29 and Group 2 (n=5) subjects will undergo small intestinal biopsy at D90.
^Follow-up phone call post small intestinal biopsies via EGD.

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Appendix B: Adverse Events Grading
Vital Signs*
Mild 
(Grade 1)
Moderate 
(Grade 2) 
Severe 
(Grade 3)
Potentially Life 
Threatening 
(Grade 4)
Fever**
(°C)
(°F)
38.0- 38.4
100.4- 101.1
38.5- 38.9
101.2- 102.0
39.0- 40.0
102.1- 104.0
>40.0
>104.0
Tachycardia 
(beats per 
minute)
101-115
116-130
>130
ER visit or 
hospitalization 
for arrhythmia
Bradycardia*** 
(beats per 
minute)
50-54
45-49
<45
ER visit or 
hospitalization 
for arrhythmia
Hypertension- 
systolic 
(mm Hg)
141- 150
151- 155
>155
ER visit or 
hospitalization 
for malignant 
hypertension
Hypertension- 
diastolic 
(mm Hg)
91- 95
96- 100
>100
ER visit or 
hospitalization 
for malignant 
hypertension
Hypotension- 
systolic
(mm Hg)
85-89
80-84
<80
ER visit or 
hospitalization 
for hypotensive 
shock
*      Should be at rest for all vital sign measurements
**   Oral temperature; no recent hot or cold beverages or smoking

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*** When resting heart rate is between 60-100 beats per minute. Use clinical judgement when characterizing 
bradycardia among some healthy subject populations, for example, conditioned athletes. 
Systemic
(General)
Mild 
(Grade 1)
Moderate 
(Grade 2) 
Severe 
(Grade 3)
Potentially Life 
Threatening 
(Grade 4)
Nausea/vomiting
No interference 
with activity or 
1-2 episodes/24 
hours
Some 
interference with 
activity or 
>2 episodes/24 
hours
Prevents daily 
activity, requires 
outpatient IV 
hydration
ER visit or 
hospitalization 
for hypotensive 
shock
Diarrhea
2-3 loose stools 
or <400 gms/24 
hours
4-5 loose stools 
or 400-800 
gms/24 hours
6 or more watery 
stools or >800 
gms/24 hours or 
requires 
outpatient IV 
hydration
ER visit or 
hospitalization
Headache
No interference 
with activity
Repeated use of 
non-narcotic pain 
reliever> 24 
hours or some 
interference with 
activity
Significant; any 
use of narcotic 
pain reliever or 
prevents daily 
activity 
ER visit or 
hospitalization
Fatigue
No interference 
with activity
Some 
interference with 
activity
Significant; 
prevents daily 
activity 
ER visit or 
hospitalization
Abdominal pain
No interference 
with activity
Some 
interference with 
activity
Significant; 
prevents daily 
activity
ER visit or 
hospitalization

Hope Clinic Protocol Cholera 1
Version 11
 4 March 2025
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33
Lack of appetite
No interference 
with activity
Some 
interference with 
activity
Significant; 
prevents daily 
activity
ER visit or 
hospitalization