A Phase II Randomized, Placebo-Controlled, Multicenter Trial to Evaluate the Protective Function of CMV-MVA Triplex Vaccine in Adult Recipients of Haploidentical Hematopoietic Stem Cell Transplant
Phase: PHASE2
Conditions: Accelerated Phase Chronic Myelogenous Leukemia, BCR-ABL1 Positive, Acute Lymphoblastic Leukemia, Acute Myeloid Leukemia, Chronic Lymphocytic Leukemia, Chronic Phase Chronic Myelogenous Leukemia, BCR-ABL1 Positive, Hematopoietic and Lymphoid Cell Neoplasm, Hodgkin Lymphoma, Lymphoblastic Lymphoma, Myelodysplastic Syndrome, Myelofibrosis, Myeloproliferative Neoplasm, Non-Hodgkin Lymphoma
Sponsor: City of Hope Medical Center

IRB# 19065  
 
08/23/23 
Packet 14 
City of Hope  
TITLE: A PHASE II RANDOMIZED, PLACEBO-CONTROLLED, MULTICENTER TRIAL TO EVALUATE 
THE PROTECTIVE FUNCTION OF CMV-MVA TRIPLEX VACCINE IN ADULT RECIPIENTS OF 
HAPLOIDENTICAL HEMATOPOIETIC STEM CELL TRANSPLANT 
 
 
 
 
CITY OF HOPE PROTOCOL VERSION: #19065 
 
Protocol Date: 09/28/22 
IND: COH IND #15792 
 
 
DATE(S)/ OF AMENDMENT(S)/REVISION(S): 
COH Initial Approval  
               Protocol Dated       08/07/19 
                 
 
Version 00 
Amendment V01  
 
  Protocol/TP Dated 08/23/19 
 
 
 
Version 01 
Amendment V02  
 
  Protocol/TP Dated 12/02/19 
 
 
 
Version 02 
Amendment V03  
 
  Protocol/TP Dated 01/27/20 
 
 
 
Version 03 
Amendment V04  
 
  Protocol/TP Dated 07/15/20 
 
 
 
Version 04 
Amendment V05  
 
  Protocol/TP Dated 08/26/20 
 
 
 
Version 05 
Amendment 06 
 
 
  Protocol Dated 09/30/20 
 
 
 
Packet 06 
Amendment 07 At Continuation 
  Protocol Dated 09/30/20 (tp) 
 
 
 
Packet 07 
Amendment 08 
 
 
  Protocol Dated 01/11/22 
 
 
 
Packet 08 
Amendment 09 At Continuation 
  Protocol Dated 01/11/22 (tp) 
 
 
 
Packet 09 
Amendment 10   
 
  Protocol Dated 07/15/22 
 
 
 
Packet 10 
Amendment 11                                 Protocol Dated 08/25/22                                                 Packet 11 
Amendment 12                                 Protocol Dated 09/28/2022                                             Packet 12 
Amendment 13                                 Protocol Dated 08/23/2023                                             Packet 13 
Amendment 14                                 Protocol Dated 08/23/2023 (tp)                                       Packet 14 
 
 
DISEASE SITE:                                  Hematopoietic System 
 
TYPE (e.g., Pilot, Phase I, etc.): 
 
Phase II, Therapeutic 
 
 
PRINCIPAL INVESTIGATORS: 
 
 
 
 
 
Ryotaro Nakamura M.D. (Study and Coordinating PI) 
Department of Hematology and HCT,  
City of Hope National Medical Center 
1500 E. Duarte Road, Duarte, CA 
Phone: 626-256-4673 
Fax: 626-301-8116 
e-mail: RNakamura@coh.org 
 

IRB# 19065  
 
08/23/23 
Packet 14 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ibrahim Aldoss, M.D. (Site PI) 
Department of Hematology and HCT,  
City of Hope National Medical Center 
 
1500 E. Duarte Road, Duarte, CA 
Phone: 626-256-4673 
Fax: 626-301-8116 
e-mail: IAldoss@coh.org 
 
Lindsey Baden, M.D. (Site PI) 
Primary Address: Brigham and Women’s Hospital, Infectious Disease 
Division, 75 Francis Street, PBB-4th Floor 
Boston, MA 02115 
Phone: 617-632-60664 
 
Fax:  617-732-6829 
e-mail: LBADEN@PARTNERS.ORG 
Additional location where clinical investigation will be conducted: 
Dana-Farber Cancer Institute, 
Blood and Marrow Transplant Program 
450 Brookline Ave, Boston, MA 02115  
 
Scott Solomon, M.D. (Site PI) 
Blood and Marrow Transplantation Program 
Northside Hospital Cancer Institute 
5670 Peachtree Dunwoody Road, Atlanta, GA 30342 
Phone: (404) 255-1930 
Fax:  (404) 255-1939 
e-mail: ssolomon@bmtga.com 
 
 
COLLABORATING INVESTIGATORS: 
 
 
 
 
 
 
 
 
 
 
Don J. Diamond, Ph.D. 
Department of Hematology and HCT,  
City of Hope National Medical Center 
1500 E. Duarte Road, Duarte, CA 
Phone: 626-256-4673 
Fax: 626-301-8981 
e-mail: DDiamond@coh.org 
 
Corinna La Rosa, Ph.D. 
Department of Hematology and HCT,  
City of Hope National Medical Center 
1500 E. Duarte Road, Duarte, CA 
Phone: 626-256-4673 
Fax: 626-301-8981 
e-mail: Clarosa@coh.org 
 
Dongyun Yang, Ph.D. 
Department of Computational and Quantitative Medicine 
City of Hope National Medical Center 
1500 E. Duarte Road 
Duarte, CA 
Phone: 800-826-4673 ext 84891 

IRB# 19065  
 
08/23/23 
Packet 14 
e-mail: donyang@coh.org 
 
Monzr Al Malki, M.D. 
Department of Hematology and HCT,  
City of Hope National Medical Center 
1500 E. Duarte Road, Duarte, CA 
Phone: 626-256-4673 
e-mail: malmalki@coh.org 
 
 
PARTICIPATING CLINICIANS: 
 
Haris Ali, M.D., Ibrahim Aldoss, M.D., Idoroenyi Amanam, M.D., Shukaib 
Arslan, M.D., Andrew Artz, M.D., Brian Ball, M.D., Elizabeth Budde, M.D., 
Ji-Lian Cai, M.D.,, Len Farol, M.D., Stephen Forman, M.D., Alex Herrera, 
M.D., Myo Htut, M.D., Paul Koller, M.D., Amrita Krishnan, M.D., Joshua 
Mansour, M.D., Matthew Mei, M.D., Monzr Al Malki, M.D., Liana 
Nikolaenko, M.D., Leslie Popplewell, M.D., Vinod Pullarkat, M.D., 
Amandeep Salhotra, M.D., Karamjeet Sandhu, M.D., Tanya Siddiqi, M.D., 
Eileen Smith, M.D., Ricardo Spielberger, M.D., Anthony Stein, M.D., Sean 
(Shirong) Wang, M.D., Michael Rosenzweig, M.D, Ahmed Aribi, M.D, Nitya 
Nathwani, M.D., John Zaia, M.D., Jasmine Zain, M.D., Yazeed Samara, 
M.D., Nahid Rashid, M.D.,  
 
COLLABORATING BIOSTATISTICIAN: 
 
 
 
 
Joycelynne Palmer, Ph.D. 
Department of Computational and Quantitative Medicine 
City of Hope National Medical Center 
1500 E. Duarte Road 
Duarte, CA 
Phone: 626-256-4413 (Admin) 
Fax: 626-380-9388 
e-mail: jmpalmer@coh.org   
 
 
PARTICIPATING SITES: 
City of Hope, Duarte, CA (Lead Institution) 
The Dana-Farber Cancer Institute, MA (Participating Site)          
Northside Hospital Cancer Institute (Participating Site)          
 
COORDINATING CENTER: 
Data Coordinating Center 
City of Hope National Medical Center 
1500 E. Duarte Road 
Duarte, CA 
Phone: 626-256-4673 x 63968 
e-mail: DCC@coh.org 
 
AGENT NSC#              NSC#  745100    
 

 
Page 1 of 81 
IRB#19065               
 
 
VERSION DATE:  08/23/2023               
CITY OF HOPE NATIONAL MEDICAL CENTER 
1500 E. DUARTE ROAD, DUARTE, CA 91010 
DEPARTMENT OF HEMATOLOGY AND HCT 
TITLE:  A PHASE II RANDOMIZED, PLACEBO-CONTROLLED, MULTICENTER TRIAL TO EVALUATE THE 
PROTECTIVE FUNCTION OF CMV-MVA TRIPLEX VACCINE IN ADULT RECIPIENTS OF HAPLOIDENTICAL 
HEMATOPOIETIC STEM CELL TRANSPLANT  
 
CITY OF HOPE PROTOCOL NUMBER: 
19065 
 
SPONSOR/IND NUMBER: 
City of Hope / IND #15792 
 
PRINCIPAL INVESTIGATORS: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ryotaro Nakamura M.D. (Study and Coordinating PI) 
Department of Hematology and HCT,  
City of Hope National Medical Center 
1500 E. Duarte Road, Duarte, CA 
Phone: 626-256-4673 
Fax: 626-301-8116 
e-mail: RNakamura@coh.org 
 
Ibrahim Aldoss, M.D. (Site PI) 
Department of Hematology and HCT,  
City of Hope National Medical Center 
1500 E. Duarte Road, Duarte, CA 
Phone: 626-256-4673 
Fax: 626-301-8116 
e-mail: IAldoss@coh.org 
 
Lindsey Baden, M.D. (Site PI) 
Primary Address: Brigham and Women’s Hospital, Infectious Disease 
Division, 75 Francis Street, PBB-4th Floor 
Boston, MA 02115 
Phone: 617-632-60664 
Fax:  617-732-6829 
e-mail: LBADEN@PARTNERS.ORG 
Additional location where clinical investigation will be conducted: 
Dana-Farber Cancer Institute, 
Blood and Marrow Transplant Program 
450 Brookline Ave, Boston, MA 02115  
 
Scott Solomon, M.D. (Site PI) 
Blood and Marrow Transplantation Program 
Northside Hospital Cancer Institute 
5670 Peachtree Dunwoody Road, Atlanta, GA 30342 
Phone: (404) 255-1930 
Fax:  (404) 255-1939 
e-mail: ssolomon@bmtga.com 
 

 
Page 2 of 81 
IRB#19065               
 
 
VERSION DATE:  08/23/2023               
COLLABORATING INVESTIGATORS: 
 
 
 
 
 
 
 
 
 
 
Don J. Diamond, Ph.D. 
Department of Hematology and HCT,  
City of Hope National Medical Center 
1500 E. Duarte Road, Duarte, CA 
Phone: 626-256-4673 
Fax: 626-301-8981 
e-mail: DDiamond@coh.org 
 
Corinna La Rosa, Ph.D. 
Department of Hematology and HCT,  
City of Hope National Medical Center 
1500 E. Duarte Road, Duarte, CA 
Phone: 626-256-4673 
Fax: 626-301-8981 
e-mail: Clarosa@coh.org 
 
Dongyun Yang, Ph.D. 
Department of Computational and Quantitative Medicine 
City of Hope National Medical Center 
1500 E. Duarte Road 
Duarte, CA 
Phone: 800-826-4673 ext 84891 
e-mail: donyang@coh.org 
 
Monzr Al Malki, M.D. 
Department of Hematology and HCT,  
City of Hope National Medical Center 
1500 E. Duarte Road, Duarte, CA 
Phone: 626-256-4673 
e-mail: malmalki@coh.org 
 
COLLABORATING BIOSTATISTICIAN: 
 
 
Joycelynne Palmer, Ph.D. 
Department of Computational and Quantitative Medicine 
City of Hope National Medical Center 
1500 E. Duarte Road 
Duarte, CA 
Phone: 626-256-4413 (Admin) 
Fax: 626-380-9388 
e-mail: jmpalmer@coh.org   
 
PARTICIPATING SITES: 
City of Hope, Duarte, CA (Lead Institution) 
The Dana-Farber Cancer Institute, MA (Participating Site)          
Northside Hospital Cancer Institute (Participating Site)          
 
COORDINATING CENTER: 
Data Coordinating Center 
City of Hope National Medical Center 
1500 E. Duarte Road 
Duarte, CA 
Phone: 626-256-4673 x 63968 
e-mail: DCC@coh.org 
 
AGENT NSC#              NSC#  745100  
 
 

 
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IRB#19065               
 
 
VERSION DATE:  08/23/2023               
EXPERIMENTAL DESIGN SCHEMA 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Days 70-93 post-HCT Randomization 
(Randomization Stratified by: Donor CMV Serostatus and Center) 
Research blood sample 
CMV Triplex Arm  N=64 
Placebo Arm   
N=64 
Day 100 
Research blood sample + SOC assessments 
Review of vaccine administration criteria 
Vaccine Administration 
Day 140 
Research blood sample + SOC 
CMV Positive Adults with Hematologic Malignancy undergoing haploidentical hematopoietic stem cell transplant (HCT) 
Day 180 
Research blood sample + SOC 
Day 210-240 
Research blood sample + SOC 
Routine clinic visits, 
monitoring and 
assessments per SOC 
(1-2x/week) 
-  Engraftment 
-  Physical Exam 
-  Clinical labs 
-  CMV-PCR 
-  CMV disease 
- Disease relapse 
- Acute/chronic GVHD 
-  Adverse events 
Day 114 
Research blood sample + SOC 
Day 128 
Research blood sample + SOC assessments 
Review of vaccine administration criteria 
Vaccine Administration 
Enrollment: 
- 
d0-60 pre-HCT 
 
Randomization 
- 
Allocation communicated to 
pharmacy ~d70-93 post HCT.  
d7-d100 
- 
Prevymis administration per COH 
SOC 
d100 Evaluation for Vaccination  
- 
Participants who do not meet the 
d100 vaccine criteria are taken 
off study and replaced: 
- 
Primary engraftment without 
secondary graft failure 
- 
Absence of CMV disease and 
CMV viremia (qPCR ≤ 500 gc/ml) 
- 
Disease has not relapsed 
- 
No ongoing ≥ Grade 3 AEs 
- 
Prednisone or equivalent must be 
<1 mg/kg/day for 7 days 
- 
Only participants who receive a 
Day 100 vaccine are considered 
“randomized”. 
Vaccine Administration 
- 
Vaccine must be administered 
within 4 hours of preparation 
start time. 
- 
 1 ml or 0.55 ml  IM injection to 
upper arm. 
Disease Relapse 
- 
Participants who experience 
disease relapse are followed for 
survival only through d365. 
Clinical Care During Trial  
- 
Clinical care will be per SOC 
except: 
- 
Vaccines are prohibited to d142 
Post-HCT 
- 
Prophylactic use of CMV IgG 
prohibited 
- 
In vivo T-cell depleting agents 
are prohibited 
- 
Prednisone or equivalent must be 
<1 or 1.5 mg/kg/day for 7 days 
prior to d100 and d128 to meet 
vaccine administration criteria 
Days 100 to 200 post-HCT 
Prevymis 
Prophylaxis 
Days 7 to 100 post-HCT 
Day 270 
Research blood sample + SOC 
Day 365 
Research blood sample + SOC 
Up to 365 Days post-HCT 
Days 0-60 pre-HCT Enrollment
Day 42 post-HCT Research blood sample + SOC 
 Day 56 post-HCT Research blood sample + SOC 
Day 0 HCT 

 
Page 4 of 81 
IRB#19065               
 
 
VERSION DATE:  08/23/2023               
PROTOCOL SYNOPSIS 
Protocol Title: 
A Phase II randomized, placebo-controlled, multicenter trial to evaluate the protective function of 
CMV-MVA Triplex vaccine in adult recipients of haploidentical hematopoietic stem cell transplant 
Brief Protocol Title for the Lay Public (if applicable): 
Triplex, a new vaccine designed to prevent cytomegalovirus infection after haploidentical stem cell 
transplantation 
Sponsor, IND 
COH under IND# 15792 
Study Phase: 
Phase II, Randomized, Blinded, Interventional 
Participating Site: 
City of Hope National Medical Center, Northside Cancer Center and Dana-Farber Cancer Institute 
Rationale for this Study: 
Cytomegalovirus (CMV) is associated with a number of clinical syndromes [1]. Since the inception of 
hematopoietic cell transplant (HCT) as a cure for hematologic malignancies, one of the main infectious 
complications during the first 100 days post-transplant is viremia caused by CMV [2-7]. HCT patients 
are vulnerable to herpes-virus infections, including CMV, as a result of immunosuppression associated 
with treatment strategies aimed at preventing graft rejection or graft versus host disease (GVHD) [8-
10].  While anti-viral agents that limit viral replication can initially control CMV viremia, they are 
associated with significant toxicity and fail to protect against late-onset CMV disease, including 
reactivation and failure to reconstitute CMV-specific immunity.  Complementing antiviral prophylaxis 
with a vaccine that harnesses the abundant native immune response to CMV may improve outcomes 
for HCT recipients [11]. 
CMV-MVA (Triplex) is a multiple-antigen recombinant Modified Vaccinia Ankara (MVA) with genes 
encoding 3 immunodominant CMV proteins: UL83 (pp65), UL123 (IE1), and UL122 (IE2). MVA is  
attractive as a therapeutic agent due to its safety record as a smallpox vaccine, including in the  young 
and elderly [12]. Recently published data from a randomized, placebo-controlled, double-blind study 
has shown that MVA was safe, well tolerated and immunogenic when used as an immunogen in HCT 
recipients [13]. Additionally, previous results strongly support its use as a vector for delivering 
infectious disease antigens, since MVA vaccination safely induced robust cellular immune responses in 
HCT recipients [13].  
These facts motivated the development of an MVA vaccine candidate incorporating immunogenic 
targets of human CMV.  No current vaccine strategy against CMV developed for HCT recipients uses a 
recombinant vector incorporating multiple cellular response antigens.  The  Triplex vaccine is 
manufactured at City of Hope (COH) Center for Biomedicine and Genetics (CBG), and has been tested 
in a phase I dose escalation study in healthy volunteers. The vaccine was administered twice in a 28-
day period and shown marked safety in healthy adults vaccinated with up to 5x108 pfu/mL. Additionally,  
Triplex induced robust expansion of CMV-pp65, IE1 and IE2 CD8 and CD4 T cells in the healthy 
volunteers. There were no serious adverse events (SAE) or dose limiting toxicity (DLT). Following this, 

 
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IRB#19065               
 
 
VERSION DATE:  08/23/2023               
a Phase II study to assess safety and efficacy of  Triplex to protect against CMV reactivation and disease 
in allo-HCT patients was initiated. In the study vaccine arm also demonstrated significant increase in 
concentration of pp65-specific immune cells comparing to placebo, and maintained excellent 
tolerability with no significant difference in Grade >3 AEs between vaccine and placebo arms. The study 
also met the primary endpoint by showing clinically significant reduction in CMV events prior to d100 
post-HCT.  
 
The target of this new multi-center study is 128 evaluable patients (n=64 in each arm).  
 
Anti-viral agent Prevymis was recently approved for CMV prophylaxis, however there is a significant 
risk of CMV reactivation that occurs after the completion of Prevymis administration [14]. This unmet 
need motivated the development of the protocol for the study to include a combination of Prevymis 
followed by Triplex vaccination. Complementing antiviral administration with a vaccine that harnesses 
the abundant native immune response to CMV may improve outcomes for HCT recipients [11]. In 
addition, this approach may protect against early reactivation in haplo HCT-R that was observed in the 
absence of Prevymis prophylaxis. 
 
HaploHCT-donor (D) as a source of peripheral blood stem cells (PBSC) is the best option for finding a 
suitable donor when no conventional MR (matched related) or MU (matched unrelated) donor can be 
identified [15-18]. The incidence of CMV reactivation is far higher in haploHCT than in MRD or MUD 
HCT [19-23]. Consequently, these patients could benefit a from a vaccine preventing CMV infectious 
complications, especially after 18 weeks, when it has been shown that Prevymis prophylaxis declines 
in effectiveness [14].  
 
Objectives: 
The study will evaluate the Triplex vaccine in CMV+ adult patients undergoing haploHCT for 
hematological malignancy. This follows studies of the Triplex vaccine in lower risk MRD and MUD HCT 
where we have established tolerability (Trial NCT02506933). 
 
Primary Objectives:  
• To determine if CMV-MVA Triplex reduces the frequency of clinically significant CMV reactivation in 
CMV+ haploHCT adult recipients from when Prevymis prophylaxis is stopped at d100 until d180 post 
HCT.  A clinically significant CMV reactivation encompasses use of antiviral treatment for CMV, or CMV 
disease by tissue histology (end-organ disease). 
 
Secondary Objectives:  
• To evaluate the safety and tolerability of Triplex up to d365 post-HCT in vaccinated HCT recipients 
by assessing the following:  non-relapse mortality (NRM) at 180 days post-HCT, severe (grade 3-4) acute 
GVHD (aGVHD), and grade 3-4 AEs (CTCAE 5.0) probably or definitely related to the vaccination within 
2 weeks from each vaccination at d180 post-HCT. 
• 
To characterize CMV related events in recipients of Triplex compared to placebo up to d365 by 
assessing: time-to viremia (defined as number of days from d100 to the date of ≥625 IU/mL), duration 
of viremia, recurrence of viremia, incidence of late CMV viremia/disease (≥625 IU/mL >200 and ≤ 365 
days post HCT), use of antiviral drugs other than Prevymis (triggered by clinically significant viremia), 
cumulative number of CMV specific antiviral treatment days. 

 
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• 
To evaluate the impact of  Triplex  on transplant related outcomes up to d365 post-HCT by 
assessing the incidence of acute GVHD (aGVHD), chronic GVHD (cGVHD), relapse, non-relapse 
mortality, all-cause mortality, infections.  
• 
To determine 1) if Triplex increases levels, function and kinetics of CMV-specific T cell immunity 
in vaccinated compared to placebo treated, CMV seropositive HCT-recipients up to d365 post-HCT, 2) 
whether vaccination induces adaptive NK cell population changes, and increase in the highly cytotoxic 
memory NKG2C+ NK cells up to d365 post-HCT, and 3) to compare GVHD biomarkers between the 
vaccine and placebo groups up to d365 post-HCT. 
• 
To determine if immunity to 3 CMV antigens contained in the Triplex vaccine correlates with 
protection against CMV events, and if T-cell increases reflect vaccine response and exceed placebo 
immune response levels up to d365 post-HCT.  
 
Study Design: 
Overall design: This is a multisite (COH, DFCI, Northside), randomized, blinded, placebo-controlled, 
Phase II trial in CMV positive, adult haploHCT recipients. The study will evaluate: a) safety and reduction 
in the frequency of CMV reactivation after the end of a SOC treatment with Prevymis and b) increase 
in CMV cellular immunity in patients vaccinated with Triplex. This trial is designed to randomly 
allocate 151 (assuming 15% dropout rate) participants 1:1 to the Triplex or placebo arm. Both arms will 
be administered Prevymis from day ≤7 to day 100 post-HCT according to COH SOC. The accrual target 
is 64 evaluable patients for each arm. 
Enrollment and randomization:  
The trial is a double-blind randomized comparison of Triplex to placebo, powered to detect a clinically 
significant protective effect of vaccination on CMV reactivation, antiviral treatment and disease (CMV 
events) from d100 until d180 post-HCT. Patients will be enrolled d0-60 pre-HCT. Each adult haploHCT-
R will be randomized to vaccine or placebo arm, stratified by donor CMV status and participating site. 
All eligible participants will receive vaccine dose or placebo on d100 post-HCT, with an identical second 
dose at d128 post-HCT. The design permits a direct comparison of placebo and vaccine with regard to 
the primary endpoint.  
Administration of Triplex /placebo:  Triplex vaccine or placebo is administered intramuscularly (IM) on 
d100 and d128 post-HCT.  
Duration of participation: Study participation will be completed on d365 Post-HCT for all participants 
who receive a study-agent injection. Participants who do not receive an injection will discontinue any 
further follow-up once the determination is made that the vaccine will not be administered.  
Stopping rules:  One interim analysis with non-binding conclusion will be planned. Formal stopping 
rules for safety will be implemented, two major safety endpoints; non-relapse mortality (NRM) at d180 
post-HCT, severe GVHD (grade 3-4 aGVHD, cGVHD requiring systemic therapy, secondary graft failure), 
and Serious AEs (SAE, grade 3-4) related to the vaccination within 2 weeks from each vaccination will 
be monitored, but based on assessment of individual cases. This study will have an external 
independent DMC for review of protocol events and progress, with reporting of recommendations to 
COH IRB. 
Endpoints: 
The primary aims of this trial are to estimate the efficacy of Triplex in reducing the frequency of CMV 
reactivation after stopping Prevymis prophylaxis, and to further evaluate the safety and tolerability of 
Triplex vaccine in HCT recipients. Secondary endpoints will include additional safety, clinical and 
immunological parameters. 

 
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Primary endpoint:  
1. Clinically significant CMV reactivation prompting antiviral therapy, or CMV disease (defined by 
histology) from d100 to d180 post-HCT. 
Secondary endpoints:  
1) Key safety endpoints: non-relapse mortality (NRM) at d365 post-HCT, severe (grade 3-4) acute 
GVHD, and grade 3-4 AEs probably/definitely related to the vaccination and MVA vector 
persistence. 
2) CMV-related events:  duration of viremia, duration of anti-CMV therapy, peak CMV PCR value, 
recurrence of CMV viremia, and incidence of late CMV reactivation or disease up to d365 post-
HCT.  
3) Transplant-related events: time to engraftment, incidence of aGVHD, chronic GVHD (cGVHD), 
relapse, non-relapse mortality, all-cause mortality, infections and overall survival up to d365 
post-HCT.   
4) Immunological function:  levels and kinetics of CMV-specific T cell immunity, combined with 
immunophenotyping, and functional studies, NK phenotype and function (cytotoxicity and 
cytokine production) up to d365 post-HCT. 
Sample Size: 
The target is 128 randomized, evaluable subjects.  
Projected enrollment: 151 enrolled patients should provide at least 64 per arm that are evaluable at 
d180. This is achievable in 10 years of accrual at the three sites. 
Estimated Duration of the Study 
10 years 
Summary of Subject Eligibility Criteria: 
Pre-HCT Inclusion Criteria 
• 
Age 18 years and over  
• 
Planned HCT for the treatment of hematologic malignancy (some exceptions including multiple 
myeloma) 
• 
Planned related HCT with molecular 3/6 HLA donor allele matching (haploidentical) 
• 
CMV seropositive (recipient)  
• 
Seronegative for HIV, HCV and active HBV 
Pre-HCT Exclusion Criteria 
• Patients undergoing a second haploHCT are not eligible (patients who have undergone a 
previous autologous HCT are eligible) 
• 
Prior investigational CMV vaccine, experimental anti-CMV chemotherapy in the last 6 months 
• 
Planned use of the following after HCT: Live attenuated vaccines, medically indicated subunit 
or killed vaccines, alemtuzumab or any equivalent in vivo T cell depleting agent, medications 
with known activity against CMV, CMV immunoglobulin  
• 
Aplastic anemia 

 
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• 
Patients with active autoimmune conditions requiring systemic immunosuppressive therapy 
within the previous 5 years  
• 
Women who are pregnant or breast feeding 
Investigational Product Dosage and Administration: 
Participants will be randomized to receive either the Triplex vaccine or the placebo.  The pharmacy will 
know the randomization status of participants, while the clinical study team and participants will 
remain blinded to the randomization status. 
Approximately 5 x 108 pfu of Triplex Vaccine (or an equivalent volume of placebo) will be administered 
intramuscularly in the upper arm on d100 and d128 post-HCT.  There are no dose modifications, 
although participants must meet vaccine administration criteria in order to receive the vaccine. 
Triplex vaccine is constituted of 5.1 or 9.1 x108 pfu/mL in PBS containing 7.5% lactose.   
Placebo comprises an isotonic solution of PBS containing 7.5% lactose.   
Prevymis will be administered per COH SOC guidelines. 
Clinical Observations and Tests to be Performed: 
Clinical observations/clinical tests: medical history, physical exams, performance status, routine 
laboratory tests (CBC, chemistry panel), CMV qPCR, GVHD assessment, AE assessment, diagnostics for 
disease relapse assessment (bone marrow and imaging studies), diagnostics for CMV disease 
assessment,  according to institutional standard of care. Clinical CMV disease and use of anti-viral drugs 
will be prospectively monitored and recorded. 
Immunologic studies:  Immunologic studies will include monitoring levels, function and kinetics of 
CMV-specific T cell immunity, combined with immunophenotyping studies.  The phenotypic ratios of 
CMV-specific T cells will be related to improvement in controlling CMV viremia. Characterization of 
highly cytotoxic memory NKG2C+ NK cells, linked to CMV reactivation and critical for CMV adaptive 
immune response will be performed.   
Statistical Considerations: 
At COH, CMV reactivation is found in ~76% of CMV+ haploHCT recipients by day 100 post-HCT (ASH 
abstract 2017 95% CI: 67-84%). At Northside hospital, of 127 consecutive CMV+ haploHCT recipients 
who had not reactivated by day 28, 60% reactivated by d100 (unpublished). In Marty et al study among 
102 high risk patients in Prevymis arm, 21 had clinically significant CMV infection at d100+, and 43 had 
clinically significant CMV infection through d168 post-HCT. CMV reactivation developed in 22 patients 
from d100+ to d168 among 81 patients who were event-free on d100+ (22/81=0.27). This trial will have 
80% power at a one-sided 0.05 significance to detect reduction of CMV-reactivation from a 
conservatively assumed rate of 27% in Prevymis + placebo arm to 10% in Prevymis + vaccine arm at 
d180, attainable based on similar effect size in TransVax™ Phase 2 trial [24].  
Analysis of CMV events: The primary statistical analyses will compare vaccine and placebo regarding 
subhazards of CMV events from d100 vaccine injection to d180. Events prior to injection will inform 
Kaplan-Meier estimates for both arms to obtain unbiased estimates of reactivation rates applicable to 
all transplanted subjects on each arm. 
Non Relapse Mortality (NRM): NRM will be monitored as every 20th subject on the vaccine arm reaches 
the d100 evaluation point, i.e. d180 of follow-up or death. Stopping rules are specified in Table 4, which 
gives the maximum tolerated d180 NRM at each monitoring point. If NRM frequencies exceed these, 
then the trial will be suspended for safety review.  
 

 
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Severe GVHD/secondary graft failure: GVHD/secondary graft failure will be monitored as every 20th 
subject on the vaccine arm reaches the d100 evaluation point. The study will be interrupted for safety 
review by the external DMC if 6 or more of the first 15 recipients experience Grade 3-4 aGVHD. This 
would be a significant elevation from the expected maximum rate of 15% based on COH historical 
benchmark of 13.7% of haploHCT-R (M. Al-Malki et al, ASH 2017 Abstract). 
 
Event-Free Survival (EFS) will be defined as the time from HCT to severe aGVHD, relapse, or death. EFS 
will be analyzed at the end of the study to produce a 90% 1-sided confidence limit on the hazard ratio. 
The EFS analysis thus provides due diligence in checking for a substantial adverse impact. 
 
 
 

 
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TABLE OF CONTENTS 
SECTION 
 ................................................................................................................................      PAGE 
Experimental Design Schema ......................................................................................................................... 3 
Protocol Synopsis 4 
Table of Contents 10 
List of Tables 
12 
List of Figures 
12 
1.0 
Goals and Objectives (Scientific Aims) ........................................................................................... 15 
2.0 
Background..................................................................................................................................... 16 
2.1 
Introduction/Rationale for Development ........................................................................ 16 
2.2 
Pre-Clinical and Clinical Evaluation of Triplex .................................................................. 20 
2.3 
Triplex Vaccination in Allo-HCT ........................................................................................ 23 
2.4 
Triplex in HaploHCT .......................................................................................................... 24 
2.5 
HaploHCT Study Overview ............................................................................................... 25 
3.0 
Participant Eligibility Criteria .......................................................................................................... 26 
3.1 
Pre-HCT Inclusion Criteria ................................................................................................ 26 
3.2 
Pre-HCT Exclusion Criteria ................................................................................................ 28 
3.3 
Participation of Special Populations ................................................................................ 29 
4.0 
Participant Enrollment and Randomization ................................................................................... 30 
4.1 
Pre-Enrollment Informed Consent and Screening Procedures ........................................ 30 
4.2 
Participant registration .................................................................................................... 30 
4.3 
Randomization ................................................................................................................. 31 
4.4 
Emergency Unblinding Procedures .................................................................................. 31 
5.0 
Treatment Program ........................................................................................................................ 32 
5.1 
Treatment Overview ........................................................................................................ 32 
5.2 
Maintaining a blinded randomization .............................................................................. 32 
5.3 
Assessments ..................................................................................................................... 33 
5.4 
Criteria for Completing/Discontinuing Study Participation ............................................. 35 
5.5 
Follow-Up and Duration of Participation ......................................................................... 35 
5.6 
Supportive Care, Other Concomitant Therapy, Prohibited Medications ......................... 36 
6.0 
Vaccine Administration Criteria ..................................................................................................... 38 
6.1 
D100 Post-HCT Vaccine Administration Criteria .............................................................. 38 
6.2 
D128 post-HCT Vaccine Administration Criteria .............................................................. 38 
7.0 
Data and safety monitoring ............................................................................................................ 39 
7.1 
Monitoring and Personnel Responsible (PMT) ................................................................ 39 
7.2 
AE and UP Definitions ...................................................................................................... 39 
7.3 
Routine Reporting of Non-Serious Adverse Events by Site Investigators ........................ 41 
7.4 
Expedited Reporting of SAEs and Unanticipated Problems (UPs) by Site Investigators to the COH 
Regulatory Committees ................................................................................................... 41 
7.5 
Independent Data Monitoring Committee (DMC) ........................................................... 42 
7.6 
Toxicities of Triplex .......................................................................................................... 43 
7.7 
Toxicities to the placebo .................................................................................................. 43 

 
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7.8 
Risks from Vaccinations and Blood Draws ....................................................................... 43 
8.0 
Agent Information .......................................................................................................................... 44 
8.1 
Triplex and placebo –information applicable to vaccine components ............................ 44 
8.2 
Triplex .............................................................................................................................. 45 
8.3 
PBS containing 7.5% lactose solution for the placebo ..................................................... 46 
8.4 
Preparation of Triplex injection ....................................................................................... 46 
8.5 
Preparation of placebo injection ...................................................................................... 47 
9.0 
Correlative/Special Studies ............................................................................................................ 48 
9.1 
Immunogenicity testing ................................................................................................... 48 
9.2 
MVA vector persistence ................................................................................................... 49 
10.0 
Study Calendar ............................................................................................................................... 50 
11.0 
Endpoint Evaluation Criteria/Measurement of Effect .................................................................... 53 
12.0 
Statistical Considerations ............................................................................................................... 54 
12.1 
Study Design..................................................................................................................... 54 
12.2 
Randomization ................................................................................................................. 54 
12.3 
Sample Size Accrual Rate ................................................................................................. 54 
12.4 
Data Analysis Plan ............................................................................................................ 55 
12.5 
Safety Monitoring ............................................................................................................ 55 
12.6 
Interim analyses ............................................................................................................... 56 
13.0 
Data Handling, Data Management, Record Keeping ...................................................................... 57 
13.1 
Source Documents ........................................................................................................... 57 
13.2 
Data Capture Methods and Management ....................................................................... 57 
13.3 
Case Report Forms/Data Submission Schedule ............................................................... 58 
13.4 
Regulatory Records .......................................................................................................... 59 
14.0 
Adherence to the Protocol ............................................................................................................. 59 
15.0 
Study Oversight, Quality Assurance, and Data & Safety Monitoring ............................................. 60 
15.1 
Site Principal Investigator ................................................................................................ 60 
15.2 
Study Principal Investigator ............................................................................................. 60 
15.3 
Protocol Management Team (PMT) ................................................................................. 60 
15.4 
Monitoring ....................................................................................................................... 61 
15.5 
Quality Assurance ............................................................................................................ 61 
15.6 
Risk Determination .......................................................................................................... 61 
15.7 
City of Hope Data and Safety Monitoring Committee ..................................................... 61 
16.0 
Ethical and Regulatory Considerations ........................................................................................... 62 
16.1 
Ethical Standard ............................................................................................................... 62 
16.2 
Regulatory Compliance .................................................................................................... 62 
16.3 
Institutional Review Board ............................................................................................... 62 
16.4 
Informed Consent ............................................................................................................ 62 
16.5 
Women, Minorities, Children, HIV-Positive Individuals (Special Populations) ................ 63 
16.6 
Participant Confidentiality ............................................................................................... 64 
16.7 
Conflict of Interest ........................................................................................................... 65 
16.8 
Financial Obligations, Compensation, and Reimbursement of Participants .................... 65 
16.9 
Publication/Data Sharing ................................................................................................. 65 
17.0 
References ...................................................................................................................................... 67 

 
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Appendix A: Acute GVHD Staging ................................................................................................................. 76 
Appendix B: Chronic GVHD GradinG ............................................................................................................. 77 
Appendix C: Karnofsky Performance Scale ................................................................................................... 78 
Appendix D: Reagents, Equipment and Supplies Necessary for Vaccine Preparation .................................. 79 
Appendix E: SAE/UP Reporting Coversheet .................................................................................................. 80 
Appendix F: Registration Coversheet ........................................................................................................... 81 
 
LIST OF TABLES 
Table 1. AEs  in healthy adults trial (Phase Ib trial, Protocol 08173) .......................................................... 21 
Table 2. Grade 3-4 attributable adverse events observed in IRB 14295 (NCT02506933) .......................... 43 
Table 3. Study Activity Calendar ................................................................................................................. 50 
Table 4.  Stopping rules for mortality and severe GVHD/secondary graft failure ...................................... 56 
Table 5. Interim non-binding stopping rule ................................................................................................ 57 
Table 6. Operating characteristics of the design ........................................................................................ 57 
Table 7. Data Submission Schedule ............................................................................................................ 58 
LIST OF FIGURES 
Figure 1. Construction of  Triplex vaccine 
19 
Figure 2. Schema for Phase II Triplex study IRB 14295 (NCT02506933) 
23 
Figure 3. Reactivation data from Phase II Triplex trial IRB 14295 (NCT02506933) 
24 
 
 
 
 
 

 
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ABBREVIATIONS 
Abbreviation 
Meaning 
AE 
Adverse Event 
aGVHD 
BDP 
CBC 
cGVHD 
Acute Graft Versus Host Disease 
Biopharmaceutical Development Program NCI-Frederick, MD 
Complete Blood Count 
Chronic Graft Versus Host Disease 
cGMP 
Current Good Manufacturing Practice  
CLIA 
Clinical Laboratory Improvement Amendments 
CMV 
Cytomegalovirus 
COH 
City of Hope 
CRA 
Clinical Research Associate 
CRF 
Case Report Form 
CTCAE 
Common Terminology Criteria for Adverse Events 
CTEP 
Cancer Therapy Evaluation Program 
CTL 
Cytotoxic T lymphocytes  
DET 
DFCI 
DMC 
Department of Experimental Therapeutics 
Dana-Farber Cancer Institute 
Data Monitoring Committee 
ECG 
FDA 
FC 
Electrocardiogram 
Food and Drug Administration  
Flow Cytometry 
FOS 
Foscarnet 
GCP 
Good Clinical Practice 
GCV 
Ganciclovir 
GVHD  
Graft versus host disease  
LCL 
haploHCT 
HBV 
Human B-lymphoblastoid cell lines  
Haplo identical Hematopoietic Stem Cell Transplant 
Hepatitis B virus 
HCT 
Hematopoietic Stem Cell Transplant 
HCT-R+ 
CMV positive HCT recipients 
HCV 
Hepatitis C virus 
HHV6 
Human herpes virus 6 
HIV 
Human immunodeficiency virus 
HPV 
Human papilloma virus 
HSV 
Herpes simplex virus 
HVTN/DAIDS 
HIV Vaccine Trials Network/Division of AIDS 
ICS 
ID50 
IDS 
IFN 
ICF 
Intra cellular staining 
Median Infective Dose 
Investigational Drug Service 
Interferon 
Informed Consent Form 
IM  
Intramuscular  
IND 
Investigational New Drug  
IRB 
Institutional Review Board 
IV  
Intravenous  
IVS 
MRD 
MUD 
In vitro stimulation 
Matched related donor 
Matched unrelated donor 
NRM 
Non-relapse mortality 
OIDRA 
PBMC 
Office of IND Development and Regulatory Affairs 
Peripheral Blood Mononuclear Cells  
PBS 
PD-1 
Phosphate Buffered Saline 
Program death receptor-1 

 
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pfu 
PI 
R+ 
Plaque forming unit 
Principal Investigator 
CMV positive HCT recipients 
PMT 
Protocol Monitoring Team 
SAE 
Serious Adverse Event 
SAIC 
Science Applications International Corporation  
SOC 
Standard Of Care 
Triplex  
 
VAL 
Cytomegalovirus-Modified 
Vaccinia 
Ankara 
(CMV-MVA) 
encoding 
3 
immunodominant CMV proteins 
Valganciclovir 
 
 
 

 
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1.0 
GOALS AND OBJECTIVES (SCIENTIFIC AIMS) 
Primary Objectives:  
• 
To determine if CMV-MVA Triplex reduces the frequency of clinically significant CMV reactivation 
in CMV+ haploHCT adult recipients from when Prevymis prophylaxis is stopped at d100 until d180 post 
HCT.  A clinically significant CMV reactivation encompasses use of antiviral treatment for CMV, or CMV 
disease by tissue histology (end-organ disease). 
Secondary Objectives:  
• 
To evaluate the safety and tolerability of Triplex in vaccinated, haploHCT recipients by assessing 
the following:  non-relapse mortality (NRM) at d180 post-HCT, severe (grade 3-4) acute GVHD, and grade 
3-4 AEs (CTCAE 5.0) probably or definitely related to the vaccination within 2 weeks from each vaccination 
at d180 post-HCT. 
• 
To characterize CMV related events in recipients of Triplex compared to placebo, by assessing 
time-to viremia (number of days from d100 to the date of ≥625 IU/mL), duration of viremia, recurrence 
of viremia, incidence of late CMV viremia/disease (≥625 IU/mL, >200 and ≤ 365 days post-HCT), use of 
antiviral drugs (triggered by clinically significant viremia), cumulative number of CMV specific antiviral 
treatment days. 
• 
To evaluate the impact of Triplex on transplant related outcomes up to d365 post-HCT by 
assessing the incidence of acute GVHD (aGVHD), chronic GVHD (cGVHD), relapse, non-relapse mortality, 
all-cause mortality, infections.  
• 
To determine 1) if Triplex increases levels, function and kinetics of CMV-specific T cell immunity 
in vaccinated compared to placebo treated, CMV seropositive HCT-recipients, 2) whether vaccination 
induces adaptive NK cell population changes, and increase in the highly cytotoxic memory NKG2C+ NK 
cells, and 3) to compare GVHD biomarkers between the vaccine and placebo groups up to d365 post-HCT. 
• 
To determine if immunity to 3 CMV antigens contained in the Triplex vaccine correlates with 
protection against CMV events, and if T-cell increases reflect vaccine response and exceed placebo 
immune response levels up to d365 post-HCT.  

 
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2.0 
BACKGROUND 
2.1 Introduction/Rationale for Development 
Human CMV is a double-stranded DNA β-herpes virus which is highly prevalent globally, but rarely elicits 
disease in healthy immunocompetent hosts. The human immune system is unable to clear CMV infection 
and latency, but mounts a robust response targeting multiple immune-evasion genes. CMV is among the 
largest and most complex of known viruses, with a genome encoding around 165 genes [25]. The 
magnitude of the CMV-specific cellular immune response is the most striking aspect of the dynamic, life-
long interaction between the host and CMV. CMV-specific T cells are essential to control CMV viral 
replication and prevent disease, though do not eliminate the virus or preclude transmission. 
Significant suppression of host antiviral immunity can alter the life-or-death immune surveillance 
homeostasis, allowing CMV reactivation to become detectable or primary infection to cause clinical 
symptoms. Uncontrolled viral replication and dissemination results in the development of life-threatening 
end-organ damage (CMV disease) [26-28]. CMV infection is the cause of major complications and 
significant morbidity in the recovery of immune-compromised recipients both at early and late times post-
HCT [4, 6, 7]. HCT patients are vulnerable to herpes virus infections, including CMV, as a result of 
immunosuppression associated with treatment aimed at preventing rejection or GVHD [29-31].  
Pharmacologic agents used to limit virus replication, such as, GCV or its oral form VAL, and foscarnet (FOS) 
are the methods of choice for prophylaxis CMV infection [4, 32]. Despite this, CMV remains an important 
cause of mortality after HCT diminishing the full curative potential of this successful cancer therapy [33, 
34]. Furthermore, anti-viral chemotherapy has major side effects, including nephrotoxicity, neutropenia, 
and delayed immune reconstitution which exposes HCT recipients to other opportunistic viral, bacterial 
and fungal infections [7, 35]. For example, the use of GCV/VAL is associated with a higher proportion of 
recipients becoming neutropenic and increased numbers of concomitant fatal infections [7, 35]. As 
GCV/VAL therapy has become ubiquitous in practice, delayed onset of CMV-pneumonia (interstitial 
pneumonitis, IP) is more frequent which suggests that GCV/VAL impairs immunologic reconstitution [36, 
37]. When antivirals are stopped or when virus resistance occurs, the same disease symptoms appear; 
only frame shifted to ~d180 post-HCT [6, 38-40]. Thus, new strategies to control CMV are required. 
Antivirals have limitations, and their use does not address the risks of late-onset CMV disease including 
early CMV reactivation and failure to reconstitute CMV-specific immunity [33].  Complementing 
prophylaxis using antivirals with a vaccine that harnesses the abundant native immune response to CMV 
may improve outcomes for HCT recipients. In particular, a CMV vaccine that confers protective immunity 
early post-transplant, until normal immunocompetence is re-established in the HCT recipient (6 months 
or earlier post-HCT) may reduce CMV morbidity and the use of antivirals[11].  
Cellular immune response to CMV in healthy adults: After primary infection, CMV persists under control 
of cell-mediated immune (CMI) surveillance [41-44]. Using whole genome overlapping peptide libraries, 
the targets of the healthy human T cell response to CMV were identified [25, 45]. These studies show that 
the main target for HLA Class 1-restricted T cells is the tegument protein UL83, referred to as pp65 [46-
48]. However, immediate early proteins UL123 (IE1) and UL122 (IE2) also are prominent targets for CD8 
T cell responses in healthy individuals and patients [25, 49-52]. These 3 targets have a profile that is 
consistent with protective immunity documented in HCT and SOT recipients [34, 53-55]. Phase 1 and 2 
studies showed that pp65-ALVACTM stimulated primary immunity among CMV-negatives to levels 
approaching naturally CMV-positive individuals [56].  Similarly, AlphaVaxTM confirmed that property for 
pp65 and IE1 [57], and TransVaxTM DNA vaccine to a lesser extent [58]. These results provide a rationale 
for our choice of CMV pp65, IE1 and IE2 antigens to be incorporated into the vaccine. 
CMV immune response in HCT Recipients: CMV interferes with proper immune function [58-65], thus 

 
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altering the host immune response to CMV. Subunit Ag vaccination strategies are the best option to 
overcome CMV-mediated immunosuppression by limiting viremia, an independent predictor of disease 
[66]. Several reports have associated protection from CMV disease in HCT recipients with CMV-specific 
CD8+ T cell levels between 7-10/µL [59, 61, 67]. IE1-specific T cells were found to protect against CMV 
disease in SOT patients demonstrating the need for both types of T cells for efficient protection [54, 55]. 
COH studies demonstrated that the CD8+ T cell expansions can occur prior to d40 post-HCT, and in some 
cases, these T cells have been traced as clonal expansions derived from the donor [62]. Early clinical 
studies show that CD8+ cytotoxic T lymphocyte (CTL) development is necessary to protect from CMV-IP in 
HCT recipients [3, 11, 68]. In patients who have measurable CMV viremia, expansion of CD8+ T cells occurs, 
especially after viral reactivation [61, 63]. In addition, CMV disease occurred only in patients with low level 
CMV-tetramer+ CD8+ T cells [34, 60, 64]. Immunologic monitoring showed the benefit of CMV-positive 
donors even in the case of CMV-negative HCT recipients for long term CMV immune reconstitution [59, 
65]. Cellular immunity in HCT recipients is augmented during CMV reactivation as shown by increased 
levels of functional CMV-specific CD8+ T cells [34, 60, 61]. In the largest study of its kind, we evaluated 
impact of T cell memory on the pace of CMV- specific immune reconstitution. We confirmed results from 
multiple clinical trials showing that a CMV-positive donor enhances CMV immunity in the recipient and 
decreases severity and duration of CMV infection [66, 69-72]. 
 
Vaccine Strategies against CMV for HCT recipients: The purpose of live viral vaccination is to induce both 
helper and cytotoxic immunity, leading to a durable memory response [73, 74]. Plotkin and co-workers 
established an attenuated strain of CMV, the Towne strain, as a proposed therapeutic vaccine in the 
1970's, however concerns about using live CMV have minimized its applicability [68, 75]. More 
problematic for using attenuated CMV as a vaccine is the frequency of acquisition of a new CMV strain 
under pre-existing strain-specific natural immunity [76]. Alternative live viral approaches for CMV vaccines 
have focused on canarypox (ALVAC) expressing gB (UL55) which did not elicit significant antibody in CMV-
negatives [77, 78], or ALVAC-UL83 (PP65) which stimulated robust cellular immunity in CMV-negatives 
equivalent to levels in natural CMV-positives [56]. Further studies with ALVAC-UL55 and purified soluble 
UL55 protein only revealed minimal efficacy, insufficient for licensure [79, 80]. Another approach using 
AlphaVaxTM expressing UL83, UL123 and UL55 [57] showed promise when used in healthy adults. 
However, it is unlikely that AlphaVaxTM can be accepted in HCT, since it is based on a recombinant VEE, a 
live virus that could propagate in humans [57]. TransVaxTM DNA vaccine vector expressing either UL55 or 
UL83 have been evaluated in animal models with good results [81-83]. When clinically evaluated, 
TransVaxTM vaccine, which requires multiple injections showed weak immune response in healthy adults, 
and failed to meet its primary endpoint of reduced GCV usage in HCT recipients [84, 85]. CMVPepVax, 
derived from the CMV-UL83 antigen showed remarkable safety and elicited vaccine driven immune 
responses when tested in healthy adults (IRB protocol #03121, NCT00712634) [86]. CMVPepVax was also 
being evaluated in HCT recipients (IRB protocol #12022, NCT01588015). In the HCT setting, the study 
indicated safety of injecting CMVPepVax in HCT recipients on d28 and d56 post-HCT, no increase in acute 
GVHD and reduced CMV reactivation associated with vaccine-stimulated immunity [87]. While 
CMVPepVax immunologic activity has shown promise, a limitation of HLA A*0201 restricted CMVPepVax 
is that it is solely active in the HLA A*0201 population, that only makes up ~30-40% of the at-risk HCT 
population. The Triplex vaccine is superior to DNA vaccines in stimulating potent immunogenicity. In 
addition, since it expresses whole CMV proteins it has broader recognition and greater applicability for 
HCT recipients than CMVPepVax.  
 
MVA: The attenuated poxvirus MVA, engineered with recombinant genes, is being evaluated as a clinical 
vaccine for infectious disease and cancer.  The attractiveness of MVA for clinical use stems from its 
previous safety record as a smallpox vaccine in youngsters and in the elderly [12]. Recent clinical trials 
have affirmed its safety and efficacy in protecting against malaria challenge and generating immune 
responses in humans exposed to the TB bacterium [88, 89].  Lack of viral assembly and avirulence in 

 
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mammals, together with studies showing its safety in heavily immunosuppressed macaques, rodents, and 
in HIV-AIDS patients supports its use in HCT recipients [90-92].  Recently published data from a 
randomized, placebo-controlled, double-blind study [Clinical Trials Registration: NCT00565929] has 
shown that MVA was safe, well tolerated and immunogenic when used as an immunogen in HCT recipients 
[13]. Additionally, they strongly support its use as a vector for delivering infectious disease antigens, since 
MVA vaccination safely induced robust cellular immune responses in HCT recipients [13].  Unlike other 
attenuated poxviruses, the block in viral assembly does not interfere with production of large quantities 
of recombinant proteins in otherwise non-permissive hosts [93].  Multiple sites of foreign gene integration 
in MVA allow the virus to be modifed to express multiple full-length antigens. These facts motivated the 
development of vaccine candidates incorporating immunogenic targets of human CMV.  Consistent with 
the ability to elicit responses against a recombinant MVA transgene product even in the presence of pre-
existing anti-vaccinia virus immunity, repeated administration of recombinant MVA allows re-boosting of 
responses, despite induction of cellular and humoral immune responses against the vector  [94]. This has 
been reported both in Phase I/II therapeutic cancer vaccine trials in which up to 12 recombinant MVA 
vaccinations were given one month apart [95], as well as in a Phase I HIV vaccine trial in which up to three 
recombinant MVA vaccinations were given eight weeks apart [96].   
 
MVA for immunocompromised patients: Clinical trials were conducted in HIV infected and healthy adults 
[97] with a similar adverse event (AE) profiles in both groups. MVA was deemed safe to administer to HIV 
infected adults alone or alternating with a fowl pox vector [98]. In 2015 (NCT01571466), an MVA 
expressing multiple HIV antigens was given to patients who received disulfiram in a 3 injection regimen 
that was well tolerated without serious adverse event (SAE)[99]. Heavily immunocompromised patients 
who were both HIV and mycobacterium tuberculosis (MTB) positive were treated with an MVA expressing 
an MTB antigen (MVA85A) that was well tolerated with no vaccine-related SAE [100]. The same vaccine 
was also evaluated in adolescents (N=36) and 4-6-month infants (N=2797) in South Africa. There were no 
differences in AEs, and none of the SAEs were related to MVA85A [101, 102]. Critical to our program was 
an MVA vaccine trial in HCT-R [13]. There were 24 HCT patients who received MVA, 10 at low or high dose, 
and 4 received placebo. MVA was given twice separated by 28 days, the same time frame as in our 
completed trial in HCT-R (NCT02506933). There were 69 non-serious AEs, and all were unrelated to MVA. 
No subject had clinical symptoms, ECG findings, or troponin levels suggestive of vaccine-related 
myopericarditis. The patient cohort was comprised of equal numbers of allogeneic and autologous HCT-
R, without significant differences in AEs and immunogenicity in both groups. Individuals who received 
prior smallpox vaccination were not at greater risk for AE. The conclusion is that HCT patients tolerate two 
doses of MVA with limited or no AEs. The Triplex approach using multiple CMV antigens should elicit 
broader immunity than previous single or dual antigen vaccines based on soluble protein, attenuated 
viruses, or DNA plasmids. 
 
Construction, Expression and Function of 3-antigen MVA Vaccine against CMV:  
3 CMV gene products, UL83, UL122, and UL123 have been selected as targets for cell mediated immune 
(CMI) responses [50, 103-105].  [See Section 2.1.3 for a definition of these proteins.]  UL83 has been 
shown by several groups to be the most immunogenic CMV structural protein (derived from the 
tegument) in terms of human CD8+ and CD4+ T cell responses [46-48, 106-109]. Recently, several reports 
have suggested that the CTL response to UL123 is as vigorous as the response to UL83 [25, 50-52, 110].  
Each of the 3 antigens that are engineered into the multi-protein Triplex vaccine are immunodominant, 
and their aggregate CMI recognition should exceed 95% of most ethnic populations [103].  All 3 antigens 
elicit memory CTL in humans that both lyse CMV-infected fibroblasts in vitro and are quantifiable using 
HLA tetramers in fresh PBMC from CMV+ individuals, thereby confirming their existence in vivo.  A recent 
report suggests association of cellular immunity to UL83 and UL123 with recovery from CMV-retinitis in 
AIDS patients [111].  The accumulation of T cells specific for each of these 3 antigens in individuals with 

 
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CMV reactivation episodes provides an additional justification for their inclusion in a vaccine [112].  The 
strong cellular immune response induced  by the Triplex vaccine does not neutralize CMV [113].  The 
majority of the CMV-neutralizing antibody response has been localized to the gB (UL55) and UL128 gene 
products [114-118].  As strong evidence that a humoral component impacts protection against CMV 
infection after HCT is lacking, gB has been omitted from this vaccine.  Consequently, Triplex vaccine 
focuses on inducing a cell mediated response, which is associated with protection from disease in HCT 
recipients.   
Functional modification of CMV genes incorporated into MVA: A recent study of the immune response to 
full length UL83 in ALVAC and in TransVax™ DNA vaccine reported no short-term side effects (1-2 years) 
in both healthy volunteers and HCT patients [56, 84, 85]. Investigators have defined regulatory activity of 
the UL123 protein, including trans-activating properties on various cellular promoters [119-121].  
Consequently 85 aa comprising coding exons 2 and 3 have been deleted. Deletion of the two coding exons 
results in a 406 aa protein that is no longer nucleus-associated, but cytoplasmic [50]. The 406 aa protein 
has minimal transactivation activity [120, 121].  Most known CTL epitopes from UL123 are found in exon 
4, including the identified HLA A*0201-restricted CTL epitopes [51, 52, 110, 122].  Exon5 of UL122 was 
fused in frame to exon4 of UL123 without modification [53]. 
Figure 1. Construction of  Triplex vaccine 
 
Insertion sites, promoter selection and permissive host cells for Triplex vaccine generation: MVA was 
derived by serial transfer of the parental Ankara strain through chicken embryo fibroblasts (CEF) in order 
to derive a safe alternative to the smallpox vaccine [12].  As a result of its adaptation to CEF, several 
genomic deletions occurred [53, 123, 124].  These adaptations allow MVA to freely propagate in CEF to 
titers exceeding 10e10 pfu/mL, whereas standard mammalian cell lines such as CV-1 are non-permissive 
for propagation.  For the GLP, pre-clinical studies, specific pathogen-free (SPF) CEF obtained from Charles 
River-SPAFAS), were used.  As shown in Figure 1, deletion regions referred to as deletion II (del II) and III 

 
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(del III) were used to insert foreign genes by homologous recombination [123].  To obtain the level of 
foreign protein expression that results in a stable virus for manufacturing purposes, the modified H5 
(mH5), promoter emphasizing early vaccinia gene expression has been utilized in MVA [125], and it 
provides a powerful boost to transgene expression without genomic instability [93, 126] (Figure 1).   
 
2.2 Pre-Clinical and Clinical Evaluation of Triplex 
2.2.1 
 Triplex vaccine  
Evaluation of the immunogenicity of the Triplex in mouse models showed that the vaccine could stimulate 
primary immunity against all three CMV antigens (pp65, IE1 and IE2) in both the CD4 and CD8 T cell subsets 
[53, 127]. Furthermore,  Triplex was evaluated in vitro for its ability to stimulate memory responses in 
PBMC from healthy adults and HCT recipients Interestingly,  Triplex induced strong expansions of CMV-
specific CD4+ and CD8+ T cell subsets in both healthy adults and in patients within 6 months of receiving 
HCT [53, 127].   
 
Based on the body of pre-clinical and in vitro results the FDA (BB-IND #15792) granted allowance to 
proceed with human studies. A Phase Ib clinical trial to evaluate the safety and biological efficacy of Triplex 
vaccine in healthy volunteers, with or without prior immunity to CMV and vaccinia was initiated.  
 
2.2.2 
Phase Ib clinical trial in healthy adults (IRB 08173, NCT01941056) 
 Triplex vaccine was evaluated in a Phase Ib clinical trial, conducted in healthy adults to assess safety and 
immune response. To establish tolerability of  Triplex vaccine, a dose escalation study was performed in 
healthy volunteers (COH employees), ≥18 and ≤60 years of age, either CMV seropositive or seronegative.  
The study treated 8 subjects at 3 dose levels: 1x107 pfu/dose, 5x107 pfu/dose, and 5x108 pfu/dose.  
Volunteers received two IM injections of 1.0mL volume in the upper non-dominant arm, each at the same 
dose over a 4-week period.  
 
 
2.2.3 
Safety of Triplex vaccine 
Twenty-four healthy volunteers (HV) were vaccinated with Triplex Vaccine. Three doses of vaccine were 
evaluated: 
DL1:  1 x 107 pfu 
DL2:  5 x 107 pfu 
DL3:  5 x 108 pfu 
 
Some AEs were reported at each dose level, but the majority were grade 1-2 (see Table 1).  The trial has 
been completed, with none of the patients experiencing SAEs or DLT, or withdrawing from the study [128]. 
Thus, the first in human study of Triplex vaccine has met the primary objective, showing excellent 
tolerability (Table 1). 
 
  

 
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Table 1. AEs  in healthy adults trial (Phase Ib trial, Protocol 08173) 
*There were 8 patients dosed at each dose level (DL1, DL2, and DL3). 
 
Cardiac Adverse Events: Since rare occurrences of carditis with heart failure has occurred in human studies 
using a replicating vaccinia virus, the FDA recommended that all volunteers on this study be monitored 
for any change in electrocardiogram and cardiac troponin after vaccination [129].  No change in ECG and 
troponin levels was reported for all Triplex vaccinated volunteers and no other cardiac AE were reported 
(data from Phase 1b and Phase 2 studies).  
Persistence of Viral DNA: Persistence of the Triplex vaccine in healthy volunteers was monitored in 
accordance with FDA recommendations. A real-time PCR approach employing separate sets of primers for 
Grade 3-4 
Grade 1-2 

 
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the MVA backbone and the CMV insert genes utilizing TaqMan™ reagents was used. The assay is sensitive 
to <20 copies of MVA DNA per sample and can be used to detect low level residual MVA in blood and 
other tissues. A plasmid DNA standard was employed to quantify the copy number of MVA and insert 
genes detectable in blood specimens.  Persistence of the Triplex vaccine was monitored in healthy 
volunteers after administration of both doses of vaccine.  DNA from the dose level 1 and 2 cohorts showed 
undetectable levels of MVA DNA. In the Dose Level 3 cohort, low levels of MVA DNA, above the assay 
detection limit, were detected in 2/8 of the vaccinated subjects at d90 post vaccination. Considering the 
high doses of Triplex vaccine administered to this cohort, the low level of MVA DNA detected, at a single 
time point, is not a cause for concern.  
 Triplex Induced Immune Responses – secondary endpoint 
We evaluated the cellular CMV-specific response by measuring CD137 on the surface of CD8+ and CD4+ T 
cells after 24 hours stimulation with pp65, IE-1 and IE2 peptides [130].  Triplex vaccine driven immune 
responses were robust in DL1 (N=8) and DL2 (N=8) healthy volunteers. Most immunized volunteers 
showed post-vaccination increases in CMV pp65, IE1- and IE2-specific T cell levels. The most significant 
values were observed in CMV positive subjects who had low levels of CMV-specific T cells pre-vaccination. 
Statistical comparisons (rank-sum test) indicate that average post-vaccination levels of pp65, IE1 or IE2 
specific CD8 and CD4 T cells were significantly higher than baseline, with p-values ranging from 3 x 10-5 to 
0.025.  For example, pp65 stimulated CD4+ CD137+ T cells rose from a pre-vaccination median of 1.3 
cells/µL to a post-vaccination median of 4.4 (p = 3 x 10-5) and pp65 stimulated CD8+ CD137+ T cells rose 
from a pre-vaccination median of 0.22 cells/µL to a post-vaccination median of 3.1 (p = 0.003) [128]. 
 

 
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2.3 Triplex Vaccination in Allo-HCT 
We obtained FDA approval for a trial entitled “A Phase 2 randomized placebo-controlled trial to evaluate 
the protective function of a Triplex vaccine in recipients of an allogeneic HCT (NCT 02506933).” Target 
accrual of the multi-center study (COH, DFCI, and MD Anderson) was 102 evaluable patients (n=51 each 
arm). Primary objectives were assessing safety and tolerability of Triplex (NRM at d100 post-HCT, severe 
aGVHD, Grade 3-4 AEs related vaccination). In addition, we assessed whether Triplex reduces the 
frequency of CMV events, defined as CMV reactivation (DNAemia >625 IU/ml by qPCR), viremia treated 
by antivirals, or detection of CMV by tissue histology (end-organ disease). Secondary objectives included 
measurement of viremia and treatment duration, HCT-related outcomes (aGVHD, chronic GVHD, relapse, 
NRM, and infections). Figure 2 shows the Clinical Trial schema for this study. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Figure 2. Schema for Phase II Triplex study IRB 14295 (NCT02506933) 
Schema for the Phase 2 randomized, placebo-controlled multicenter trial to evaluate the protective 
function of Triplex vaccine in recipients of an allogeneic hematopoietic stem cell transplant.  

 
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Figure 3. Reactivation data from Phase II Triplex trial IRB 14295 (NCT02506933) 
Kaplan-Meier estimates of cumulative incidence, as estimated probability of reactivation as a function of 
day post-HCT.  The p-value shown is for the protocol-specified test comparing CMV events in Triplex and 
placebo arms at d100. 
 
Figure 3 shows Kaplan-Meier estimates of compiled data from 102 patients (24 CMV events, including 14 
in placebo and 10 in vaccine arms). In this study Triplex met the protocol-specified primary endpoint – 
clinically significant reduction in CMV events prior to d100 post-HCT, even though fewer CMV events 
occurred in this trial than were anticipated in trial design. There was no statistical difference in NRM, 
severe aGVHD or Grade >3 AE between placebo and vaccine arms. 
We have also conducted immunologic assessments of patients on this double blinded trial. Strong 
immunity to CMV was apparent shortly after the first injection. There was a substantial increase in pp65 
CD8+ T-cells in the vaccine arm compared to placebo by d42, and d56 for IE1 and IE2 which continued to 
rise through d100. CD4 and CD8 pp65-specific T cell concentration was higher in vaccine arm across all 
vaccination times (data available on request). This is associated with protective immunity in published 
natural history studies of immune reconstitution [61, 67].  
2.4 Triplex in HaploHCT 
HaploHCT was designed to overcome major HLA barriers in HCT by using alternative donors when fully 
HLA-matched donors were unavailable, particularly for those who are racial/ethnic minorities [131]. 
Major HLA mismatches can lead to severe GVHD or graft rejection. T cell depletion (TCD) can minimize 
GVHD, but can lead to unacceptable relapse, infection, graft failure, and non-relapse mortality (NRM) 
[132]. Current regimens which include post-transplant cyclophosphamide (PTCY) are successful in 
reducing morbidity and mortality on par with MRD and MUD HCT [133, 134]. PTCY was evaluated clinically 
as a two-step approach in which it was administered in both the conditioning regimen and post-HCT on 
d3 and d4 (50 mg/kg) with improved clinical outcomes [135]. Utilizing more intensive myeloablative 
conditioning (MA) and separating mature T cells from CD34+ stem cells (to avoid exposure of CD34+ cells 
to PTCY), can increase 2 year survival [136, 137]. In older patients intolerant of MA, reduced intensity 
conditioning (RIC) was employed, followed by PTCY. This results in outcomes similar to MA, and has 
generalized the use of PTCY to most leukemia patients [138, 139]. The Hopkins approach has now been 
expanded to include greater MA conditioning regimens including total body irradiation (TBI) or 
chemotherapy-based and use of GCSF-mobilized PBSC. In summary, haploHCT has outcomes similar to 
traditional HCT, with the added benefit of expanding the donor pool. 

 
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CMV infection in haploHCT-R. A serious complication of haploHCT is slow immune reconstitution leading 
to multiple viral infections. While PTCY lowers GVHD rates, it contributes to delayed immune 
reconstitution and infectious complications which are important causes of morbidity and mortality. The 
immunosuppressive therapy for GVHD prophylaxis antagonizes the immune reconstitution that protects 
against infections. GVHD treatment, or GVHD itself, slows immune recovery and makes patients 
susceptible to opportunistic infections for several months after haploHCT. Reactivation of viruses such as 
CMV, EBV, HSV or VZV can lead to symptomatic disease [22].  
Antiviral agent Prevymis has been approved by the FDA for all CMV seropositive HCT recipients to 
minimize the chance of CMV reactivation and disease development and the use of Prevymis for this 
purpose is now adopted into the HCT SOP. Unfortunately, CMV-specific T cell immune reconstitution has 
not been described in patients receiving Prevymis, and late CMV reactivation after stopping Prevymis on 
d100 remains a major clinical problem [14]. This problem can be potentially overcome by the sequential 
use of Prevymis and Triplex. We are intending to study this highly novel treatment strategy combining the 
benefits of Prevymis and Triplex vaccine developed by COH. This combination has no overlapping 
toxicities, and is potentially synergistic, or at least should possess additive protective effect for CMV 
infection.  
The importance of CMV-specific memory T cells is illustrated by the fact that HCT recipients with CMV-
positive donors have better outcomes (reduced NRM, improved survival) than those with CMV- donors. 
This is attributed to donor-derived CMV-specific T cells allowing rapid CMV-specific immune 
reconstitution [140].  
One attribute of the Triplex vaccine is its ability to enhance CMV-specific T cells, particularly those from 
the TEM (Terminal-Effector Memory) and TEMRA (TEM-CD45RA) subsets that are associated with 
protection against sequelae of CMV infection. It was understood that TCD haploHCT made the patient 
vulnerable to multiple infections, including CMV [132]. Earlier attempts to overcome deficits in T cell 
reconstitution for CMV utilized adoptive transfer of CMV-specific CD4+ T cell clones which was an effective 
strategy to limit mortality associated with CMV infection [141]. Nonetheless, obstacles such as 
requirements for sophisticated devices to isolate and separate CMV-specific T cells have limited the broad 
applicability of this approach. An alternative GVHD prophylaxis using PTCy for haploHCT has been 
advocated by the Johns Hopkins group [16, 142]. The average time of CMV reactivation is d39 in a major 
Italian study that mirrors other haploHCT studies, which is consistent with the timing in conventional HCT 
(d42-45) [143]. There was a 54% CMV reactivation rate in 70 CMV+ or CMV- lymphoma patients after 
unmanipulated haploHCT using PTCy. Most CMV reactivations occurred post-d31 and up to d100 in line 
with other haploHCT series [19]. Despite the premise that PTCy retains memory T cells not reacting against 
host allo-antigens, an average of ~60-80% of CMV-P HCT-R still have CMV reactivation. This level of risk is 
an ideal scenario for evaluation of the Triplex vaccine which could substantially reduce the rate of 
reactivation and lessen the probability of uncontrolled viremia or other symptomatic CMV infections such 
as end organ disease. 
 
2.5 HaploHCT Study Overview  
This randomized, blinded, placebo controlled, multi-site Phase II safety and efficacy trial will be conducted 
at COH, Northside hospital and DFCI. This study has been designed to have sufficient statistical power for 
testing clinically significant endpoints. In particular, the efficacy of  Triplex in protecting against CMV 
reactivation and disease in haploHCT recipients (CMV positive) after d100 post-HCT (d100-d180) who are 
at risk for CMV complications after the completion of Prevymis prophylaxis [59].  
Primary hypothesis: 
• 
The CMV reactivation that leads to antiviral treatment or CMV disease by histology (end organ 
disease) for haploHCT-R will occur with less frequency on the Triplex vaccine arm than on the placebo 

 
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arm.  
 
Secondary hypothesis: 
• 
CMV protective immunity after d100 post-HCT and completion of Prevymis prophylaxis will be 
safely enhanced in haploHCT recipients receiving two Triplex vaccine injections leading to reduced 
frequency of CMV reactivation and its recurrence, antiviral use and its duration, and incidence of CMV 
disease (CMV events).  
• 
Immunity to 3 CMV antigens contained in the Triplex vaccine will correlate with protection against 
CMV events, and T-cell increases will reflect vaccine responses and exceed placebo immune response 
levels.  
 
This trial aims to treat 128 haploHCT-R+, randomized to the vaccine (N=64) or placebo arm (N=64). Because 
approximately 15% of enrolled participants may fail to meet post-HCT vaccine administration criteria, the 
total study accrual is expected to be ~151 participants.  Participants meeting vaccine administration 
criteria will receive injections of either Triplex or placebo on d100 and d128 post-HCT.  
HCT recipients are closely observed for safety according to institutional standard of care practices, which 
recommend intense monitoring during the first 100 days following transplant. This study will follow the 
standard of care (SOC) practice till d100 post-HCT of weekly or biweekly assessments of CMV qPCR, clinical 
laboratory tests, engraftment assessment, GVHD assessment and physical exam. When clinically 
indicated, CMV disease and disease relapse will be assessed. Disease relapse will also be routinely 
assessed at pre-determined time points per SOC. Rigorous stopping rules will be implemented, and will 
include three major safety endpoints: 
• 
non-relapse mortality (NRM) at d180 post HCT  
• 
severe (grade 3-4) acute GVHD between d100 and d180 
• 
grade 3-4 AEs related to the vaccination within 2 weeks from each vaccination 
 
CMV-specific immunogenicity (included in the secondary endpoints) will be evaluated in all participants 
from d100 until d365 post-HCT according to the study calendar. Immunologic studies will include 
monitoring the levels, function and kinetics of CMV-specific T cell immunity in vaccinated compared to 
placebo treated haploHCT-R, combined with immunophenotyping studies [144, 145].  The phenotypic 
ratios of CMV-specific T cells will be related to improvement in control of CMV viremia. Based on the 
encouraging results of the published Phase Ib study (COH IRB 08173, NCT01941056), levels of pp65, IE1 
and IE2-specific T cells associated with protection from CMV viremia and disease are anticipated to be 
detected in a significantly higher proportion of vaccine recipients compared to those enrolled in the 
placebo arm [34].  
3.0 
PARTICIPANT ELIGIBILITY CRITERIA 
3.1 
Pre-HCT Inclusion Criteria 
Participants must meet all of the following criteria on screening examination to be eligible to participate 
in the study:  
Informed Consent and Willingness to Participate 
___ 1. All subjects must have the ability to understand and the willingness to sign a written 
informed consent. 
___ 2. Participant must be willing to comply with study and/or follow-up procedures, including 
willingness to be followed for one year post-HCT. 

 
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Age Criteria 
___ 3. Age 18+ years.  
Nature of Illness and Transplant Related Criteria 
___ 4. Planned PBSC or BM HCT for the treatment of the following hematologic malignancies: 
o Lymphoma (Hodgkin and Non-Hodgkin) 
o Myelodysplastic syndrome 
o Acute lymphoblastic leukemia in first or second remission (For Acute Lymphoblastic 
Leukemia/Lymphoblastic Lymphoma, the disease status must be in hematologic 
remission by bone marrow and peripheral blood. Persistent lymphadenopathy on CT 
or CT/PET scan without progression is allowed.) 
o Acute myeloid leukemia in first or second remission 
o Chronic myelogenous leukemia in first chronic or accelerated phase, or in second 
chronic phase 
o Other hematologic malignancies judged appropriate by the clinical PIs, including 
chronic lymphocytic leukemia, myeloproliferative disorders and myelofibrosis. 
Patients with multiple myeloma and those with non-malignant disease such as 
aplastic anemia are excluded* 
 
*Adult cases of multiple myeloma (MM) are excluded as HCT is not standard of care for MM and is only 
performed in very advanced cases with an associated high risk of relapse and NRM. Adults with aplastic 
anemia are excluded because their standard management includes T cell depletion with agents such as 
ATG, which is not permissible on this protocol (see Section 3.2 point 6).  Patients undergoing a second 
haploHCT are not eligible (patients who have undergone a previous autologous HCT are eligible). 
___ 5. Patients receiving myeloablative (MA) or reduced intensity conditioning (RIC) are allowed 
___ 6. CMV seropositive (recipient) 
___ 7. Planned related HCT with molecular 3/6 (haploidentical) intermediate/high resolution   
HLA donor allele matching 
___ 8. Planned HCT with minimal to no-T cell depletion of graft 
___ 9. Conditioning and immunosuppressive regimens according to institutional guidelines are 
permitted 
Clinical laboratory parameters  
___ 10. Negative serum or urine β-HCG test (female patient of childbearing potential only) within 
two weeks of registration. 
___ 11. Seronegative for HIV, HCV and active HBV (Surface Antigen Negative) within 2 months of 
registration and no history of disseminated cutaneous HPV related disease. 
Child Bearing Potential 
___ 12. Agreement by females of childbearing potential and sexually active males to use an 
effective method of contraception (hormonal or barrier method of birth control or 
abstinence) prior to study entry and for up to d90 post-HCT. Should a woman become 
pregnant or suspect that she is pregnant while participating on the trial, she should inform 
her treating physician immediately.  

 
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3.2 Pre-HCT Exclusion Criteria 
Prospective participants who meet any of the following criteria will not be eligible for admission into the 
study: 
Previous therapies 
___ 1. Any prior investigational CMV vaccine 
___ 2. Experimental anti-CMV chemotherapy in the last 6 months 
 
Planned medications from the time of HCT to d70 post-HCT 
___ 3. Live attenuated vaccines  
___ 4. Medically indicated subunit (Engerix-B for HBV; Gardasil for HPV) or killed vaccines (e.g. 
influenza, pneumococcal, or allergy treatment with antigen injections) 
___ 5. Allergy treatment with antigen injections  
___ 6. Alemtuzumab or any equivalent in vivo T-cell depleting agent (or CD34+ selection) 
___ 7. Antiviral medications with known therapeutic effects on CMV such as GCV/VAL, FOS, 
Cidofovir, CMX-001, maribavir. Acyclovir has no known therapeutic efficacy against CMV 
and is allowable as standard of care to prevent HSV.  
___ 8. Prophylactic therapy with CMV immunoglobulin or prophylactic antiviral CMV treatment 
EXCEPT Prevymis prophylaxis (prior to d100) 
___ 9. Conditioning regimens d30 prior to trial participation and up to d180 post-HCT  
___ 10. Disease-based radiation therapy (not total body irradiation) 
___ 11. Other investigational product – concurrent enrollment in other clinical trials using any IND 
drugs with unknown effects on CMV or with unknown toxicity profiles is prohibited. 
___ 12. Other medications that might interfere with the evaluation of the investigational product 
(see Prohibited Medications, Section 5.6) 
Other illnesses or conditions 
___ 13. Patients with active autoimmune conditions requiring systemic immunosuppressive 
therapy within the previous 5 years are not eligible 
___ 14. Patients considered by PIs/Protocol team to have a complicated prior therapy or HCT 
regimen, or who have a low survival probability (e.g., refractory leukemia and/or 
undergoing 2nd HCT) 
___ 15. Poor risk disease/disease status including: CML in blast crisis, AML/ALL beyond 2nd 
remission, multiple myeloma, and aplastic anemia 
___ 16. Pregnant women and women who are lactating.  Triplex risks to pregnant women are 
unknown.  Because there is an unknown but potential risk for adverse events in nursing 
infants secondary to treatment of the mother with the administered vaccine, also 
breastfeeding should be discontinued if the mother is enrolled on this study.   

 
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___ 17. Any other condition that would, in the Investigator’s judgment, contraindicate the 
patient’s participation in the clinical study due to safety concerns or compliance with 
clinical study procedures, e.g., social/ psychological issues, etc. 
Noncompliance 
___ 18. Prospective participants who, in the opinion of the investigator, may not be able to 
comply with all study procedures (including compliance issues related to 
feasibility/logistics). 
 
3.3 Participation of Special Populations 
A discussion of the inclusion, exclusion, and representation participation of women, minorities, children, 
and HIV positive individuals is provided in Section 16.5.  
 
 

 
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4.0 
PARTICIPANT ENROLLMENT AND RANDOMIZATION 
4.1 Pre-Enrollment Informed Consent and Screening Procedures 
Diagnostic or laboratory studies performed exclusively to determine eligibility will be done only after 
obtaining written informed consent.  Studies or procedures that are performed for clinical indications (not 
exclusively to determine study eligibility) may be used for baseline values and/or to determine pre-
eligibility, even if the studies were done before informed consent was obtained. The informed consent 
process is to be fully documented, and the prospective participant must receive a copy of the signed 
informed consent document.  See Table 10 footnote f and Section 16.4 for more information regarding 
informed consent. Screening procedures are listed in Section 10, Table 10 Study Activity Calendar.  
4.2 Participant registration 
4.2.1 
COH DCC Availability and Contact Information 
Eligible subjects will be registered on the study centrally by the Data Coordinating Center (DCC) at City of 
Hope.  DCC staff are available between the hours of 8:00 a.m. and 5:00 p.m. PST, Monday through Friday 
(except holidays).   DCC contact information is as follows: 
• 
phone: (626) 256-4673 ext. 63968 
• 
e-mail: DCC@coh.org 
4.2.2 
Slot verification and reservation 
As the study nears completion of accrual, study team personnel (including physicians, protocol nurses 
and/or CRCs) may wish to contact the DCC to verify slot availability and to reserve an open slot or be 
placed in queue for slot opening.  Slots may only be held for a limited time which will be determined by 
the PMT. The Data Coordinating Center should be notified of cancellations of prospective participants 
holding slots as soon as possible. 
4.2.3 
Registration procedure 
To register a participant, the subsequent procedure is to be followed. 
1. The participating site’s data manager/coordinator/research nurse should contact the DCC via 
telephone or email to provide notification regarding the pending registration and 
communicate desired timeline of the registration, especially if it must be completed promptly 
to 
meet 
the 
registration 
window 
(d60 
to 
d0                             
before planned HCT). 
2. The data manager/coordinator/research nurse should then e-mail copies to DCC@coh.org  of 
the following documents to the DCC:  
o Registration Cover Sheet (Appendix F) 
o Completed Eligibility Criteria List  
o Source documentation to support eligibility criteria**  
o Signed informed consent document (if permitted by institutional policy) 
o Signed HIPAA authorization form (if separate from the informed consent document) 
o Signed subject’s Bill of Rights (COH only)  
**For COH participants, provide copies of source documentation only if not readily 
available as a finalized record in the COH EMR  
3. After having received all transferred documentation, the DCC will review the documents to 

 
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verify eligibility, working with the participating site as needed to resolve any missing required 
source elements. A subject failing to meet all protocol eligibility requirements will not be 
registered.  
4. Once eligibility has been confirmed, DCC staff will register the participant by: assigning a 
subject accession number, register the subject on study centrally into OnCore for MD 
Anderson and DFCI participants (the COH CRC will directly accession into OnCore), and enter 
the subject into the eCRF system, Medidata RAVE. 
5. Once registration has been completed, DCC staff will send a Confirmation of Registration 
Form, including the participant study number and planned date of HCT procedure to:  
o the site study team: site PI, treating physician, protocol nurse, CRC and pharmacy 
o the sponsor team: (Drs. Nakamura, Aldoss, La Rosa, and the COH CRC) 
 
4.3 Randomization 
Patients will be randomized from d70-93 post-HCT with the goal of evenly distributing participants into 2 
arms (64 patients to the vaccine arm and 64 the placebo arm). The treatment assignment will be masked 
from patients and health care providers, but known to the DCC coordinators, study monitors, auditors, 
pharmacy personnel, and the statistician.   See Section 5.2 for additional information about maintaining a 
blinded randomization. 
The DCC staff will use a computer-generated randomization table, stratified by donor CMV serostatus and 
center (generated by the trial Biostatistician), to assign registered participants to the Triplex or placebo 
arm. The treatment assignment will be generated and provided to pharmacists in advance (usually ~d70-
93 post-HCT) of planned vaccination. The DCC staff will confirm that the treatment assignment was 
received by the pharmacy.  
The DCC specialist will request a copy of source documents regarding donor CMV serostatus, if not already 
provided/available. The DCC staff may contact the study team coordinator to confirm the HCT procedure 
did occur prior to generating the treatment assignment. 
As soon as the study team is aware that a registered participant will NOT meet the criteria to receive the 
initial vaccine, this should be promptly communicated to the DCC.  This information will be entered into 
the computer-generated randomization program to inform subsequent treatment assignments. 
Only participants who receive a vaccination (Triplex or placebo) on d100 will be considered “randomized”.   
 
4.4 Emergency Unblinding Procedures 
The COH IDS which will be authorized in an emergency to break the code and inform the responsible party 
at the DFCI Investigational Pharmacy and similarly at the Northside Investigational Pharmacy. 
Consequently, the HCT-R’s physician will not have access to the randomization assignment on this trial.  
Emergency un-blinding will occur if a patient on this study develops a life-threatening toxicity or SAE and 
the participant’s physician feels that it is in the patient’s best interest to know the randomization status 
of the participant. 
The following procedure should be followed:  
Information regarding the rationale for de-blinding will be provided to the Site PI, the COH DCC, 
and the Study PI.  
The Site PI will communicate with Pharmacy and will provide authorization to unblind patient’s 
treatment.  

 
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In this very unlikely event, the PMT will determine if and how the unblinding should impact the 
participant’s continued participation in the study or analysis of collection points post de-blinding. This 
plan will be provided to the IRB of record and the COH IRB and external DMC as per COH institutional 
requirements. The date and reason for unblinding must be noted in the medical record and captured in 
the eCRF. 
 
5.0 
TREATMENT PROGRAM 
5.1 Treatment Overview 
The study intervention will consist of Prevymis administration from d7 until d100 post HCT (per COH SOC 
guidelines) and vaccine administration on d100 and d128 post HCT of either Triplex (N=64) or placebo 
(N=64), depending on participant randomized treatment assignment.  
Participants will receive vaccine administration only if vaccine administration criteria are met (Sections 
6.1 and 6.2) and confirmed by the DCC (who will notify the study team pharmacy of the confirmation). 
Participants who do not receive the d100 post-HCT vaccine administration will be replaced. Participants 
who receive at least one vaccine administration will complete all procedures detailed in Section 10, except 
for participants who experience relapsed disease for whom all post-relapse assessments will cease and 
will be followed only for survival through d365 post-HCT.  
Time intervals for vaccine administration are detailed in Section 10, Study Activity Calendar. 
 
5.2 Maintaining a blinded randomization 
The treatment assignment will be masked from patients and health care providers via syringe covered for 
blinding purposes, but known to the DCC coordinators, study monitors, auditors, pharmacy personnel, 
and the statistician. The vaccine will be administered by a CRU nurse who is not involved in other protocol-
required procedures, does not provide day-to-day medical care to the patients in the trial, and is 
independent of investigators conducting the trial. Due to differences in appearance of the active agent 
and the placebo, the person administering the vaccine (placebo or active agent) should limit discussions 
regarding the characteristics regarding the agent’s appearance or administration (i.e. ease or difficulty of 
administration) to the study pharmacist. Since the person administering the vaccine may detect a 
difference in appearance between placebo and active agent, he/she will be furthermore excluded from 
performing any protocol-required procedures or providing day-to-day medical care of the participant for 
the duration of the trial. The pharmacist will keep the treatment assignments and accountability 
documentation such that the documents cannot be accessed by the individuals who conduct protocol-
required assessments, follow-up assessments, or those involved in the day-to-day medical care of the 
subjects during the trial. An un-blinded PMT contact for Pharmacy will be designated. Disclosure of any 
knowledge of the randomization status to persons other than those permitted to know the randomization 
status would result in a protocol violation. These procedures of maintaining blinded randomization are 
based on successful implementation of identical procedures in completed clinical trial IRB#14295. 
 
Unblinding to know the randomization status will be permissible when all enrolled patients have finished 
the planned follow up and the study is closed to accrual. 
 

 
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5.3 Assessments 
Patients undergoing HCT are heavily monitored for safety according to institutional SOC practices. The 
following assessments will occur for safety and/or endpoint analysis with the schedule indicated in Study 
Activity Calendar (Section 10), per institutional SOC, and as clinically indicated.  
5.3.1 
Post-Vaccination Assessment 
Vaccine and placebo injections will be administered intramuscularly. All subjects will be monitored for at 
least 30 minutes after each immunization for any local or systemic reactions including vital signs 
(temperature, pulse, blood pressure, and respiratory rate). Notation will be made of the subject’s 
temperature and of any local reaction at the injection site.  
 
5.3.2 
GVHD assessment and performance status 
Acute GVHD will be assessed and graded according to the Keystone Consensus grading system (Appendix 
A). Chronic GVHD will be classified per Appendix B by type of onset (progressive, interrupted, de novo, or 
chronic); basis of diagnosis (histologic/biopsy proven, clinical evidence, both, or unknown); Limited or 
Extensive chronic GVHD; and overall severity of GVHD (mild, moderate, or severe). Performance status 
will be evaluated utilizing the Karnofsky Performance Scale (Appendix D).  
5.3.3 
CMV monitoring 
Trial participants will be quantitatively monitored for viremia, by plasma qPCR test once every two weeks 
(+/- 5d) from d100 to d180. CMV monitoring will use standard qPCR clinical laboratory methods to 
evaluate CMV viral load and possible vaccine failure. The methods used at the study sites are as follows:  
COH:  Focus 3M Integrated Cycler and Simplexa CMV Kit for in vitro diagnostic use, detection limit 250 
gc/ml, reported in WHO IU/ml (conversion factor 2.5; 250 gc/ml = 625 IU/mL). 
DFCI: Roche Cobas CMV VL assay, detection limit 150 gc/ml, one copy equivalent to 0.91 WHO 
International Units (IU).  
Northside:  Qiagen qCMV PCR, detection limit 100 CMV copies mL (conversion factor: LOG IU = 
[1.0264*(LOG copies/ml)] – 0.0156, anti-LOG equals IU/mL). 
 
Based on available information these methods are considered sufficiently similar. However, selected 
samples with measured viral load ≥625 IU/ml from DFCI and Northside study subjects will be stored for 
batch testing at COH to confirm equivalence of methods at external sites with COH method (see study 
calendar for details). 
Clinical CMV disease status will be documented at each study visit, which may include the absence or 
presence of suspected CMV disease.  Late CMV disease typically occurs around 6 months post-HCT, and 
will be monitored. When clinically indicated and per SOC, CMV disease will be assessed. The site (upper 
GI, lower GI, other, specify) and method of detection in the tissue (tissue culture, pathology etc.) will be 
documented. Presentations or suspected presentations of CMV disease in the absence of qPCR ≥625 
IU/mL will be evaluated by the treating investigator in conjunction with the blinded PMT before a 
determination is made. Viremia diagnosed using qPCR [146] of ≥625 IU/mL will be treated with antivirals 
according to institutional guidelines. 
5.3.4 
Engraftment assessment 
Engraftment will be assessed by monitoring the recipient’s absolute neutrophil count. The date of 
engraftment is defined as the first date of 3 consecutive laboratory values obtained on different days 
when the peripheral blood absolute neutrophil count is ≥ 500/mm3; for the purposes of recording into the 

 
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case report form, the date of engraftment can be derived from the ANC values in the clinical laboratory 
results so long as there is accompanying documentation in the medical record that engraftment did occur.  
Graft failure following engraftment (secondary graft failure) is defined as a fall in the absolute neutrophil 
count below 500/mm3 for 3 or more consecutive laboratory values following initial engraftment that is 
not due to disease relapse/progression, infection or secondary medication effect; the date of graft failure 
will be defined as the date when the criteria for graft failure are confirmed by the clinician-investigator. 
5.3.5 
Disease relapse 
Disease relapse will be assessed (including timing of assessment) according to institutional SOC practice 
for the participant’s specific hematologic malignancy. At defined clinic visits, the disease relapse status 
should be documented, which may include the presence or absence of clinical signs of disease relapse. 
Relapse is defined as “morphologic relapse” for acute/chronic leukemia including AML, ALL, MDS, CML. 
Patients who are found to be in relapse only by molecular methods or cytogenetics will continue with the 
protocol therapy, except for cases which received conventional cytotoxic chemotherapy. The following 
FDA-approved tyrosine kinase inhibitors/hypomethylating agents are allowed in case of 
molecular/cytogenetic relapse: imatinib, nilotinib, dasatinib, ponatinib, sorafenib, azacitidine and 
decitabine. Participants who undergo disease relapse will cease all future study visits/procedures and will 
be followed only for survival through d365. 
5.3.6 
Clinical laboratory chemistry, hematology and pregnancy test 
A complete metabolic panel will include the following 18 blood chemistry parameters (CMP): glucose, 
BUN (blood urea nitrogen), creatinine, uric acid, total proteins, albumin, calcium, phosphorous, sodium, 
potassium, chlorine, total CO2, total bilirubin, alkaline phosphatase, ALT (alanine transaminase), AST 
(aspartate aminotransferase), LDH (lactate dehydrogenase), total cholesterol. 
For women of child bearing potential, a serum or urine pregnancy test is acceptable. Female participants 
who are menopausal are not considered of child bearing potential. Menopausal status is defined as more 
than 12 months without menses, or a medical history of menopausal status (estrogen level and follicle 
stimulating hormone in the menopausal range).  
The hematology testing will include a complete blood count (CBC) with differential. 
5.3.7 
Adverse event assessment (CTCAE v.5.0) 
All adverse events will be assessed using NCI CTCAE v. 5.0, which can be found at the following link: 
https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/CTCAE_v5_Quick_Referenc
e_8.5x11.pdf. AEs will be attributed (unrelated, unlikely, possibly, probably or definitely) to study 
injections, described as “expected” or “unexpected problem”, and analyzed from d100 injection through 
d365 observation period and accompanied by a written description to meet IRB requirements. The CTCAE 
v5.0 toxicity scale will be used to characterize expected AEs. Adverse events recorded in the source 
documents and the case report forms include: 
o All events considered possibly, probably or definitely related to study agent till d180 
o Highest grade events that occur within 2 weeks from each vaccination  
o All grade 3/4/5 and highest grade events will be reported from d100 through d180 
o All serious adverse events will be reported to the sponsor from d100 through d180 
o After d100, all deaths will only be reported in the follow-up visit page of the eCRF. 
 

 
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5.3.8 
Physical exam, vital signs, medical history, baseline symptoms, and demographics 
Physical exam including a review of skin will be performed. Vital signs will include review of weight, heart 
rate, blood pressure, respiration rate, and temperature.  Height will only be required at baseline. 
Medical history is defined as any significant medical condition up to d0, but prior to stem cell infusion.      
Baseline symptoms are defined as any symptoms on d100 prior to vaccination. 
5.3.9 
Concomitant medications 
All antiviral medications, immunosuppressive agents, prednisone, and other anti-cancer therapy or 
maintenance therapy taken or administered during the trial will be documented in the subject’s 
clinical/hospital record, using COH, Northside and DFCI documentation guidelines.  Medications related 
to a serious adverse event will be collected in the study case report forms as appropriate:  
o Concomitant medications 
o Anti-viral medications, including indication, start and stop date 
o Immunosuppressive agents 
o Prednisone, or equivalent, dosage for the 7 days prior to vaccine administration 
o Prohibited medications 
5.3.10 Immunogenicity testing 
All participants will undergo serial blood sampling for future immunogenicity testing. Section 9.0 details 
regarding sample collection, storage, and processing procedures for immunogenicity studies.  
 
5.4 Criteria for Completing/Discontinuing Study Participation 
Participation may continue until one of the following criteria applies: 
o Participant becomes ineligible prior to the d100 vaccine (such participants are not 
randomized and are replaced, with ineligibility data recorded) 
o Completion of study procedures 
o Participant withdraws from the study 
o General or specific changes in the participant's condition that render the participant 
unacceptable for participation in the opinion of the treating investigator. 
Documentation of the reason for completing study participation and the date effective should be made 
in the medical record and appropriate eCRF.  The COH DCC should be promptly notified of the change in 
participant status. 
 
5.5 Follow-Up and Duration of Participation 
The length and involvement of study participation will vary based on vaccine administration, disease 
relapse, or decision to withdraw from the study, as detailed in the subsections that follow:  
5.5.1 
Participants who do not receive d100 vaccine administration 
Participants who do not meet criteria for d100 vaccine will discontinue any further follow-up. 
5.5.2 
Participants who relapse after receiving vaccine administration 
Participants who relapse after receiving vaccine administration will have procedures performed and 
documented up to that time of determination of relapse, and then will be followed for survival only 
(including reason for mortality) until d365 post-HCT.   

 
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5.5.3 
Participants who withdraw from the study after receiving a vaccine administration 
Participants who withdraw from the study after receiving a vaccine administration may continue with 
follow-up per the participant’s agreement: 
– 
may elect to continue study monitoring procedures without d128 vaccine (if not already 
administered),  
– 
may elect to continue to be monitored for survival (including reason for mortality) until 
d365 only, or  
– 
may elect to withdraw completely; further follow-up or assessments will not occur. 
5.5.4 
All other participants (vaccine administered, have not relapsed or withdrawn)  
All participants who received at least one vaccine, have yet to have disease relapse, and have not 
withdrawn from the study, will continue follow up assessments and research blood draws as indicated in 
the Study Activity Calendar (Section 10) through d365 post-HCT. Study participation will be completed on 
d365 post-HCT.   
5.5.5 
Long-term Follow Up  
Using a specific long-term follow-up protocol at COH (IRB05116, Dr. Armenian, PI) and similar schemes at 
DFCI and Northside that will be described in their clinical protocol, enrolled patients will be consented to 
participate in an extended follow-up of 3 years post-HCT. This extended period of observation will help 
understand differences in outcome in vaccine and placebo cohorts. Long-term immune response to CMV 
and survival will be compared in these two subgroups.  
 
5.6 Supportive Care, Other Concomitant Therapy, Prohibited Medications 
In general, the use of any concomitant medication/therapies and supportive care of the participant are 
allowed, with the following exceptions: 
1. No other investigational agents may be given to patients 
2. Alemtuzumab or any equivalent in vivo T-cell depleting agent is not permitted in this study following 
HCT, because its administration results in in vivo depletion of B, T and dendritic cells, potentially 
negating any positive effect of vaccinating the recipient with Triplex. 
3. Preemptive therapy with CMV immunoglobulin or antivirals (GCV/VAL, FOS, Cidofovir, CMX-001) is 
not allowed following HCT, EXCEPT: 
1) Prevymis administration between d7 and d100 post-HCT according to COH SOC guidelines.  
2) GCV/VAL, FOS, Cidofovir, CMX-001 may be used according to institutional SOC for preemptive 
management of CMV viremia, but vaccination is only allowed no less than a month after 
administration of antivirals is completed. In general, therapy should not commence until after 
CMV ≥625 IU/mL. For preemptive therapy when qPCR<500 IU, the study PIs are to be consulted. 
4. Prophylactic antiviral treatment for HSV, HHV6, EBV and adenovirus including the use of GCV/VAL, 
FOS, Cidofovir, CMX-001 may also suppress reactivation of CMV, thus will not be allowed in this study 
following HCT. Therapeutic use of these agents is permitted per institutional standard practice. 
Acyclovir has no therapeutic efficacy against CMV and is allowed as standard of care to prevent HSV. 
5. Medications that might interfere with the evaluation of the investigational product are prohibited up 
to 14 days after the second vaccination (d142 post-HCT). Medications in this category include, but are 
not limited to:  
• 
Live attenuated vaccines  
• 
Medically indicated subunit (Engerix-B for HBV; Gardasil for HPV) or killed vaccines 
(e.g. influenza, pneumococcal, or allergy treatment with antigen injections) 

 
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O Steroid therapy with prednisone, or equivalent, is permitted (see 
Section 6.0 for specific steroid dose criteria prior to vaccinations). 

 
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6.0 
VACCINE ADMINISTRATION CRITERIA 
6.1 D100 Post-HCT Vaccine Administration Criteria 
If the criteria are not clear cut, the treating clinician/Site PIs will make a determination. This consultation 
should be documented. Eligibility for d100 study-agent injection will be assessed at approximately d 70 
post-haploHCT. Randomization will occur coincident with assessment of eligibility for d100 injection. At 
d100, a first injection shall be administered if the following criteria are met: 
1. NOT experienced ≥ Grade 3+ GVHD within past 7 days 
2. Disease has NOT relapsed since HCT 
3. Successful primary engraftment WITHOUT secondary graft failure 
4. NO ongoing post-HCT ≥Grade 3 non-hem AE’s (exceptions: glucose intolerance, cholesterol, 
triglyceride, and hyperglycemia) 
5. Negative for CMV viremia: CMV qPCR ≤625 IU/mL from samples collected within the past 7 days 
6. Negative for CMV end organ disease (biopsy proven) post-HCT 
7. All prednisone (or equivalent) doses within the past 7 days were ≤1 mg/kg/day  
8. NOT received any prohibited medications (Section 5.6), EXCEPT antiviral use if the administration 
was completed at least 1 month before vaccination 
9. Negative pregnancy test result for females of child bearing potential 
10. No active pathogen infection defined as positive blood cultures within 72 hours of injection or 
radiographic changes consistent with infection 
11. Platelet count of >50,000/ml (transfusions to achieve this level are acceptable) 
The DCC should be promptly notified of registered participants who fail d100 vaccine eligibility criteria. 
 
6.2 D128 post-HCT Vaccine Administration Criteria 
Prior to d128, patients will be reviewed for eligibility. D128 vaccine shall be administered if all the 
following are met: 
• 
NOT experienced >Grade 2 GVHD since d100 vaccination 
• 
NO Grade 3 GVHD within the past 7 days 
• 
Disease has NOT relapsed since HCT 
• 
NO secondary graft failure (ANC<500/m3) 
• 
NO ongoing post-HCT ≥ Grade 2 non-hem AE’s (exceptions: grade 3 glucose intolerance, 
cholesterol, triglyceride and hyperglycemia) 
• 
All prednisone doses (or equivalent) within the past 7 days were ≤ 1 mg/kg/day 
• 
NOT received any prohibited medications (Section 5.6) 
• 
Negative pregnancy test result for females of child bearing potential 
CMV reactivations/anti-CMV treatment between d100 and d128 do not disqualify patients from d128 
injection.   
 

 
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7.0 
DATA AND SAFETY MONITORING 
This study will have an external, independent DMC for review of protocol events and progress, with 
reporting of recommendations to the COH IRB. Data and safety monitoring for the protocol will be 
performed in accordance with the NCI-approved City of Hope Data and Safety Monitoring Plan (DSMP) for 
Cancer Center Trials. In accordance with the NCI Comprehensive Cancer Center rules, safety monitoring 
on subsite patients will be performed locally. Data and safety monitoring will be performed in accordance 
with the NCI-approved Data and Safety Monitoring Plan (DSMP) for Cancer Center Trials.  Similarly for 
DFCI and Northside Hospital, the COH DSMP will be followed. These comprehensive plans describe risk 
assignment, AE reporting procedures and the data and safety monitoring procedures overseen by the 
respective IRBs and by the COH and/or external DMC. 
 
7.1 Monitoring and Personnel Responsible (PMT) 
The PMT will consist of the Study PI, Site PIs, collaborating investigators, Biostatistician and CRC/protocol 
nurse. They will be responsible for monitoring the data and safety of this study, including implementing 
stopping rules for safety and efficacy. In addition, monitoring of research subjects following treatment 
will be conducted by the Clinical Trials Office and/ or designee. Study data and safety information from all 
participating sites will be collected at COH for evaluation by the Independent DMC prior to DMC meetings. 
 
7.2 AE and UP Definitions 
The research team is responsible for classifying AEs and UPs as defined in the relevant regulations and 
reporting to all applicable parties, including but not limited to the COH IRB, DSMC, Food and Drug 
Administration (FDA), National Institutes of Health (NIH) and other collaborators, e.g., pharmaceutical 
companies. The research team is responsible for the continued monitoring and tracking of all AEs in order 
to ensure non-reportable events are reviewed and monitored and do not rise to a reporting level. 
7.2.1 
Adverse event (AE) 
An adverse event is any untoward medical experience or change of an existing condition that occurs 
during or after treatment, whether or not it is considered to be related to the protocol intervention.  
7.2.2 
Unexpected Adverse Event [21 CFR 312.32 (a)] 
An adverse event is unexpected if it is not listed in the investigator’s brochure and/or package insert; is 
not listed at the specificity or severity that has been observed; is not consistent with the risk information 
described in the protocol and/or consent; is not an expected natural progression of any underlying 
disease, disorder, condition, or predisposed risk factor of the research participant experiencing the 
adverse event. 
7.2.3 
Expected Adverse Event  
Any event that does not meet the criteria for an unexpected event OR is an expected natural progression 
of any underlying disease, disorder, condition, or predisposed risk factor of the research participant 
experiencing the adverse event. 
7.2.4 
Serious Adverse Event (SAE) [Modified from 21 CFR 312.32]  
Serious adverse events will be reported to the sponsor (COH) within 1 business day of study staff becoming 
aware of them. A serious adverse event is defined as any expected or unexpected adverse event up to 
d180 post-HCT that results in any of the following outcomes: 
• 
Death 
• 
Life-threatening (places the subject at immediate risk of death from the event as it occurred)  

 
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• 
Unplanned hospitalization (equal or greater than 24 hours) or prolongation of existing 
hospitalization 
• 
A persistent or significant disability/incapacity  
• 
A congenital anomaly/birth defect 
• 
Secondary Malignancy 
• 
Any other adverse event that, based upon appropriate medical judgment, may jeopardize the 
subject’s health and may require medical or surgical intervention to prevent one of the 
outcomes listed above (examples of such events include allergic bronchospasm requiring 
intensive treatment in the emergency room or at home, blood dyscrasisas or convulsions that 
do not result in inpatient hospitalization, or the development of drug dependency or drug 
abuse). 
7.2.5 
Unanticipated problems Involving Risk to Subjects or Others  
An unanticipated problem is any incident, experience or outcome that meets all three of the following 
criteria: 
1. Unexpected (in terms of nature, severity, or frequency) given the following: a) the research 
procedures described in the protocol-related documents such as the IRB approved research 
protocol, informed consent document or Investigator Brochure (IB); 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 outcomes may have been caused by the 
drugs, devices or procedures involved in the research); AND 
3. Suggests that the research places subjects or others at greater risk of harm (including physical, 
psychological, economic, or social harm) than previously known or recognized. 
7.2.6 
Assessment of Adverse Events 
The site Investigator will be responsible for determining the event name, and assessing the severity (i.e. 
grade), expectedness, and attribution of all adverse events as applicable per the City of Hope Clinical 
Research Adverse Event and Unanticipated Problem policy. Adverse events will be characterized using the 
descriptions and grading scales found NCI CTCAE v5.0. A copy of the scale can be found at: 
https://ctep.cancer.gov/protocoldevelopment/electronic_applications/ctc.htm.  
The following definitions will be used to determine the causality (attribution) of the event to the study 
agent or study procedure. 
• 
Unrelated – The event is clearly NOT related to study treatment, and is clearly related to other 
factors such as the participant’s clinical state, other therapeutic interventions, or concomitant 
medications administered to the participant. 
• 
Unlikely – The event is unlikely related to the study treatment, and is most likely related to 
other factors such as the participant’s clinical state, other therapeutic interventions, or 
concomitant drugs. 
• 
Possible – The event may be related to study treatment, as it follows a reasonable temporal 
sequence from the time of drug administration, but could have been produced by other factors 
such as the participant’s clinical state, other therapeutic interventions, or concomitant drugs.  
• 
Probable – The event is most likely related to the study treatment, as it follows a reasonable 
temporal sequence from the time of drug administration and a known response pattern to the 
study drug, and is unlikely related to the participant’s clinical state, other therapeutic 
interventions, or concomitant drugs.  

 
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• 
Definite – The event is clearly related to the study treatment, as it follows a reasonable 
temporal sequence from the time of drug administration and a known response pattern to the 
study drug, and is not reasonably explained by other factors such as the participant’s condition, 
therapeutic interventions, or concomitant drugs.  
 
7.3 Routine Reporting of Non-Serious Adverse Events by Site Investigators 
Adverse events of all grades will be reported into the eCRFs by the study CRA. Adverse events recorded in 
the case report forms include: 
o Highest grade events in the reporting period considered possibly, probably or definitely 
related to study agent 
o Highest grade events regardless of attribution  
o All serious adverse events from d100 to d180 
Information should include: participant ID, date of the event, whether the event meets the definition of 
serious, whether the event is an unanticipated problem, grade of event, attribution of event, whether the 
event is a known expected toxicity to study agent. Provide all possible causality to the event (e.g. subject’s 
disease, medical history, comorbidities) 
All adverse events must be followed until the event is resolved, stabilized, or determined to be irreversible 
by the participating investigator; for ongoing adverse events that are unrelated to study agent, the follow-
up period may end at the d30 post-study drug assessment. The Coordinating Center should be consulted 
prior to ending the follow-up of events that have stabilized. 
 
7.4 Expedited Reporting of SAEs and Unanticipated Problems (UPs) by Site Investigators to the COH 
Regulatory Committees 
Serious Adverse Events that require expedited reporting and unanticipated problems will be reported 
according to the approved City of Hope Clinical Research Adverse Event and Unanticipated Problem policy.  
Reporting of all UPs and SAEs will begin from the first vaccine administration till d30, and must be followed 
until the 30 days after the last dose of vaccine.  Follow-up SAE reports must be submitted for all events 
that require expedited reporting when the status of the event changes and until the resolution or 
stabilization of the event. 
Non-COH Sites:  
Serious Adverse Events meeting the criteria specified in the City of Hope Clinical Research Adverse Event 
and Unanticipated Problem policy will be reported to the Data Coordinating Center (DCC) and PI within 
24 hours of notification that the event occurred.  
Procedure for reporting SAEs/UPs to the COH DCC: 
1. Sites are to report to their local IRB per their site’s specific institutional and IRB guidelines. 
As soon as possible, non-COH sites will provide to the COH DCC copies of the IRB submission 
and corresponding IRB response.  
2. Document/describe the SAE/UP on each of the following: 
a. MedWatch 3500A: Downloadable form at 
http://www.fda.gov/medwatch/getforms.htm  
b. UP/SAE Coversheet: A modifiable Microsoft Word document is also available from the 
DCC.  An electronic signature on the document will be accepted. 

 
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3. Scan and email above documents to study Principal Investigator (rnakamura@coh.org) and 
DCC@coh.org with the subject title as “COH IRB 19065 SAE”.  If an email receipt from DCC 
personnel is not received within one working day, please email DCC@COH.org. 
All UPs reported at COH and external sites will be compiled and submitted for review by the Independent 
DMC. 
7.4.1 
Rationale for Expedited Adverse Event Reporting to Local IRB 
The criteria defining expedited reporting is derived from FDA and COH reporting criteria. The following 
should be reported to the local IRB and Study PI within 24 hours of being aware that the event met the 
expedited reporting criteria: 
•  
All unanticipated problems 
• 
All serious adverse events regardless of relationship to study agent, study procedure, underlying 
disease or concomitant treatment from the first vaccine administration till d30 after the vaccine dose. 
• 
All serious adverse events that are considered possibly, probably, or definitely related to the study 
agent observed 30 days after the last dose of vaccine 
Note: follow-up reports must be submitted for all events that require expedited reporting when the status 
of the event changes and until the resolution or stabilization of the event. 
7.4.2 
Reporting of Unanticipated Problems to the FDA  
SAEs meeting the requirements for expedited reporting to the FDA, as defined in 21 CFR 312.32, will be 
reported by COH as an IND safety report using the MedWatch Form FDA 3500A for Mandatory Reporting 
which can found at: 
 http://www.fda.gov/Safety/MedWatch/HowToReport/DownloadForms/default.htm 
The COH PI or designee will be responsible for contacting the Office of IND Development and Regulatory 
Affairs (OIDRA) at COH to ensure prompt reporting of safety reports to the FDA.  OIDRA will assist the PI 
with the preparation of the report and submit the report to the FDA in accordance with the following: 
• 
any unexpected fatal or life threatening adverse experience associated with use of the drug must 
be reported to the FDA no later than 7 calendar days after initial receipt of the information [21 
CFR 312.32(c)(2)]; 
• 
any adverse experience associated with use of the drug that is both serious and unexpected must 
be submitted no later than 15 calendar days after initial receipt of the information [21 CFR 
312.32(c)(1)]; 
• 
any follow-up information to a study report shall be reported as soon as the relevant information 
becomes available [21 CFR 312.32(d)(3)]. 
 
7.5 Independent Data Monitoring Committee (DMC) 
Aggregate data (see Tables 1-5 of the DMC Charter) will be compiled by the Study Statistician. The COH 
DCC will report this study data to the independent Data Monitoring Committee. The Independent DMC 
will comprise three members with appropriate scientific and medical expertise to monitor the study 
progress (see DMC Charter for Committee members). The DMC charter has been written by COH and 
agreed by all DMC members prior to the initial DMC meeting. A DMC chairperson will be appointed who 
will be responsible for conducting the meeting and summarizing the minutes of the closed portions of the 
meeting. All meetings will be held by teleconference, approximately one month after the following occurs:  
• 
approx 32 patients reach d180; 

 
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• 
approx 64 patients reach d180; 
• 
approx 96 patients reach d180; 
• 
At study conclusion (optional final DMC meeting). 
After any NRM within 180 days post-HCT, grade 3-4 aGVHD, grade 3-4 reaction with an attribution of 
‘probably’ or ‘definitely’ related to vaccination (within 2 weeks of a vaccine administration), or any other 
concerning reaction as deemed by the PMT, the DMC chair will be provided information and will 
determine if a DMC review is required.  This information will be provided to the DMC chair as soon as 
practically possible after PMT review. 
NOTE. Modifications to this schedule may be required due to study progress/findings. 
7.6 Toxicities of Triplex 
7.6.1 
Expected (known) toxicities of Triplex 
The potential risks associated with Triplex injection includes pain, swelling, and erythema at the injection 
site, and the potential for bleeding into the site, with possible later abscess, though these risks appear to 
be minimal based on our prior experience. In the completed Phase 2 clinical trial (NCT02506933), in 
alloHCT, the following AEs were attributable to the injection beyond Grade 2 in 11 patients immunized 
twice (Table 2).  
 
Table 2. Grade 3-4 attributable adverse events observed in IRB 14295 (NCT02506933) 
Within 2 weeks after d28 injection 
MEDDRA term 
Max.Grade Attribution Placebo Vaccine 
Alanine aminotransferase increased 
3 
Probable 
1 
0 
Anemia 
3 
Possible 
1 
0 
Lymphocyte count decreased 
4 
Possible 
0 
1 
Neutrophil count decreased 
3 
Possible 
0 
1 
Platelet count decreased 
3 
Possible 
1 
0 
White blood cell decreased 
3 
Possible 
0 
1 
Within 2 weeks after d56 injection 
MEDDRA term 
Max.Grade 
Attribution 
Placebo 
Vaccine 
Alanine aminotransferase increased 
3 
Possible 
2 
0 
 
7.7 Toxicities to the placebo  
7.7.1 
Expected (known) toxicities to placebo 
There are no expected (known) toxicities associated with administering the placebo.  
 
7.8 Risks from Vaccinations and Blood Draws  
In the event of an AE related to vaccination or blood draws, emergency medical care to treat the injury 
will be provided. Patients will be treated at the HCT unit by highly skilled medical staff. Treatment of such 
patients is the responsibility of the HCT physician who will consult with either Dr. Nakamura or the local 
PI in regard to appropriate medication and intervention.  
7.8.1 
Vaccinations 
Vaccinations will be performed in the appropriate CRU at COH, DFCI or Northside. Injection procedure will 
conform to guidance on vaccination of persons with bleeding problems of the Committee on Infectious 
Diseases. Patients will be observed in the clinic after vaccination. There will be telephone contact with the 

 
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CRA and the HCT nurse coordinator assigned to this study.  
7.8.2 
Blood draws 
HCT-R blood draws will take place at either inpatient or outpatient facilities. To minimize risks, draws are 
performed through a central catheter at times when routine blood tests are done and by nurses highly 
skilled in this procedure (>1500 HCT yearly among all three sites). Peripheral blood collections later in the 
study, when the central line is removed, will be limited to monthly or bimonthly. 
 
To avoid lengthy study related travel, blood specimen mailers and questionnaires will be sent for patients 
who live far from COH. Specimens will be returned by express mail.  
 
8.0 
AGENT INFORMATION 
8.1  Triplex and placebo –information applicable to vaccine components 
 Triplex injection will be prepared by the investigational pharmacy from the following component 
provided by the COH CBG:  
 
cGMP Triplex vaccine vials containing 5.1x108  pfu/mL (Lot#0786-181-0001-1) or 9.1x108  pfu/mL 
(Lot#0786-181-0002-1). 
 
COH CBG has filled vials with cGMP Triplex vaccine without lyophilization in the formulation 
buffer of PBS containing 7.5% lactose.  Vials contain approximately 1 mL. 
 
 
The placebo will be prepared by the investigational pharmacy from the following components provided 
by the COH CBG: 
• 
PBS containing 7.5% lactose.  
For all of the above listed components, the following elements apply: 
8.1.1 
Accountability 
The investigator, or a responsible party designated by the investigator, must maintain a careful record of 
the inventory and disposition of each of the agents using the NCI Drug Accountability Record or another 
comparable drug accountability form.  
In addition, documentation of the vaccine preparation (placebo or Triplex) is required.  
8.1.2 
Handling 
Qualified personnel, familiar with aseptic technique and procedures that ensure the quality of the agent 
and minimize undue exposure to themselves and the environment, should undertake the preparation, 
handling, and, when applicable, safe disposal of the agent.  
8.1.3 
Ordering 
The COH IDS pharmacy will order all agents from COH CBG in coordination with and as approved by Dr. 
Diamond (ddiamond@coh.org) and Dr. Nakamura (rnakamura@coh.org). 
The Northside and DFCI pharmacy will order all agents from the COH IDS pharmacy.  
8.1.4 
Destruction and Return 
Vials used in the preparation of vaccine for administration and any residual agents there in may be 
disposed of by the research pharmacy according to approved institutional standard of practice or policy. 
Unused agent will either be returned to the sponsor or disposed of according to approved institutional 

 
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standard of practice. No unused agent will be disposed of without prior written approval by Dr. Don 
Diamond (ddiamond@coh.org).   
 
8.2  Triplex  
8.2.1 
Description 
The Triplex vaccine is a multiple-antigen recombinant MVA with genes encoding 3 major CMV proteins: 
UL83 (pp65), UL123 (IE1), and UL122 (IE2).  All clinical batches of the Triplex vaccine have been 
manufactured at COH CBG, a California Food and Drug Branch (CFDB) licensed manufacturing facility 
which operates under the principles of cGMP for the manufacture of phase I/II biologics.   
Triplex will be expanded on CEF grown in complete VP serum-free medium (Invitrogen). CEF will be 
inoculated into 407 T225 flasks at a seeding density of 4.9 x 104 cells/cm2 and incubated for ~96 hours at 
37°C, 95% humidity and 5% CO2. After ~96 hours, viable cells will be determined from a single flask using 
trypan blue exclusion method. The remaining 400 flasks will be infected at an MOI equal to 0.02 using the 
Triplex Master Viral Seed Stock (MVSS), Batch# 0825-181-0001. Each flask, containing ~9.2 x 106 cells, will 
be infected with 1.8 x 105 pfu of MVSS. Cytopathic effect will be observed ~48 hours post-infection. ~4L 
per sub-batch of harvested crude cell suspension will be collected and ~280 mL of sample from each sub-
batch will be collected for QC testing. Purification of Triplex from pellets produced from four sub-batches 
will be performed on 4 consecutive days. Following Benzonase® treatment (500U/mL), the virus 
suspension will be layered in 6 ultracentrifuge rotor tubes pre-filled with 15 mL of 36% sucrose. Tubes will 
be spun at 32,000xg using a Beckman Optima L90K for 80’ at 4°C. After the second and final wash step, 
the effluent will be removed and viral pellets will be reconstituted in a total of 24mL of 7.5% Lactose/PBS. 
The clinical lot will be prepared by thawing bulk product containers at room temperature and pooling 4 
purified sub-batches. The combined pooled bulk total will be ~80 mL. Prepared pooled bulk will be diluted 
to achieve a final concentration of 5.0-6.0 x 108 pfu/mL in 7.5% lactose/PBS. 
The release testing of the vialed Triplex vaccine to be used in the current Phase II trial was performed by 
BioReliance Corporation (Rockville, MA) and Wuxi-Apptec (Marietta, GA), in compliance with the 
requirements of the FDA Good Laboratory Practice Regulations (21 CFR 58). The vaccine passed all 
applicable release tests specified by the FDA. The toxicology testing of the cGMP Triplex vaccine was 
performed at Southern Research (Birmingham, AL; Study # 13928.01.01). The IND is held by COH (BB-IND 
#15792). 
8.2.2 
Supplier  
Triplex vaccine is being produced, formulated and provided by COH CBG. COH IDS pharmacy or COH CBG 
will supply Northside and DFCI with Triplex vaccine for this study.  
Triplex vaccine is supplied frozen at 5.1x108 pfu/mL or 9.1x108 pfu/mL in the formulation buffer of PBS 
containing 7.5% lactose.  COH CBG has filled vials with cGMP Triplex vaccine without lyophilization as a 
sterile, preservative-free, solution packaged in 2 mL polypropylene cryogenic vials with silicone washer 
seals. Each vial contains approximately 1mL (0.9 - 1.1mL). 
8.2.3 
Storage and stability 
Triplex is to be stored in a monitored freezer between -60 to -90 oC.  Stability analyses of Triplex are 
performed every 12 months.  
8.2.4 
Handling, Ordering, Accountability, Destruction and Return 
See section 8.1. 
 

 
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8.3 PBS containing 7.5% lactose solution for the placebo 
8.3.1 
Description 
PBS containing 7.5% lactose is a sterile, non-pyrogenic solution which is the diluent used in the 
formulation of Triplex. This solution will be used for the placebo injection.  
8.3.2 
Toxicology 
There are no known warnings. Lactose is a reducing sugar commonly used in multiple drugs as an excipient 
or bulking agent.  It is a natural disaccharide consisting of galactose and glucose [147]. It can be 
administered by different routes including IM, as in SOLU-MEDROL® (Pfizer, NY) the anti-inflammatory 
glucocorticoid, often prescribed to HCT patients as in immunosuppressive agent. There are no restrictions 
for diabetes and lactose intolerant patients to take lactose containing medicines, since the amount of 
lactose delivered in drugs is minimal[147]. 
8.3.3 
Formulation 
PBS containing 7.5% lactose will be supplied in a 1.2 mL polypropylene cryovial with a fill volume of 
approximately 1 mL/vial.  The solution contains no bacteriostatic, antimicrobial agent or added buffer.  
8.3.4 
Supplier 
PBS containing 7.5% lactose is produced by COH CBG. The COH IDS pharmacy or COH CBG will supply PBS 
containing 7.5% lactose to Northside and DFCI. 
8.3.5 
Storage and Stability 
PBS containing 7.5% lactose should be maintained between -60oC and -90oC in a temperature-monitored 
freezer. The release testing for PBS containing 7.5% lactose fill includes sterility, bacteriostasis and 
fungistasis, endotoxin, pH and particulate testing. The testing will be performed until the end of the study. 
8.3.6 
Handling, Availability, Ordering, Accountability, Destruction and Return 
See section 8.1. 
 
8.4 Preparation of Triplex injection 
A list of reagents, equipment and supplies needed to prepare the vaccine is located in Appendix D. 
Note: the Triplex vaccine must be administered within 4 hours after thaw. 
Thawing and preparing Triplex injection 
Before the scheduled patient administration, obtain frozen Triplex vaccine vial from -70°C freezer in the 
Pharmacy.   
 
Put cooling block in hood and set to 4-8°C. Once the LCD on the cooling block reads 4-8°C, measure 
the temperature of the cooling block using the NIST thermometer and Enviro-Safe liquid or digital 
thermometer. Adjust LCD until thermometer reads 4-8°C.  Only the thermometer should be relied 
upon for accuracy. 
 
Allow vaccine vial to thaw at room temperature (approximately 15-30 minutes).  Record time at which 
vial is completely thawed. This is the start time of the vaccine dose preparation. Once thawed, place 
vial on the cooling block maintained at 4-8°C.  If there is any delay between thaw and the subsequent 
steps, keep the thawed vial on the cooling block until it is vortexed and spun. 
 
 Thoroughly wipe the exterior of the vial(s) with an alcohol swab.  
 
Vortex vial for 30 seconds at highest setting (this is to minimize clumping). 
 
Spin for 5 seconds in a microfuge at 6000 rpm (this is to maximize the extractable volume).   

 
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 
Unscrew the cap from the vaccine vial and withdraw Triplex into an appropriately sized sterile syringe. 
If using Lot#0786-181-0001-1, withdraw the entire contents of vial (0.9-1mL of vaccine). If using 
Lot#0786-181-0002-1, withdraw 0.55 mL.  
 
Record the time that the Triplex vaccine is placed in an insulated container with ice packs and is ready 
for transport. 
Labeling of the vaccine to communicate necessary information and maintain the blind 
 
The prepared syringe or accompanying documents should be labeled in a manner to maintain a blind 
randomization status with the clinical study team and participant. After labeling appropriately, place 
syringe in sealable, plastic amber bag and place in container with ice packs. 
 
The time by which the vaccine needs to be administered – start time +4 hours – must be clearly noted 
in order to inform the person administering the vaccine (e.g. “Administer before xx:xx am/pm”). 
 
8.5 Preparation of placebo injection 
Preparation 
Note: PBS containing 7.5% lactose solution for the placebo must be administered within 4 hours after 
the solution has been removed from the freezer. 
 
Put cooling block in hood and set to 4-8°C. Once the LCD on the cooling block reads 4-8°C, measure 
the temperature of the cooling block using the NIST thermometer and Enviro-Safe liquid or a digital 
thermometer. Adjust LCD until NIST thermometer reads 4-8°C.  Only the thermometer should be 
relied upon for accuracy. 
• 
Obtain PBS containing 7.5% lactose solution from the Pharmacy freezer.  Record the time at which 
the PBS containing 7.5% lactose solution is removed from the freezer; this is the start time of the 
placebo dose preparation. Allow the vial contents to thaw at room temperature, then keep cold by 
placing vials on the cooling block, maintained at 4-8°C.   
• 
Vortex the vial (containing approximately 1.0 mL of volume) for 30 seconds at highest setting. 
Centrifugation is not required. 
• 
Withdraw 0.55-1.0 mL (depending on vaccine Lot) and cap syringe.  
• 
After labeling appropriately, place syringe in sealable plastic amber bag and place in ice bucket.  
Record the time that the placebo is placed in a container with ice packs and is ready for transport. 
 
Labeling of the syringe to communicate necessary information and maintain the blind 
• 
The prepared syringe or accompanying documents should be labeled in a manner to maintain a blind 
randomization status with the clinical study team and participant. 
• 
The time by which the placebo needs to be administered – start time +4 hours – must be clearly noted 
in order to inform the person administering the vaccine (e.g. “Administer before xx:xx am/pm”). 
 
 

 
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9.0 
CORRELATIVE/SPECIAL STUDIES 
9.1 Immunogenicity testing 
The correlative immunogenicity studies will include monitoring levels and quality of CMV-specific CD8+ T 
cells and highly cytotoxic memory NKG2C+ NK cells, by multi-color flow cytometric analyses. Samples 
drawn for immunologic analysis will be analyzed retrospectively in batch, to improve precision of 
comparisons.  
9.1.1 
Specimen Collection and Transport to Processing Laboratory 
All participants will undergo serial blood sampling for immunogenicity testing at the schedule indicated in 
the Study Activity Calendar (Section 10), which, in general, includes d42, d56, d70, d100, d114, d128, d140, 
d180, d210-240, d270 and d365 post-HCT. A volume of approximately 30 mL of blood in heparin (green-
top) tubes, will be collected, gently inverted several times to mix anti-coagulant, and kept at room 
temperature until transport to authorized personnel in Fox South at COH or at DFCI or Northside.  Samples 
from all pre-registered participants, including Pre-HCT samples from participants who are not randomized 
(vaccinated), will be maintained/included for analysis.   PLEASE SEE SECTION 9.2. 
9.1.2 
Initial specimen processing, storage, and shipping 
Sample processing and storage will occur at COH. All samples from Northside and DFCI will be shipped as 
whole blood. PBMC will be separated from heparinized blood by standard density gradient centrifugation 
methods*, washed, re-suspended in 90% fetal calf serum (FCS) with 10% DMSO, aliquoted, and 
cryopreserved in a centrally monitored liquid nitrogen tanks at the COH Fox South laboratories. Samples 
will be processed and stored according to institutional SOP; it is recommended to freeze 5 million cells 
per aliquot.  Samples will be labeled with the study time point (e.g. d42), date of collection, and study 
protocol number (COH 19065), participant study number and site (e.g. Northside, COH or DFCI).   
* Prior to the processing of the PBMCs, 3 mL of blood will be set aside for plasma extraction. This 3mLs of 
blood will be centrifuged at around 3,000g for 20 mins to spin down the cell fraction. After spinning, the 
upper layer of plasma is removed, transferred to labeled cryotubes and stored at in a suitable laboratory 
freezer between -20oC and -70C, or liquid nitrogen. The cell fraction will be discarded.  
9.1.3 
Analytical Method 
CMV-specific CD8 and CD4 T cells  
All patients will undergo immunogenicity evaluations using Flow cytometry (FC). Blood samples for 
research are collected according to the study calendar to measure CMV-specific T cells by FC at COH. We 
will longitudinally evaluate the CMV-specific T cell response elicited by Triplex by measuring the levels of 
the CD137 surface marker expressed on CD3+ CD8+ and CD3+ CD4+ T cells stimulated for 24 hours with 
either pp65, IE-1-exon4 and IE2-exon5 overlapping peptide libraries (pp65138 at 1 mg/mL; BEI Resources, 
NIH, Bethesda; IE1[128] and IE2[53] at 2 mg/mL; synthesized in-house). CD137 is expressed only on 
recently activated T cells, and its expression correlates with functional activation of T cells [148, 149]. 
Multifunctional, actively proliferating CMV-specific T cells with antiviral activity have a predominantly 
differentiated memory phenotype that is characterized by loss of membrane expression of the 
costimulatory molecule CD28 (TEM, effector memory T cells), and include large T cell populations which 
re-express the RA isoform of CD45 (TEMRA, CD28-CD45 RA+)[150-153]. Thus, measurements of CD137 
levels will be combined with immunophenotyping studies by using antibodies to CD28 and CD45RA cell 
surface markers as recently described to identify percentage of effectors (TEM and TEMRA), memory 
(TCM, CD28+ CD45-) and naïve (CD28+CD45+) CMV-specific T cells. We will utilize a modified 6-parameter 
FC approach as we published for CD4+ and CD8+ T cells,[69]. All immunophenotyping will be conducted on 
freshly thawed PBMC without stimulation in vitro.  PBMC will be stained with each fluorochrome-
conjugated antibody combination using standard methods (BD Biosciences, San Jose, CA), as described in 

 
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our published studies [112],[154].  In combination with the complete blood count (CBC), we will be able 
to calculate the absolute number of pp65 or IE1-exon 4 or IE2-exon 5–specific CD8 and CD4 T cells/L and 
their phenotypic profiles.  The phenotypic ratios and levels of CMV-specific T cells will be related to control 
of CMV viremia as a 20 endpoint.  
 
PD-1 expression [155] will be measured on CD137+ T cells following stimulation with pp65, IE-1-exon4 and 
IE2-exon5 peptide libraries. Assessment of CMV-specific T cell growth kinetics will be performed using 
CFSE dilution, while cell death will also be evaluated using ApoAlert (Clontech) [156]. Reduction of PD-1 
expression, decreased apoptosis and increased proliferation of CMV-specific T cells is expected in Triplex 
(VA) injected compared to placebo injected (PA) HCT-R. Based on recent mechanistic studies on the fate 
of T cells during chronic viral infections, the differential expression of the T-box transcription factors T-bet 
and Eomesodermin (Eomes) will be measured[161-163]. Combining intracellular Eomes and T-bet analysis 
with measurements of CD137 levels and T cell memory markers detailed above will better define if Triplex 
compared to placebo alters the recognition, activation and differentiation properties of expanded, 
resident or circulating CMV-specific T cells.  
 
CD57+NKG2CHi NK cells  
Characterization of CD57+NKG2CHi NK cells, known to play a role in CMV infection [157-160] will be 
performed by flow cytometric analysis after staining PBMC samples with the following antibodies: CD3, 
CD16, CD56, CD57, NKG2C (BD Biosciences).  
 
9.2 MVA vector persistence 
As recommended by FDA, persistence of the Triplex vaccine in the blood of vaccinated patients will 
monitored during the 12 month observation period after receipt of both doses of vaccine.  
We developed and published a strategy of simultaneously detecting the MVA backbone and CMV 
transgenes for analysis of stability of the vector through passage by real-time qPCR using SYBR®-green 
and conventional short oligonucleotides as required by the FDA [127]. As per the FDA guidance, we will 
employ sensitivity of <50 copies of MVA/µg genomic DNA to the analysis utilizing longitudinal blood 
specimens drawn on d100 and d180 from trial participants. Samples collected at external trial sites will be 
frozen as whole blood, or cell fractions prior to batch shipping to COH for analysis. If samples are collected 
in non-glass vacutainer tubes, they can be frozen in the collection tube with no further processing. Whole 
blood or cell fractions should be frozen and stored in a suitable laboratory freezer between -20oC and -
80oC until shipping to COH. DNA will be extracted from the white cell fraction of the blood and qPCR 
analysis performed. The analysis will be performed in a single batch at end of the study after un-blinding 
procedures have been completed.  

 
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10.0 STUDY CALENDAR 
Table 3. Study Activity Calendar  
 
Pre-Vaccination 
Vaccination and Bi-Weekly 
Visits b 
Post-d180 Follow-
Up c 
Study day a 
** -60 to 0 (pre-HCT) 42 56 70-93 100 d 
114 128 d 140 180 210-240 270 365 
Informed Consent f 
X 
 
 
 
 
 
 
 
 
 
 
 
Medical history & demographics g 
X 
 
 
 
 
 
 
 
 
 
 
 
Concurrent medications h 
 
 
 
Xi 
X 
X 
X 
X 
X 
Xj 
X 
X 
Physical exam and vital signs k 
 
 
 
X 
X 
 
X 
 
 
 
 
 
KPS performance status l 
 
 
 
X 
X 
 
X 
 
 
 
 
 
Adverse event (CTCAE) assessment m 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
Engraftment status n 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
Disease relapse o 
 
 
 
 
X 
X 
X 
X 
X 
X 
X 
X 
GVHD assessment and grading p 
 
 
 
 
Xq 
X 
Xr 
Xr 
X 
X 
X 
X 
CMV disease s 
 
 
 
 
Xt 
X 
Xt 
X 
X 
 
 
Xu 
CMV qPCR v 
 
 
 
 
X 
X 
X 
X 
X 
Xw 
X    
X 
HIV, HCV, CMV, active HBV x 
X 
 
 
 
 
 
 
 
 
 
 
 
Pregnancy test y 
 
 
 
 
X 
 
X 
 
 
 
 
 
Chemistry/metabolic panel z 
 
 
 
 
X 
 
X 
 
 
 
 
 
CBC with differential aa 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Research blood sample bb 
 
X 
X 
X 
X* 
X 
X 
X 
X* 
X 
X 
X* 
Criteria review 
 
 
 
Xcc,dd 
Xee 
 
X ee 
 
 
 
 
 
Registration/verify with DCC 
Xdd,ff 
 
 
 
 
 
 
 
 
 
 
 
Vaccine administration gg 
 
 
 
 
X 
 
X 
 
 
 
 
 
** Criteria review, screening, consent and Registration with DCC permitted d-60 to d0 
a. Study day is defined relative to the day of HCT which is defined as d0. 
b. Window for post-HCT d100 and Bi-Weekly Assessment procedures is the assigned day +/- 5 days.  
c. Windows for the ‘Post-d180 Follow-Up’ visits is the assigned day +/- 15 days. 
d. All assessments to be performed and reviewed on the day of and prior to vaccine administration, 
except for CMV qPCR for which the result may remain pending.  
e. On d142 post-HCT, 14 days after the second vaccination, administration of other vaccines is no longer 
prohibited (Section 5.6). 
f. 
Informed consent process to be fully documented. Medical history and demographics– to include 
any ongoing medical conditions and medical history pertaining to eligibility on study and involvement 
during study.  
g. Concurrent medications, supportive care, blood products, or radiation therapy taken or administered 
during the trial will be documented in the subject’s medical record using institutional documentation 
guidelines. 
h. Concurrent medications pertaining to eligibility criteria will be reviewed. 

 
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i. 
Concurrent medication data collected in CRFs pertains to anti-viral medications (including start and 
stop date), immunosuppressive agents, daily prednisone dose for 7 days prior to vaccine 
administration, and prohibited medications (Section 5.6).   
j. 
Concurrent medication data collected after d180 is limited to anti-viral medications (including start 
and stop date). 
k. Physical exam to include skin assessment. Vital signs:  Weight, heart rate, blood pressure, respiration 
rate, temp.  Height required only at baseline. 
l. 
KPS scale is found in Appendix C.  
m. Adverse events (AEs) will be assessed and documented in the source documents and the case report 
forms at defined study visits and at standard of care visits. All grade 1 and 2 AEs that occur within 2 
weeks from each vaccination will be reported. All grade 3/4/5 AEs will be reported from d100 to 
d180. All serious adverse events as defined in Section 7.3.4 will be reported up to d180. All AEs 
considered possibly, probably or definitely related to study agent will be reported from d100 until 
d180.  See Section 7.0 for AE reporting. 
n. Engraftment status should be documented at each study visit, and if engraftment failure occurs the 
date of engraftment failure should be noted (see Section 5.3.3 for definitions).  
o. See Section 5.3.4 for definition of disease relapse. Disease relapse will be assessed according to and 
per the timing of institutional SOC practice for the participant’s specific hematologic malignancy. 
Note: participants who undergo disease relapse will cease all future study visits/procedures and will 
be followed only for survival through d365. 
p. Acute and chronic GVHD grading scales are found in Appendix A and B, respectively. The final grading 
may occur after a clinic visit has ended, using all diagnostic information available to determine the 
GVHD grade at the time of the visit. In the study CRF, the grade at the time of the study visit will be 
recorded, and the highest grade and date of onset during the interim period between visits (assessed 
at SOC visits), if higher than the grade at the visit. 
q. For the d100 visit, assessment and grading of GVHD for the 7 days prior to the visit must be 
determined and documented on the day of the visit to assess/support vaccine administration criteria. 
The determination may be revised as more information is available, but will be documented in the 
medical record and in the CRF as a revised GVHD assessment and grading following new information 
obtained after vaccine administration. 
r. For the d128 visit, assessment and grading of GVHD between the initial vaccination and d128 must 
be determined and documented on the day of the visit to assess/support vaccine administration 
criteria. The determination may be revised as more information is available, but will be documented 
in the medical record and in the CRF as a revised GVHD assessment and grading following new 
information obtained after vaccine administration. 
s. Clinically confirmed CMV disease will be captured in the case report forms. Presentations or 
suspected presentations of CMV disease in the absence of qPCR ≥625 IU/mL will be evaluated by the 
treating investigator in conjunction with the blinded PMT before a determination is made.  
t. Participants with suspected CMV disease on the day of planned vaccination must have testing to 
confirm the presence or absence of CMV disease prior to determining for the CMV disease 
vaccination administration criterion.  
u. For the d365 visit, the treating investigator will investigate and document whether CMV disease 
occurred d180 onward, and so note the findings accordingly.  The case report forms will be updated 
to record any positive results not yet documented. 

 
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v. CMV qPCR will be performed at minimum bi-weekly between d100 and d180 post-HCT. CMV results 
will be collected in the case report forms.   
w. Post d180, CMV qPCR to be performed only if clinically indicated or per institutional SOC. All CMV 
qPCR results will be collected in the case file.  
x. CMV serostatus, HIV antibody, Hepatitis C antibody, Hepatitis B surface antigen test must be 
performed if results are not available within 2 months of registration. If CMV seropositive status not 
already documented, CMV serotesting may be performed for eligible review. 
y. Serum or urine pregnancy test to be performed for women of child bearing potential. 
z. Chemistry/metabolic panel to include: glucose, BUN, creatinine, uric acid, total proteins, albumin, 
calcium, phosphorous, sodium, potassium, chlorine, total CO2, total bilirubin, alkaline phosphatase, 
ALT, AST, LDH, total cholesterol. 
aa. CBC with differential is to be taken at the same time as the research blood sample.  
bb. Research blood samples are to be collected at the same time as the CBC with differential. A volume 
of approximately 30 mL of Blood will be collected in heparin (green-top) tubes, gently inverted 
several times to mix anti-coagulant, and then kept at room temperature until transport to authorized 
personnel of the COH Fox South, Northside or DFCI Research laboratory. Approximately 27 ml and 3 
ml are allocated for PBMC and plasma isolation respectively. * indicates that at d100, d180 and d365 
one additional tube with approximately 3 mL of blood will be collected for the evaluation of the 
persistence of the MVA vector (see Section 9.2). In addition, in the case of a detectable CMV 
reactivation, external study sites will collect an extra tube (5 ml, EDTA) at each research blood time 
point until d100, for CMV harmonization measurements. 
cc. Eligibility criteria for enrollment in the clinical trial are found in Section 3.0.  
dd. d100 Vaccine Administration Criteria are found in Section 6.1. Participants failing to meet d100 
vaccine criteria will complete the study at this time and be replaced and the study team should 
promptly inform the DCC.  
ee. d128 Vaccine Administration Criteria are found in Section 6.2. Participants failing to meet d128 
vaccine criteria will continue with remaining study procedures; participants with disease relapse will 
continue for survival follow-up only.  
ff. The study team will submit copies of source documentation, the eligibility criteria list, signed 
consent, and registration cover sheet to the DCC who will proceed to confirm study eligibility and 
register the participant.  See Section 4.2 for details.  
gg. Vaccine administration is detailed in Section 5.0. 
 

 
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11.0 ENDPOINT EVALUATION CRITERIA/MEASUREMENT OF EFFECT 
The primary aims of this trial are to estimate the efficacy of Triplex in reducing the frequency of CMV 
events, and to further evaluate the safety and tolerability in HCT recipients. Secondary endpoints will 
include additional safety, clinical and immunological parameters. In detail: 
 
Primary endpoint:  
1) Clinically significant CMV reactivation prompting antiviral therapy, or CMV disease (defined by 
histology) from d100 post-HCT and to d180 post-HCT. Death or relapse/progression prior to d180 post 
HCT will be counted as competing risk events. Patients who are alive and free of CMV events and 
relapse/progression at the last follow-up or d180 post HCT, whichever comes first, will be censored. 
 
Secondary endpoints:  
1) Key safety endpoints: non-relapse mortality (NRM) at d365 post-HCT, severe (grade 3-4) acute 
GVHD, and grade 3-4 AEs probably or definitely related to the vaccination and MVA vector 
persistence. 
2) CMV-related events:  duration of viremia, duration of anti-CMV therapy, peak CMV PCR value, 
recurrence of CMV viremia, incidence of late CMV reactivation or disease at d365.  
3) Transplant-related events: time to engraftment, incidence of aGVHD, chronic GVHD, relapse, non-
relapse mortality, all-cause mortality, infections and overall survival at d365.   
4) Immunological function:  levels and kinetics of CMV-specific T cell immunity, combined with 
immunophenotyping [34, 144, 145], and functional studies[161, 164]. NK phenotype and function 
(cytotoxicity and cytokine production) at d365. 
 

 
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12.0 STATISTICAL CONSIDERATIONS 
12.1 Study Design 
This is a randomized, blinded and placebo controlled Phase II trial conducted at three centers, COH, 
Northside and DFCI with data coordination at COH.  The primary aim of the trial is to assess the property 
of Triplex to protect CMV-positive haploHCT recipients from CMV events. A secondary aim is to estimate 
the effect of Triplex on levels of CMV cellular immunity in HCT-R+ [165-167] and to describe the 
association of CMV cellular immunity with CMV reactivation events.  Additional secondary aims are to 
evaluate safety and to evaluate the effect of Triplex on transplant-related outcomes and CMV related 
events e.g. the duration and treatment of viremia.  The study includes rules for periodic safety monitoring. 
12.2 Randomization 
The trial has a target of 128 randomized adult HCT recipients.  We estimate that 151 enrolled patients will 
yield 128 randomized and evaluable subjects to d180. A computer-generated randomization, stratified by 
donor CMV serostatus and center, will assign registered participants to the Triplex or placebo arm; the 
treatment assignment will be provided to site pharmacists, who are unmasked to treatment-group 
allocation, in advance of planned vaccination. Registered participants will be followed for the course of 
transplant and be assessed for the eligibility for ‘d100 post-HCT’ vaccination. 
Participants who meet the initial vaccine administration criteria will receive the initial injection (vaccine 
or placebo); participants failing to meet the criteria will be replaced.  Only participants who receive an 
injection (Triplex or placebo) will be considered “randomized”, as there is no opportunity for a drop-out 
bias prior to injection in this double-blinded study.  All participants who receive a first injection will be 
included in the primary analysis, regardless of receipt of the second injection, consistent with the 
intention-to-treat principle.  Information regarding registered participants who do not receive the 
planned injection will be entered into the computer-generated randomization log to inform subsequent 
treatment assignments (their assignments will be replaced at randomly designated slots in the 
randomization log). Participants who do not meet the criteria to receive the first injection (Triplex or 
placebo) will leave the study, without further treatment or follow-up, but their data collected up to study 
departure will be included in the trial dataset as non-randomized subjects, and these data will be 
incorporated into estimates of CMV event rates post-HCT based on the intention to treat principle. 
 
12.3 Sample Size Accrual Rate 
The primary objective is the comparison of the rate of clinically significant CMV reactivation (CMV-
directed antiviral therapy, or CMV disease) in patients receiving vaccine or placebo. Event times will be 
defined as the first event meeting the definition. The time of CMV disease will be used in cases that are 
not preceded by detectable reactivation. Statistical methods will be based on time-to-event analysis with 
competing risks. A conservative power calculation is based on reactivation by d180 as a binary event. A 
reactivation rate of 27% on the PA is based on data described in Section 2.4 for subjects who have not 
reactivated prior to d100 post-HCT. We estimate that 151 enrolled participants will yield 128 randomized, 
evaluable subjects to d180, permitting a 63% reduction (from 27% to 10%) in reactivation to be detected 
with 80% power using a 1-sided hypothesis test at 0.05 level of significance, based on simplified 
comparison of binary rates with one interim analysis for futility when a half of the information has been 
collected and a final analysis. A single-boundary (non-binding futility) design is used. Spending functions 
with Rho Family (ρ=4.3) are chosen to derive futility boundary. Kaplan-Meier estimate of d100 survival is 
89.8% among 119 recipients of haploHCT at COH in the past 5 years (unpublished). Assuming 15% all-
cause attrition, a total of 151 randomized patients should provide at least 64 per arm that are evaluable 
at d180, in 8 years of accrual. Our previous work showed that recurrence was strongly influenced by donor 
CMV status, hence incorporation of time-to-events and recurrent events should increase power [14]. A 

 
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sample size of 128 patients (64 per arm) provides overall one-sided type I error of 5% and 80% power for 
a one-sided test to detect the difference of 17% in the rate of clinically significant CMV reactivation 
between 2 arms. Sample size and boundary calculation were obtained using EAST 6.4 
12.4 Data Analysis Plan 
Analysis of CMV events: The primary statistical analysis will compare vaccine and placebo regarding 
cumulative incidence of CMV events from first injection to d180 post HCT using Gray’s test. Clinically 
significant CMV reactivation is defined in section 11.0.  
Kaplan-Meier curves and log-rank test will be used to compare overall survival. Cumulative incidence 
curves and Gray’s test will be used to compare aGVHD, cGVHD, infections, relapse, and NRM. Repeated 
measures analyses will be used for immune responses.  
12.5 Safety Monitoring 
Since HCT entails substantial risks, monitoring for expected AEs involves rate comparisons, and it entails 
some risk of false alarms. Since the number of control subjects is initially small, early safety monitoring 
will involve comparisons of vaccine groups to historical benchmarks for haploHCT. Safety monitoring will 
involve interim analyses with explicit, protocol-specified stopping rules. Because interim safety 
monitoring focuses on the vaccine arm, it will involve unmasking treatment assignments, and will be done 
by an independent statistician from the COH Biostatistics Core in conjunction with the independent 
external DMC. The independent statistician from the COH Biostatistics Core will have access to unblinded 
data. Early safety monitoring will be based on comparison of severe GVHD, secondary graft failure and 
treatment-related death to historical rates.  
 
Final analysis of HCT-R safety will be based on comparison of vaccine and placebo regarding severe GVHD, 
immune reconstitution, and survival. Establishing equivalence of secondary graft failure and GVHD rates 
with and without vaccine is infeasible with modest sample sizes appropriate to a Phase 2 trial, but 
comparisons will be made using standard methods for right-censored data with interim analysis using 
standard group-sequential testing[169].  While unlikely that vaccine would have a deleterious effect on 
survival, and safety will be directly assessed as described above, early death removes patients from the 
set at risk for CMV reactivation. To avoid possibility of such an effect favoring VA, we plan a 20 analysis 
comparing event-free survival in both VA and PA. No systematic increase of grade of acute or chronic 
GVHD was observed in the in the VA in the HLA-matched Phase 2 trial (NCT02506933).  
 
Stopping rules were developed using Pocock stopping boundaries [170]. We anticipate grade 2 AEs related 
to vaccination, and this caution will be explained in the consent form.  
 
(1) d180 NRM will be monitored as every 20th subject on the VA reaches the d180 evaluation point, i.e. 
d180 of follow-up or death. Operationally, the CRC will notify the monitoring statistician as cohorts of 40 
patients (20 vaccinated) near the d180 mark.  The 3rd evaluation will be at the 64th subject on the VA, and 
will be a final test for excessive NRM. Stopping rules are specified in Table 4, which gives the maximum 
tolerated d180 NRM at each monitoring point. If NRM frequencies exceed these bounds, which are based 
on historical rates, the study will be suspended for safety review by the external DMC. These numbers 
were selected to limit the overall false-alarm probability for this endpoint to 0.03 when there is no 
additional risk due to immunization, and the expected NRM rate in this haploHCT population may be 20%.  
 
(2) Severe GVHD or secondary graft failure will be monitored as every 20th subject on the VA reaches the 
d180 evaluation point, i.e. d180 of follow-up or a grade 3-4 aGVHD or severe cGVHD event. aGVHD will 
be scored using Keystone consensus criteria [171]. Whenever possible, aGVHD will be confirmed 

 
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histologically with microscopic review. Stopping rules for severe GVHD or secondary graft failure are also 
specified in Table 4. The study will be interrupted for safety review by the external DMC if 6 or more of 
the first 20 recipients experience severe GVHD or secondary graft failure. This would be a significant 
elevation from the expected maximum rate of 15% based on COH historical benchmark of 13.7% of 
haploHCT-R (M. Al-Malki et al, ASH 2017 Abstract). However, any smaller critical number would entail an 
unacceptable false alarm rate.  These rules are determined to limit the overall GVHD or secondary graft 
failure false alarm probability at any 1 of the 3 monitoring times to 0.02 if vaccination does not increase 
risk [172], for a total false alarm rate of 0.031 across all three monitoring points.   
 
(3) Event-Free Survival (EFS) will be defined as the time from HCT to severe GVHD, relapse, or death.  The 
reason for evaluating this endpoint is to guard against the possibility that vaccination may have multiple 
deleterious effects. EFS combines potential adverse outcomes so that they reinforce, rather than disguise 
each other. Since the ad hoc nature of this endpoint comparison of the VA to concurrent controls is 
necessary, making the endpoint too variable for effective interim monitoring. EFS will be analyzed at the 
end of the study to produce a 90% 1-sided confidence limit on the hazard ratio. The EFS analysis thus 
provides due diligence in checking for a substantial adverse impact, although no difference in EFS is 
expected.   
  
Table 4.  Stopping rules for mortality and severe GVHD/secondary graft failure  
(>given number of events will stop the trial) 
Clinical endpoint 
Number of patients treated 
Total Recipients at d180 (VA and PA arms – for identifying analysis time) 
40 
80 
128 
Expected # of recipients on VA (masked information)  
20 
40 
64 
Suspend accrual if VA recipients with NRM at d180 (20% expected) 
>6 
>11 
>15 
Suspend accrual if VA recipients w/severe GVHD/secondary graft failure (15% 
expected) 
>5 
>9 
>12 
 
(4)  Simultaneously monitoring NRM, severe GVHD, and secondary graft loss safety outcomes generates 
an 11% chance of at least 1 false alarm if all safety outcomes were stochastically independent and at their 
expected and tolerable rates, with no excess risk due to vaccination. Since there is some overlap of 
endpoints, and some risks may be slightly lower than the tolerable rates cited, we expect the overall false 
alarm rate to be <10%. We believe this constitutes the most cautious safety monitoring plan that is feasible. 
Any crossing of the monitoring boundaries would immediately stop enrollment, and a decision by the 
external DMC would be required before the trial could be re-opened. 
 
12.6 Interim analyses 
One interim futility analysis will be performed after half of the patients (n=64) are evaluated for the primary 
endpoint. A final analysis after accrual and follow up for the primary endpoint is complete will be carried 
out. No efficacy interim analyses will be conducted. The stopping rules serve as a trigger for consultation 
with the DMC for additional review of safety endpoints and secondary endpoints, and are not formal 
stopping rules that would suspend accrual immediately. External DMC will monitor the study regularly. 
 
Non-binding futility boundary (Table 5) is calculated using Rho family spending functions with ρ equal to 
4.3. When 64 patients have been evaluated for the primary endpoint, we will perform interim futility 
analysis. The rate of CMV events will be calculated by arm. The test statistic and one-sided p value will be 
computed. If the rate of CMV events is higher in VA arm than PA arm (the difference >5%), Z statistic > 

 
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0.517, or one-sided p value >0.697, we would suggest DSMB to review the trial. Operating characteristics 
of the design is show Table 6. 
 
Table 5. Interim non-binding stopping rule 
Single boundary non-binding stopping rule with one-sided type I error 5%, Power 80%,  the difference of 
17% in CMV event rates at d180 between 2 arms and polled estimate for variance 
Information 
Fraction 
Sample 
Size 
Cumulative 
β spent 
Boundary 
for 
difference 
in 
CMV event rate 
(VA-PA) 
Boundary 
for p value 
Futility 
Boundary 
Z statistic 
Conditional 
power boundary 
under 
alternative 
0.5 
64 
0.01 
0.05 
0.697 
0.517 
0.132 
1 
128 
0.198 
-0.113 
0.05 
-1.645 
 
 
Table 6. Operating characteristics of the design 
Difference in rate of 
CMV events between 2 
arms (VA-PA) 
Expected Sample Size 
Overall 
cumulative 
power 
Probability 
of 
Early 
Stopping due to futility 
10% 
87 
0.2% 
70.5% 
5% 
98 
1.2% 
50.4% 
0% 
109 
5% 
30.3% 
-5% 
118 
16% 
14.8% 
-10% 
124 
38.7% 
5.8% 
-15% 
127 
69% 
1.8% 
-17% 
127 
80% 
1.0% 
-20% 
128 
92% 
0.4% 
 
13.0 
DATA HANDLING, DATA MANAGEMENT, RECORD KEEPING 
13.1 Source Documents 
Source documents are original documents, data, and records (e.g., medical records, pharmacy dispensing 
records, recorded data from automated instruments, laboratory data) that are relevant to the clinical trial.  
The Site Investigator or their designee will prepare and maintain adequate and accurate source 
documents.  These documents are designed to record all observations and other pertinent data for each 
patient enrolled in this clinical trial.  Source documents must be adequate to reconstruct all data 
transcribed onto the case report forms. 
 
13.2 Data Capture Methods and Management 
Data for this trial will be collected using Medidata RAVE, City of Hope’s electronic capture system. 
Medidata RAVE is a web based, password protected system that is fully compliant with global regulatory 
requirements, including 21CRF Part 11 compliant.  
Study personnel at each site will enter data from source documents corresponding to a subject’s visit into 
the protocol-specific electronic Case Report Form (eCRF).  A system of computerized data validation 
checks will be implemented and applied to the database on a regular basis. Queries are entered, tracked, 

 
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and resolved through the EDC system directly. The study database will be updated in accordance with the 
resolved queries.  All changes to the study database will be documented. 
The Data Coordinating Center will run monthly data expectation reports that will list any outstanding and 
overdue data. The Data Coordinating Center will send via email to the participating site a report monthly 
on any missing and/or overdue data forms.  The participating site will be required to complete the missing 
and/or overdue data forms within 1 week of receipt of the report. 
Query reports will be generated on a monthly basis by the Data Coordinating Center. The Data 
Coordinating Center will send via email to the participating site a report monthly on any outstanding 
queries.   
The participating site staff (whether Principal Investigator or the staff collecting data at site) are required 
to take an eLearning Module within Medidata RAVE in order to obtain full access. The participating site 
staff will receive training via teleconference by COH DCC staff to review eCRFs that are specific to this 
protocol.  Continuous training will be offered to participating sites if any amendments affect changes to 
the eCRFs during the course of the trial. The eCRFs within Medidata RAVE for this trial will have detailed 
instructions in the form of Help Text that provide instructions for completing each required field on each 
form. 
 
13.3 Case Report Forms/Data Submission Schedule 
Study personnel at each site will enter data from source documents corresponding to a subject’s visit into 
the protocol-specific electronic Case Report Form (eCRF) when the information corresponding to that visit 
is available.  
The Investigator is responsible for all information collected on subjects enrolled in this study.  All data 
collected during the course of this study must be reviewed and verified for completeness and accuracy by 
the Investigator.  All case report forms must be completed by designated study personnel.  The completed 
case report forms must be reviewed, signed and dated by the Site Investigator or designee in a timely 
fashion. 
All data will be collected using electronic data collection system described in Section 13.2, and will be 
submitted according to the timelines indicated in Table 7 (below). 
Table 7. Data Submission Schedule 
Form 
Submission Timeline 
Eligibility Checklist 
Complete prior to registration  
On Study Forms 
Within 14 calendar days of registration 
Baseline Assessment Forms 
Within 14 calendar days of registration 
Treatment Forms 
Within 14 calendar days of treatment administration 
Adverse Event Report Forms 
Within 14 calendar days of the study visit 
Response Assessment Forms 
Within 10 calendar days of the response assessment 
Other Assessment Forms (concomitant 
medications, chemistry, hematology etc.) 
Within 10 calendar days of the assessment 
Off Treatment/Off Study Forms 
Within 10 calendar days of completing treatment or being 
taken off study for any reason 

 
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13.4 Regulatory Records 
The Investigator will maintain records, including updating records in accordance with Good Clinical 
Practice guidelines and FDA regulations. Additional information regarding required documents is provided 
in the DCC Operations Manual, a supplement to this protocol. 
14.0 ADHERENCE TO THE PROTOCOL 
It is understood that deviations from the protocol should be avoided, except when necessary to eliminate 
an immediate hazard to a research participant. Protocol deviations may be on the part of the subject, the 
investigator, or study staff.  As a result of deviations, corrective actions are to be developed by the study 
staff and implemented promptly. 
All deviations from the protocol must be documented in study subject source documents and promptly 
reported to the Study PI.  Protocol deviations will be submitted according to study site procedures to the 
local IRB (e.g. IRIS at COH), but programmatically exempted from local DMC review. A deviation report, 
which will include protocol deviations, will be prepared every 3 months for consideration by the COH PMT 
and Independent DMC.   
14.1.1 Emergency Modifications 
Investigators may implement a deviation from the protocol to eliminate an immediate hazard(s) for the 
protection, safety, and well-being of the study patient to trial subjects without prior IRB or Sponsor 
approval.  
For any such emergency modification implemented,  
o the local IRB must be notified according to local institutional policies.  
o the Study Principal Investigator must be notified as soon as practicable (within 24 hours) via email 
to rnakamura@coh.org and dcc@coh.org.  This email should provide input on the following: 
– 
Description of the event 
– 
Impact on participant safety or the safety to others 
– 
Impact on the study design 
14.1.2 Planned Non-Emergency Deviations 
All non-emergency planned deviations from the protocol must have prior approval by the Study Principal 
Investigator, the Site Principal Investigator and the local IRB, and if applicable the COH IRB. 
 Unplanned Deviations – Deviations Discovered After They Have Occurred 
For deviations to the protocol discovered after they have occurred,  
o the local IRB must be notified according to local institutional policies.  
o the Study Principal Investigator must be notified as soon as practicable (within 24 hours of 
awareness of event) via email to rnakamura@coh.org and dcc@coh.org.  This email should 
provide input on the following: 
– 
Description of the event 
– 
Impact on participant safety or the safety to others 
– 
Impact on the study design 
– 
A corrective and preventative action plan 
A list of deviations from all participating sites will be submitted along with the PMT progress report to the 
external DMC. 

 
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15.0 STUDY OVERSIGHT, QUALITY ASSURANCE, AND DATA & SAFETY MONITORING 
15.1 Site Principal Investigator  
The Principal Investigator is responsible for the conduct of the clinical trial at the site in accordance with 
Title 21 of the Code of Federal Regulations. The Principal Investigator must assure that all study site 
personnel, including sub-investigators and other study staff members, adhere to the study protocol and 
all FDA/GCP/NCI regulations and guidelines regarding clinical trials both during and after study 
completion. 
An investigator is responsible for ensuring that an investigation is conducted according to the signed 
investigator statement, the investigational plan, and applicable regulations; for protecting the rights, 
safety, and welfare of subjects under the investigator's care; and for the control of drugs under 
investigation.  
The Investigator agrees to: Conduct the study in accordance with the protocol and only make changes 
after notifying the Sponsor (or designee), except when necessary to protect the safety, rights or welfare 
of subjects. Personally conduct or supervise the study (or investigation). Ensure that the requirements 
relating to obtaining informed consent and IRB review and approval meet federal guidelines, as stated in 
§ 21 CFR, parts 50 and 56. Report to the Sponsor or designee any AEs that occur in the course of the study, 
in accordance with §21 CFR 312.64. Ensure that all associates, colleagues and employees assisting in the 
conduct of the study are informed about their obligations in meeting the above commitments. Maintain 
adequate and accurate records in accordance with §21 CFR 312.62 and to make those records available 
for inspection with the Sponsor (or designee). Ensure that an IRB that complies with the requirements of 
§21 CFR part 56 will be responsible for initial and continuing review and approval of the clinical study. 
Promptly report to the IRB and the Sponsor (see Section 14) all changes in the research activity and all 
unanticipated problems involving risks to subjects or others (to include amendments and IND safety 
reports). Seek IRB and Sponsor (see Section 14) approval before any changes are made in the research 
study, except when necessary to eliminate hazards to the patients/subjects. Comply with all other 
requirements regarding the obligations of clinical investigators and all other pertinent requirements listed 
in § 21 CFR part 312. 
15.2 Study Principal Investigator 
The Study Principal Investigator is responsible for the conduct of the clinical trial, including overseeing 
that sponsor responsibilities are executed in accordance with federal regulations.  
 
15.3 Protocol Management Team (PMT) 
The Protocol Management Team (PMT) minimally consisting of the study principal investigator, site 
principal 
investigators, 
collaborating 
investigators, 
research 
nurse, 
clinical 
research 
associate/coordinator, and the study biostatistician is responsible for ongoing monitoring of the data and 
safety of this study, including implementation of the stopping rules for safety/toxicity. 
The PMT is recommended to meet (in person or via teleconference) to review study status. The meeting 
is a forum to discuss study related issues including accrual, SAE/AE/UPs experienced, study response, 
deviations/violations, and study management issues. The appropriateness of further subject enrollment 
and the specific intervention for subsequent subject enrollment are addressed.  
PMT reports will be prepared at COH using the PMT report form in IRIS. Since there is an Independent 
DMC for this study, PMT reports will be exempt from COH Committee review, but stored as ‘submitted’ 
in IRIS. PMT reports will be retrieved by the study CRA for review by the Independent DMC as necessary.  
 

 
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15.4 Monitoring  
This is a moderate risk level study which requires automatic auditing after the first 2 research participants 
have been treated.)  
The Investigator/Institution will permit direct access of the study monitors and appropriate regulatory 
authorities to the study data and to the corresponding source data and documents to verify the accuracy 
of this data. 
The investigator will allocate adequate time for such monitoring activities.  The Investigator will also 
ensure that the monitor or other compliance or quality assurance reviewer is given access to all the above 
noted study-related documents and study related facilities (e.g. pharmacy, diagnostic laboratory, etc.), 
and has adequate space to conduct the monitoring visit. 
Clinical site monitoring is conducted to ensure that the rights of human subjects are protected, that the 
study is implemented in accordance with the protocol and regulatory requirements, and that the integrity 
of data and data collection methods are maintained.  Monitoring for this study will be performed by the 
City of Hope Office of Clinical Trials Auditing and Monitoring (OCTAM), who are experienced in the 
monitoring of blinded clinical studies. Monitoring is conducted according to the COH OCTAM SOP. COH 
will monitor activity at sub-sites as if the study were conducted at COH. 
Staff from OCTAM will conduct monitoring activities and provide reports of the findings and associated 
action items in accordance with the City of Hope Office of Clinical Trials Auditing and Monitoring SOP.  
Documentation of monitoring activities and findings will be provided to the site study teams, the site PI, 
study PI and Independent DMC. Monitoring reports are provided to the site study teams, the site PI, study 
PI and DMC in a format that does not reveal blinded information. 
 
15.5 Quality Assurance  
Clinical site auditing is conducted to ensure that the rights of human subjects are protected, that the study 
is implemented in accordance with the protocol and regulatory requirements, and that the quality and 
integrity of study data and data collection methods are maintained.  This trial will be audited by the City 
of Hope Office for Safety and Data Quality. Details of clinical site auditing are documented in the City of 
Hope Institutional Data and Safety Monitoring Plan (DSMP).   
 
15.6 Risk Determination  
This is a moderate risk study, as defined in the City of Hope Institutional DSMP.  This determination was 
made because the study is an investigator initiated Phase II study. 
 
15.7 City of Hope Data and Safety Monitoring Committee 
The COH Data and Safety Monitoring Committee (DSMC) will review and monitor study progress, 
compliance, toxicity, safety, and accrual data from this trial via the PMT Progress Report (submitted by 
the Study Principal Investigator according to the frequency outlined in the City of Hope Institutional 
DSMP). The DSMC is composed of clinical specialists who have no direct relationship with the study. 
Information that raises any questions about participant safety will be addressed with the Protocol 
Management Team.   
 
 
 

 
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16.0 ETHICAL AND REGULATORY CONSIDERATIONS 
16.1 Ethical Standard 
This study will be conducted in conformance with the principles set forth in The Belmont Report: Ethical 
Principles and Guidelines for the Protection of Human Subjects of Research (US National Commission for 
the Protection of Human Subjects of Biomedical and Behavioral Research, April 18, 1979) and the 
Declaration of Helsinki. 
16.2 Regulatory Compliance 
This study is to be conducted in compliance with the IRB approved protocol and according to the 
following considerations: 
• US Code of Federal Regulations (CFR) governing clinical study conduct 
o Title 21 Part 11 – Electronic Records; Electronic Signatures  
o Title 21 Part 50 – Protection of Human Subjects  
o Title 21 Part 54 – Financial Disclosure by Clinical Investigators  
o Title 21 Part 56 – Institutional Review Boards  
o Title 21 Part 58 – Good Laboratory Practice for Nonclinical Laboratory Studies  
o Title 21 Part 312 – Investigational New Drug Application  
o Title 45 Part 46 – Protection of Human Subjects  
• US Federal legislation, including but not limited to 
o Health Insurance Portability and Accountability Act of 1996  
o Section 801 of the Food and Drug Administration Amendments Act   
• Applicable state and local laws. For research occurring in California, this includes but is not 
limited to State of California Health and Safety Code, Title 17 
• Applicable institutional research policies and procedures  
 
16.3 Institutional Review Board 
Each participating institution must provide for the review and approval of this protocol and the associated 
informed consent documents by an appropriate IRB holding a current US Federal wide Assurance issued 
by and registered with the Office for Human Research Protections (OHRP). Any documents that the IRB 
may need to fulfill its responsibilities (such as protocol, protocol amendments, Investigator’s Brochure, 
consent forms or other pertinent information) will be submitted to the IRB.  The IRB’s written 
unconditional approval of the study protocol and the informed consent document will be in the possession 
of the Investigator, and, for sites external to COH, the possession of the coordinating center, before the 
study is initiated. The Investigator will obtain assurance of IRB/IEC compliance with regulations. 
The IRB will be informed of serious unexpected or unanticipated adverse experiences occurring during the 
study and any new information that may adversely affect patient safety or conduct of the study. 
Any amendment to the protocol document and accompanying informed consent document/template, as 
developed and provided by the Study PI, will require review and approval by the IRB before the changes 
are implemented in the study.  The protocol and consent will be reviewed and approved by the COH IRB 
before submission to a participating site IRB. 
 
16.4 Informed Consent 

 
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16.4.1 Informed Consent Form (ICF) 
Each participating institution will be provided with a model informed consent form. Each institution may 
revise or add information to comply with local and/or institutional requirements but may not remove 
procedural or risk content from the model consent form.  
The ICF will include all elements required by the COH-IRB and the States of California, Massachusetts, and 
Georgia namely: research project title, identification of investigators, purpose of the study, procedures, 
risks, benefits, alternatives to participation, financial responsibility, compensation, offer to answer 
questions, injury statement, confidentiality statement, voluntary participation and withdrawal statement, 
new information statement, termination of study participation without subject’s consent, potential for 
commercial development related to research, information about the vaccine and its administration, tissue 
and/or fluid samples collected as part of this research, Experimental Subject’s Bill of Rights, and 
agreement with signatures. Patient consent will be obtained for any residual research specimens being 
stored for future immunological testing. 
Prior to submission to the IRB (initial submission and amendments), the consent and accompanying HIPAA 
form must be reviewed and approved by the COH DCC. 
16.4.2 Consenting Procedure 
Consenting will occur during the information sessions held to discuss the HCT procedure. Informed 
consent will be obtained by physicians only. Hematology physicians assigned to the patient will be 
approved by the IRB to assist study PIs in obtaining consent. The study must be fully explained, including 
all treatment options and potential risks. The prospective participant must be given sufficient time for 
deliberation, and all questions answered. Written informed consent will be obtained from either the 
patient or their guardian or legal representative before study participation.  The method of obtaining and 
documenting the informed consent and the contents of the consent must comply with the ICH-GCP and 
all applicable regulatory requirements. A copy of the signed informed consent and the Experimental 
Subject’s Bill of Rights will be given to the patient or patient’s legally authorized representative.  The 
original signed consent must be maintained by the Site Investigator and available for inspection sponsor 
designated representatives, or regulatory authority at any time. Once the ICF has been signed, a physical 
exam and screening blood draw will be obtained. Per FDA requirements, the enrollment of the patient 
will be recorded in the medical record. 
Informed consent is a process that is initiated prior to the individual agreeing to participate in the study 
and continues throughout study participation.  
16.5 Women, Minorities, Children, HIV-Positive Individuals (Special Populations) 
16.5.1 Inclusion of Women and Minorities 
The study is open to anyone regardless of gender or ethnicity.  COH, DFCI and Northside are committed 
to developing approaches to increase accrual of patients from under-served minority populations, 
especially Hispanic and African-American, into clinical research. Efforts will be made to extend the accrual 
to a representative population, but in a trial which will accrue and randomize approximately 128 subjects, 
a balance must be struck between subject safety considerations and limitations on the number of 
individuals exposed to potentially toxic or ineffective treatments on the one hand and the need to explore 
gender, racial, and ethnic aspects of clinical research on the other.  If differences in outcome that correlate 
to gender, racial, or ethnic identity are noted, accrual may be expanded or additional studies may be 
performed to investigate those differences more fully. 
Women who are pregnant or plan to become pregnant are excluded from participation because Triplex 
has unknown properties and has not been explored in a developmental study in children.  Because there 

 
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is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the 
mother with the administered vaccine, breastfeeding should be discontinued if the mother is enrolled on 
this study.   
16.5.2 Exclusion of Pediatric Patients 
Pediatric recipients (children <18 years old of age) are excluded from this study because insufficient data 
are available in adults to judge potential risks in children.  Additionally, vaccine dosage and the blood 
volume established for immune-monitoring in adults cannot be applicable for both adults and children. 
Finally, the risk of CMV complications is inversely related to age, and the inclusion of younger children 
could bias the endpoint observations. There is a separate clinical trial exploring Triplex in children 
(NCT03354728). 
16.5.3 Exclusion of HIV Positive Individuals 
Individuals who are positive for HIV are expected to have very different underlying immune functions and 
therefore may respond to the Triplex vaccine differently from individuals negative for HIV.  
16.6 Participant Confidentiality 
Participant confidentiality is strictly held in trust by the investigators, study staff, and the sponsor(s) and 
their agents.  This confidentiality is extended to cover testing of biological samples in addition to any study 
information relating to participants. 
This research will be conducted in compliance with federal and state requirements relating to protected 
health information (PHI), including the requirements of the Health Insurance Portability and 
Accountability Act of 1996 (HIPAA).  HIPAA regulations require a signed subject authorization informing 
the subject of the nature of the PHI to be collected, who will have access to that information and why, 
who will use or disclose that information, and the rights of a research participant to revoke their 
authorization for use of their PHI. In the event that a subject revokes authorization to collect or use PHI, 
the investigator, by regulation, retains the ability to use all information collected prior to the revocation 
of subject authorization.  For subjects that have revoked authorization to collect or use PHI, attempts 
should be made to obtain permission to collect at least vital status (i.e. that the subject is alive) at the end 
of their scheduled study period. 
Participants will be known to their attending physician, other hematology/BMT staff, and to nursing staff 
for necessary clinical care and intervention. These persons also have had HIPAA-related training and 
routinely practice methods to protect PHI data. Participants’ names will be assigned a study number by 
the Nurse Coordinator, which will be recorded on a separate log. Study number will be exclusively used 
to identify data collection forms, and blood specimens. No other identifier will be recorded on any of 
these sheets. The log with identification data and study number will be kept in a locked cabinet, in the PI’s 
office at COH. Site-specific data will also be kept on the Cancer Center server at DFCI (password protected 
and backed up daily), and locked in a secure location in the BMT research office at Northside hospital. 
Only the principal investigator, co-investigators, research nurse, and data management coordinator will 
have access to trial data. 
The randomization log devised by J. Palmer and maintained by the Data Quality Monitor and Clinical Trials 
Administrator (Department of Hematology) in a secure shared folder with access solely by the designated 
parties.  
 
The investigator/institution will permit direct access to source data and documents by sponsor 
representatives, the FDA, and other applicable regulatory authorities.  The access may consist of trial-
related monitoring, including remote monitoring, audits, IRB/IEC reviews, and FDA/regulatory authority 

 
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inspections.  The patient’s confidentiality will be maintained and will not be made publicly available to the 
extent permitted by the applicable laws and regulations. 
 
16.7 Conflict of Interest 
Any investigator who has a conflict of interest with this study (patent ownership, royalties, or financial 
gain greater than the minimum allowable by their institution, etc.) must have the conflict reviewed by a 
properly constituted Conflict of Interest Committee with a Committee-sanctioned conflict management 
plan that has been reviewed and approved by the study Sponsor prior to participation in this study.  All 
City of Hope investigators will follow the City of Hope conflict of interest policy. 
A financial disclosure form will be obtained from each external DMC member.  The SMT will maintain a 
copy of the form with study DMC files.  The DMC members will be required to provide annual updates of 
when their financial interests change during the life of the clinical study.  DMC members who develop 
serious conflicts of interest that could impact objectivity may be removed from the DMC and will be 
replaced (see DMC Charter for further details).   
 
16.8 Financial Obligations, Compensation, and Reimbursement of Participants 
The investigational drug including Triplex and the matched placebo will be provided free of charge by 
COH.   
Neither the research participant nor the insurance carrier will be responsible for the research procedures 
related to this study. 
The standard of care drugs or procedures provided during the course of study participation will be the 
responsibility of the research participant and/or the insurance carrier. The research participant will be 
responsible for all copayments, deductibles, and other costs of treatment and diagnostic procedures as 
set forth by the insurance carrier.  The research participant and/or the insurance carrier will be billed for 
the costs of treatment and diagnostic procedures in the same way as if the research participant were not 
in a research study.  In the event of physical injury to a research participant resulting from research 
procedures, appropriate medical treatment will be available at City of Hope to the injured research 
participant. City of Hope will not provide financial compensation in the event of physical injury to a 
research participant. The research participant will not receive reimbursement or payment for taking part 
in this study. 
 
16.9 Publication/Data Sharing  
Any part of the results of the study carried out under this protocol, nor any of the information provided 
by City of Hope for the purposes of performing the study, will be published or passed on to any third party 
without the written approval of Dr. Don J. Diamond.  Any investigator involved with this study is obligated 
to provide City of Hope with complete test results and all data derived from the study. 
The preparation and submission of manuscripts containing the study results shall be in accordance with a 
process determined by mutual written agreement among the City of Hope and participating institutions.  
The publication or presentation of any study results shall comply with all applicable privacy laws, including, 
but not limited to, the Health Insurance Portability and Accountability Act of 1996. Published results from 
the study will be exclusively in the form of summary description of groups with no identifiable patient 
information included. 
 

 
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This study will comply with the NIH Public Access Policy, which 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. 
In accordance with the U.S. Public Law 110-85 (Food and Drug Administration Amendments Act of 2007 
or FDAAA), Title VIII, Section 801, this trial will be registered onto ClinicalTrials.gov and results will be 
reported on ClinicalTrials.gov within 12 months of the estimated or actual completion date of the trial, 
whichever date is earlier.  
The results should be made public within 24 months of reaching the end of the study. The end of the study 
is the time point at which the last data items are to be reported, or after the outcome data are sufficiently 
mature for analysis, as defined in the section on Sample Size, Accrual Rate and Study Duration. If a report 
is planned to be published in a peer-reviewed journal, then that initial release may be an abstract that 
meets the requirements of the International Committee of Medical Journal Editors. A full report of the 
outcomes should be made public no later than three (3) years after the end of the study.  

 
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17.0 REFERENCES 
1. 
Chee, M.S., et al., Analysis of the protein-coding content of the sequence of human cytomegalovirus strain 
AD169. Curr Top Microbiol Immunol, 1990. 154: p. 125-69. 
2. 
Applebaum, F.R., et al., Nonbacterial nonfungal pneumonia following marrow transplantation in 100 
identical twins. Transplantation, 1982. 33(3): p. 265-8. 
3. 
Quinnan, G.V., Jr., et al., Cytotoxic T cells in cytomegalovirus infection: HLA-restricted T- lymphocyte and 
non-T-lymphocyte cytotoxic responses correlate with recovery from cytomegalovirus infection in bone-
marrow- transplant recipients. N.Engl.J.Med., 1982. 307: p. 7-13. 
4. 
Reusser, P., et al., Randomized multicenter trial of foscarnet versus ganciclovir for preemptive therapy of 
cytomegalovirus infection after allogeneic stem cell transplantation. Blood, 2002. 99(4): p. 1159-1164. 
5. 
Winston, D.J., et al., Infectious complications of human bone marrow transplantation. Medicine (Baltimore), 
1979. 58(1): p. 1-31. 
6. 
Boeckh, M. and W.G. Nichols, The impact of cytomegalovirus serostatus of donor and recipient before 
hematopoietic stem cell transplantation in the era of antiviral prophylaxis and preemptive therapy. Blood, 
2004. 103(6): p. 2003-2008. 
7. 
Nichols, W.G., et al., High Risk of Death Due to Bacterial and Fungal Infection among Cytomegalovirus 
(CMV)-Seronegative Recipients of Stem Cell Transplants from Seropositive Donors: Evidence for Indirect 
Effects of Primary CMV Infection. J.Infect.Dis., 2002. 185(3): p. 273-282. 
8. 
Hillyer, C.D., D.R. Snydman, and E.M. Berkman, The risk of cytomegalovirus infection in solid organ and bone 
marrow transplant recipients: transfusion of blood products. Transfusion, 1990. 30(7): p. 659-66. 
9. 
Zaia, J.A., Epidemiology and Pathogenesis of Cytomegalovirus Disease. Semin Hematol, 1990. 27: p. 5-10. 
10. 
Gallant, J.E., et al., Incidence and natural history of cytomegalovirus disease in patients with advanced 
human immunodeficiency virus disease treated with zidovudine. The Zidovudine Epidemiology Study Group. 
J Infect Dis, 1992. 166(6): p. 1223-7. 
11. 
Khanna, R. and D.J. Diamond, Human cytomegalovirus vaccine: time to look for alternative options. Trends 
Mol.Med., 2006. 12(1): p. 26-33. 
12. 
Mayr, A., [Historical review of smallpox, the eradication of smallpox and the attenuated smallpox MVA 
vaccine]. Berl Munch Tierarztl Wochenschr, 1999. 112(9): p. 322-8. 
13. 
Walsh, S.R., et al., Safety and immunogenicity of modified vaccinia ankara in hematopoietic stem cell 
transplant recipients: a randomized, controlled trial. J Infect Dis, 2013. 207(12): p. 1888-97. 
14. 
Marty, F.M., et al., Letermovir Prophylaxis for Cytomegalovirus in Hematopoietic-Cell Transplantation. N 
Engl J Med, 2017. 377(25): p. 2433-2444. 
15. 
Solomon, S.R., et al., Haploidentical transplantation using T cell replete peripheral blood stem cells and 
myeloablative conditioning in patients with high-risk hematologic malignancies who lack conventional 
donors is well tolerated and produces excellent relapse-free survival: results of a prospective phase II trial. 
Biol Blood Marrow Transplant, 2012. 18(12): p. 1859-66. 
16. 
Luznik, L., et al., HLA-haploidentical bone marrow transplantation for hematologic malignancies using 
nonmyeloablative conditioning and high-dose, posttransplantation cyclophosphamide. Biol Blood Marrow 
Transplant, 2008. 14(6): p. 641-50. 
17. 
Kekre, N. and J.H. Antin, Hematopoietic stem cell transplantation donor sources in the 21st century: 
choosing the ideal donor when a perfect match does not exist. Blood, 2014. 124(3): p. 334-43. 
18. 
Baker, M., et al., Comparative Outcomes after Haploidentical or Unrelated Donor Bone Marrow or Blood 
Stem Cell Transplantation in Adult Patients with Hematological Malignancies. Biol Blood Marrow 
Transplant, 2016. 22(11): p. 2047-2055. 
19. 
Crocchiolo, R., et al., Infections after T-replete haploidentical transplantation and high-dose 
cyclophosphamide as graft-versus-host disease prophylaxis. Transpl Infect Dis, 2015. 17(2): p. 242-9. 
20. 
Young, J.A., et al., Infections after Transplantation of Bone Marrow or Peripheral Blood Stem Cells from 
Unrelated Donors. Biol Blood Marrow Transplant, 2016. 22(2): p. 359-70. 

 
Page 68 of 81 
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VERSION DATE:  08/23/2023               
21. 
Goldsmith, S.R., et al., Cytomegalovirus viremia, disease, and impact on relapse in T-cell replete peripheral 
blood haploidentical hematopoietic cell transplantation with post-transplant cyclophosphamide. 
Haematologica, 2016. 101(11): p. e465-e468. 
22. 
Slade, M., et al., Epidemiology of infections following haploidentical peripheral blood hematopoietic cell 
transplantation. Transpl Infect Dis, 2017. 19(1). 
23. 
Aversa, F., et al., Immunity to Infections after Haploidentical Hematopoietic Stem Cell Transplantation. 
Mediterr J Hematol Infect Dis, 2016. 8(1): p. e2016057. 
24. 
Wilck, M.B., et al., Interim Analysis of a Phase 2 Trial of TransVax™, a Therapeutic DNA Vaccine for Control 
of Cytomegalovirus in Transplant Recipients. ICAAC, 2010(G1-1113a). 
25. 
Sylwester, A.W., et al., Broadly targeted human cytomegalovirus-specific CD4+ and CD8+ T cells dominate 
the memory compartments of exposed subjects. J.Exp.Med., 2005. 202(5): p. 673-685. 
26. 
Steininger, C., Clinical relevance of cytomegalovirus infection in patients with disorders of the immune 
system. Clin.Microbiol.Infect., 2007. 13(10): p. 953-963. 
27. 
Limaye, A.P., et al., Impact of cytomegalovirus in organ transplant recipients in the era of antiviral 
prophylaxis. Transplantation, 2006. 81(12): p. 1645-1652. 
28. 
Griffiths, P., et al., Contemporary management of cytomegalovirus infection in transplant recipients: 
guidelines from an IHMF workshop, 2007. Herpes., 2008. 15(1): p. 4-12. 
29. 
Boeckh, M., et al., Cytomegalovirus in hematopoietic stem cell transplant recipients: Current status, known 
challenges, and future strategies. Biol.Blood Marrow Transplant., 2003. 9(9): p. 543-558. 
30. 
Tomblyn, M., et al., Guidelines for preventing infectious complications among hematopoietic cell 
transplantation recipients: a global perspective. Biol.Blood Marrow Transplant, 2009. 15(10): p. 1143-1238. 
31. 
Zerr, D.M., et al., HHV-6 reactivation and its effect on delirium and cognitive functioning in hematopoietic 
cell transplantation recipients. Blood, 2011. 117(19): p. 5243-5249. 
32. 
Reusser, P., Oral valganciclovir: a new option for treatment of cytomegalovirus infection and disease in 
immunocompromised hosts. Expert.Opin.Investig.Drugs, 2001. 10(9): p. 1745-1753. 
33. 
Ljungman, P., M. Hakki, and M. Boeckh, Cytomegalovirus in hematopoietic stem cell transplant recipients. 
Infect.Dis.Clin.North Am., 2010. 24(2): p. 319-337. 
34. 
Gratama, J.W., et al., Immune monitoring with iTAg MHC Tetramers for prediction of recurrent or persistent 
cytomegalovirus infection or disease in allogeneic hematopoietic stem cell transplant recipients: a 
prospective multicenter study. Blood, 2010. 116(10): p. 1655-1662. 
35. 
Hakki, M., et al., Immune reconstitution to cytomegalovirus after allogeneic hematopoietic stem cell 
transplantation: impact of host factors, drug therapy, and subclinical reactivation. Blood, 2003. 102(8): p. 
3060-3067. 
36. 
Nguyen, Q., et al., Late cytomegalovirus pneumonia in adult allogeneic blood and marrow transplant 
recipients. Clin.Infect.Dis., 1999. 28(3): p. 618-623. 
37. 
Razonable, R.R., et al., Allograft rejection predicts the occurrence of late-onset cytomegalovirus (CMV) 
disease among CMV-mismatched solid organ transplant patients receiving prophylaxis with oral ganciclovir. 
J.Infect.Dis., 2001. 184(11): p. 1461-1464. 
38. 
Boeckh, M., et al., Late cytomegalovirus disease and mortality in recipients of allogeneic hematopoietic stem 
cell transplants: importance of viral load and T-cell immunity. Blood, 2003. 101(2): p. 407-414. 
39. 
Peggs, K.S. and S. Mackinnon, Immune reconstitution following haematopoietic stem cell transplantation. 
Br.J.Haematol., 2004. 124(4): p. 407-420. 
40. 
Singh, N., Delayed occurrence of cytomegalovirus disease in organ transplant recipients receiving antiviral 
prophylaxis: are we winning the battle only to lose the war? Eur.J.Clin.Microbiol.Infect.Dis., 2002. 21(12): p. 
902. 
41. 
Khan, N., et al., T cell recognition patterns of immunodominant cytomegalovirus antigens in primary and 
persistent infection. J Immunol, 2007. 178(7): p. 4455-65. 

 
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42. 
van de Berg, P.J., et al., Cytomegalovirus infection reduces telomere length of the circulating T cell pool. J 
Immunol, 2010. 184(7): p. 3417-23. 
43. 
Gandhi, M.K., et al., Late diversification in the clonal composition of human cytomegalovirus-specific CD8+ 
T cells following allogeneic hemopoietic stem cell transplantation. Blood, 2003. 102(9): p. 3427-38. 
44. 
Khan, N., et al., Herpesvirus-specific CD8 T cell immunity in old age: cytomegalovirus impairs the response 
to a coresident EBV infection. J Immunol, 2004. 173(12): p. 7481-9. 
45. 
Elkington, R., et al., Ex vivo profiling of CD8+-T-cell responses to human cytomegalovirus reveals broad and 
multispecific reactivities in healthy virus carriers. J Virol, 2003. 77(9): p. 5226-40. 
46. 
Boppana, S.B. and W.J. Britt, Recognition of human cytomegalovirus gene products by HCMV-specific 
cytotoxic T cells. Virology, 1996. 222(1): p. 293-6. 
47. 
McLaughlin-Taylor, E., et al., Identification of the major late human cytomegalovirus matrix protein pp65 as 
a target antigen for CD8+ virus-specific cytotoxic T lymphocytes. J Med Virol, 1994. 43(1): p. 103-10. 
48. 
Wills, M.R., et al., The human cytotoxic T-lymphocyte (CTL) response to cytomegalovirus is dominated by 
structural protein pp65: frequency, specificity, and T-cell receptor usage of pp65-specific CTL. J Virol, 1996. 
70(11): p. 7569-79. 
49. 
Lacey, S.F., et al., Functional comparison of T cells recognizing cytomegalovirus pp65 and intermediate-early 
antigen polypeptides in hematopoietic stem-cell transplant and solid organ transplant recipients. J Infect 
Dis, 2006. 194(10): p. 1410-21. 
50. 
Gyulai, Z., et al., Cytotoxic T lymphocyte (CTL) responses to human cytomegalovirus pp65, IE1-Exon4, gB, 
pp150, and pp28 in healthy individuals: reevaluation of prevalence of IE1-specific CTLs. J Infect Dis, 2000. 
181(5): p. 1537-46. 
51. 
Kern, F., et al., Target structures of the CD8(+)-T-cell response to human cytomegalovirus: the 72-kilodalton 
major immediate-early protein revisited. J Virol, 1999. 73(10): p. 8179-84. 
52. 
Khan, N., et al., Comparative analysis of CD8+ T cell responses against human cytomegalovirus proteins 
pp65 and immediate early 1 shows similarities in precursor frequency, oligoclonality, and phenotype. J Infect 
Dis, 2002. 185(8): p. 1025-34. 
53. 
Wang, Z., et al., A fusion protein of HCMV IE1 exon4 and IE2 exon5 stimulates potent cellular immunity in 
an MVA vaccine vector. Virology, 2008. 377(2): p. 379-90. 
54. 
Bunde, T., et al., Protection from cytomegalovirus after transplantation is correlated with immediate early 
1-specific CD8 T cells. J Exp Med, 2005. 201(7): p. 1031-6. 
55. 
Nickel, P., et al., High levels of CMV-IE-1-specific memory T cells are associated with less alloimmunity and 
improved renal allograft function. Transpl Immunol, 2009. 20(4): p. 238-42. 
56. 
Berencsi, K., et al., A canarypox vector-expressing cytomegalovirus (CMV) phosphoprotein 65 induces long-
lasting cytotoxic T cell responses in human CMV-seronegative subjects. J Infect Dis, 2001. 183(8): p. 1171-9. 
57. 
Bernstein, D.I., et al., Randomized, double-blind, Phase 1 trial of an alphavirus replicon vaccine for 
cytomegalovirus in CMV seronegative adult volunteers. Vaccine, 2009. 28(2): p. 484-93. 
58. 
Selinsky, C., et al., A DNA-based vaccine for the prevention of human cytomegalovirus-associated diseases. 
Hum Vaccin, 2005. 1(1): p. 16-23. 
59. 
Aubert, G., et al., Cytomegalovirus-specific cellular immune responses and viremia in recipients of allogeneic 
stem cell transplants. J.Infect.Dis., 2001. 184(8): p. 955-963. 
60. 
Gratama, J.W., et al., Tetramer-based quantification of cytomegalovirus (CMV)-specific CD8+ T lymphocytes 
in T-cell-depleted stem cell grafts and after transplantation may identify patients at risk for progressive CMV 
infection. Blood, 2001. 98(5): p. 1358-64. 
61. 
Cwynarski, K., et al., Direct visualization of cytomegalovirus-specific T-cell reconstitution after allogeneic 
stem cell transplantation. Blood, 2001. 97(5): p. 1232-40. 
62. 
Lacey, S.F., et al., Characterization of cytotoxic function of CMV-pp65-specific CD8+ T-lymphocytes identified 
by HLA tetramers in recipients and donors of stem-cell transplants. Transplantation, 2002. 74(5): p. 722-32. 

 
Page 70 of 81 
IRB#19065               
 
 
VERSION DATE:  08/23/2023               
63. 
Gallez-Hawkins, G., et al., Cytomegalovirus immune reconstitution occurs in recipients of allogeneic 
hematopoietic cell transplants irrespective of detectable cytomegalovirus infection. Biol Blood Marrow 
Transplant, 2005. 11(11): p. 890-902. 
64. 
Pourgheysari, B., et al., Early reconstitution of effector memory CD4+ CMV-specific T cells protects against 
CMV reactivation following allogeneic SCT. Bone Marrow Transplant, 2009. 43(11): p. 853-61. 
65. 
Lilleri, D., et al., Human cytomegalovirus-specific CD4+ and CD8+ T-cell reconstitution in adult allogeneic 
hematopoietic stem cell transplant recipients and immune control of viral infection. Haematologica, 2008. 
93(2): p. 248-56. 
66. 
Luo, X.H., et al., Protective immunity transferred by infusion of cytomegalovirus-specific CD8(+) T cells within 
donor grafts: its associations with cytomegalovirus reactivation following unmanipulated allogeneic 
hematopoietic stem cell transplantation. Biol Blood Marrow Transplant, 2010. 16(7): p. 994-1004. 
67. 
Gratama, J.W., et al., Immune monitoring with iTAg MHC Tetramers for prediction of recurrent or persistent 
cytomegalovirus infection or disease in allogeneic hematopoietic stem cell transplant recipients: a 
prospective multicenter study. Blood, 2010. 116(10): p. 1655-62. 
68. 
Plotkin, S.A., et al., Effect of Towne live virus vaccine on cytomegalovirus disease after renal transplant. A 
controlled trial. Ann Intern Med, 1991. 114(7): p. 525-31. 
69. 
Zhou, W., et al., Impact of donor CMV status on viral infection and reconstitution of multifunction CMV-
specific T cells in CMV-positive transplant recipients. Blood, 2009. 113(25): p. 6465-76. 
70. 
Scheinberg, P., et al., The transfer of adaptive immunity to CMV during hematopoietic stem cell 
transplantation is dependent on the specificity and phenotype of CMV-specific T cells in the donor. Blood, 
2009. 114(24): p. 5071-80. 
71. 
Ljungman, P., et al., Donor CMV serologic status and outcome of CMV-seropositive recipients after unrelated 
donor stem cell transplantation: an EBMT megafile analysis. Blood, 2003. 102(13): p. 4255-60. 
72. 
Uzunel, M., et al., Unrelated versus related allogeneic stem cell transplantation after reduced intensity 
conditioning. Transplantation, 2006. 82(7): p. 913-9. 
73. 
Jamieson, B.D. and R. Ahmed, T cell memory. Long-term persistence of virus-specific cytotoxic T cells. J Exp 
Med, 1989. 169(6): p. 1993-2005. 
74. 
Matloubian, M., R.J. Concepcion, and R. Ahmed, CD4+ T cells are required to sustain CD8+ cytotoxic T-cell 
responses during chronic viral infection. J Virol, 1994. 68(12): p. 8056-63. 
75. 
Plotkin, S.A., et al., Protective effects of Towne cytomegalovirus vaccine against low-passage 
cytomegalovirus administered as a challenge. J Infect Dis, 1989. 159(5): p. 860-5. 
76. 
Boppana, S.B., et al., Intrauterine transmission of cytomegalovirus to infants of women with preconceptional 
immunity. N Engl J Med, 2001. 344(18): p. 1366-71. 
77. 
Gonczol, E. and S. Plotkin, Progress in vaccine development for prevention of human cytomegalovirus 
infection. Curr Top Microbiol Immunol, 1990. 154: p. 255-74. 
78. 
Adler, S.P., et al., A canarypox vector expressing cytomegalovirus (CMV) glycoprotein B primes for antibody 
responses to a live attenuated CMV vaccine (Towne). J Infect Dis, 1999. 180(3): p. 843-6. 
79. 
Bernstein, D.I., et al., Effect of previous or simultaneous immunization with canarypox expressing 
cytomegalovirus (CMV) glycoprotein B (gB) on response to subunit gB vaccine plus MF59 in healthy CMV-
seronegative adults. J Infect Dis, 2002. 185(5): p. 686-90. 
80. 
Pass, R.F., et al., A subunit cytomegalovirus vaccine based on recombinant envelope glycoprotein B and a 
new adjuvant. J Infect Dis, 1999. 180(4): p. 970-5. 
81. 
Endresz, V., et al., Optimization of DNA immunization against human cytomegalovirus. Vaccine, 2001. 
19(28-29): p. 3972-80. 
82. 
Endresz, V., et al., Induction of human cytomegalovirus (HCMV)-glycoprotein B (gB)-specific neutralizing 
antibody and phosphoprotein 65 (pp65)-specific cytotoxic T lymphocyte responses by naked DNA 
immunization. Vaccine, 1999. 17(1): p. 50-8. 

 
Page 71 of 81 
IRB#19065               
 
 
VERSION DATE:  08/23/2023               
83. 
Pande, H., et al., Direct DNA immunization of mice with plasmid DNA encoding the tegument protein pp65 
(ppUL83) of human cytomegalovirus induces high levels of circulating antibody to the encoded protein. 
Scand J Infect Dis Suppl, 1995. 99: p. 117-20. 
84. 
Wloch, M.K., et al., Safety and immunogenicity of a bivalent cytomegalovirus DNA vaccine in healthy adult 
subjects. J Infect Dis, 2008. 197(12): p. 1634-42. 
85. 
Kharfan-Dabaja, M.A., et al., A novel therapeutic cytomegalovirus DNA vaccine in allogeneic haemopoietic 
stem-cell transplantation: a randomised, double-blind, placebo-controlled, phase 2 trial. Lancet Infect Dis, 
2012. 12(4): p. 290-9. 
86. 
La Rosa, C., et al., Clinical evaluation of safety and immunogenicity of PADRE-cytomegalovirus (CMV) and 
tetanus-CMV fusion peptide vaccines with or without PF03512676 adjuvant. J Infect Dis, 2012. 205(8): p. 
1294-304. 
87. 
Nakamura R., L.R.C., Longmate J., O'Donnell M., Cai J., Farol L., Salhotra M., Snyder D.S.,  Drake J., Slape C., 
Merson J., Zaia J.A., Forman S.J., Diamond DJ, Randomized Trial of a Novel CMV Vaccine (CMVPepVax) after 
Allogeneic HCT: Elevated CMV-Specific Immune Response, Reduction in Chronic GvHD and CMV Reactivation 
Only in Vaccine Arm Patients. Blood 2014. 124(21): p. 183. 
88. 
McConkey, S.J., et al., Enhanced T-cell immunogenicity of plasmid DNA vaccines boosted by recombinant 
modified vaccinia virus Ankara in humans. Nat Med, 2003. 9(6): p. 729-35. 
89. 
Hawkridge, T., et al., Safety and immunogenicity of a new tuberculosis vaccine, MVA85A, in healthy adults 
in South Africa. J Infect Dis, 2008. 198(4): p. 544-52. 
90. 
Stittelaar, K.J., et al., Safety of modified vaccinia virus Ankara (MVA) in immune-suppressed macaques. 
Vaccine, 2001. 19(27): p. 3700-9. 
91. 
Cosma, A., et al., Therapeutic vaccination with MVA-HIV-1 nef elicits Nef-specific T-helper cell responses in 
chronically HIV-1 infected individuals. Vaccine, 2003. 22(1): p. 21-9. 
92. 
Wyatt, L.S., et al., Highly attenuated smallpox vaccine protects mice with and without immune deficiencies 
against pathogenic vaccinia virus challenge. Proc Natl Acad Sci U S A, 2004. 101(13): p. 4590-5. 
93. 
Moss, B., et al., Host range restricted, non-replicating vaccinia virus vectors as vaccine candidates. Adv Exp 
Med Biol, 1996. 397: p. 7-13. 
94. 
Cottingham, M.G. and M.W. Carroll, Recombinant MVA vaccines: dispelling the myths. Vaccine, 2013. 
31(39): p. 4247-51. 
95. 
Harrop, R., et al., Cross-trial analysis of immunologic and clinical data resulting from phase I and II trials of 
MVA-5T4 (TroVax) in colorectal, renal, and prostate cancer patients. J Immunother, 2010. 33(9): p. 999-
1005. 
96. 
Goepfert, P.A., et al., Phase 1 safety and immunogenicity testing of DNA and recombinant modified vaccinia 
Ankara vaccines expressing HIV-1 virus-like particles. J Infect Dis, 2011. 203(5): p. 610-9. 
97. 
Greenberg, R.N., et al., Safety, Immunogenicity, and Surrogate Markers of Clinical Efficacy for Modified 
Vaccinia Ankara as a Smallpox Vaccine in HIV-Infected Subjects. Journal of Infectious Diseases, 2013. 207(5): 
p. 749-758. 
98. 
Greenough, T.C., et al., Safety and immunogenicity of recombinant poxvirus HIV-1 vaccines in young adults 
on highly active antiretroviral therapy. Vaccine, 2008. 26(52): p. 6883-93. 
99. 
Mothe, B., et al., Safety and immunogenicity of a modified vaccinia Ankara-based HIV-1 vaccine (MVA-B) in 
HIV-1-infected patients alone or in combination with a drug to reactivate latent HIV-1. J Antimicrob 
Chemother, 2015. 70(6): p. 1833-42. 
100. 
Scriba, T.J., et al., A phase IIa trial of the new tuberculosis vaccine, MVA85A, in HIV- and/or Mycobacterium 
tuberculosis-infected adults. Am J Respir Crit Care Med, 2012. 185(7): p. 769-78. 
101. 
Tameris, M.D., et al., Safety and efficacy of MVA85A, a new tuberculosis vaccine, in infants previously 
vaccinated with BCG: a randomised, placebo-controlled phase 2b trial. Lancet, 2013. 381(9871): p. 1021-8. 
102. 
Scriba, T.J., et al., Modified vaccinia Ankara-expressing Ag85A, a novel tuberculosis vaccine, is safe in 
adolescents and children, and induces polyfunctional CD4+ T cells. Eur.J.Immunol., 2010. 40(1): p. 279-290. 

 
Page 72 of 81 
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103. 
Longmate, J., et al., Population coverage by HLA class-I restricted cytotoxic T-lymphocyte epitopes. 
Immunogenetics, 2001. 52(3-4): p. 165-73. 
104. 
Alp, N.J., et al., Fine specificity of cellular immune responses in humans to human cytomegalovirus 
immediate-early 1 protein. J Virol, 1991. 65(9): p. 4812-20. 
105. 
Gilbert, M.J., et al., Selective interference with class I major histocompatibility complex presentation of the 
major immediate-early protein following infection with human cytomegalovirus. J Virol, 1993. 67(6): p. 
3461-9. 
106. 
La Rosa, C., et al., Enhanced immune activity of cytotoxic T-lymphocyte epitope analogs derived from 
positional scanning synthetic combinatorial libraries. Blood, 2001. 97(6): p. 1776-86. 
107. 
Jin, X., et al., High frequency of cytomegalovirus-specific cytotoxic T-effector cells in HLA-A*0201-positive 
subjects during multiple viral coinfections. J Infect Dis, 2000. 181(1): p. 165-75. 
108. 
Komanduri, K.V., et al., Direct measurement of CD4+ and CD8+ T-cell responses to CMV in HIV-1-infected 
subjects. Virology, 2001. 279(2): p. 459-70. 
109. 
Gillespie, G.M., et al., Functional heterogeneity and high frequencies of cytomegalovirus-specific CD8(+) T 
lymphocytes in healthy seropositive donors. J Virol, 2000. 74(17): p. 8140-50. 
110. 
Retiere, C., et al., Generation of cytomegalovirus-specific human T-lymphocyte clones by using autologous 
B-lymphoblastoid cells with stable expression of pp65 or IE1 proteins: a tool to study the fine specificity of 
the antiviral response. J Virol, 2000. 74(9): p. 3948-52. 
111. 
Jacobson, M.A., et al., Results of a cytomegalovirus (CMV)-specific CD8+/interferon- gamma+ cytokine flow 
cytometry assay correlate with clinical evidence of protective immunity in patients with AIDS with CMV 
retinitis. J Infect Dis, 2004. 189(8): p. 1362-73. 
112. 
La Rosa, C., et al., Longitudinal assessment of cytomegalovirus (CMV)-specific immune responses in liver 
transplant recipients at high risk for late CMV disease. J Infect Dis, 2007. 195(5): p. 633-44. 
113. 
Spaete, R.R., R.C. Gehrz, and M.P. Landini, Human cytomegalovirus structural proteins. J Gen Virol, 1994. 
75 ( Pt 12): p. 3287-308. 
114. 
Wussow, F., et al., A vaccine based on the rhesus cytomegalovirus UL128 complex induces broadly 
neutralizing antibodies in rhesus macaques. Journal of Virology, 2013. 87(3): p. 1322-32. 
115. 
Britt, W.J., et al., Cell surface expression of human cytomegalovirus (HCMV) gp55-116 (gB): use of HCMV-
recombinant vaccinia virus-infected cells in analysis of the human neutralizing antibody response. J Virol, 
1990. 64(3): p. 1079-85. 
116. 
Banks, T., et al., A major neutralizing domain maps within the carboxyl-terminal half of the cleaved 
cytomegalovirus B glycoprotein. J Gen Virol, 1989. 70 ( Pt 4): p. 979-85. 
117. 
Marshall, G.S., et al., An adenovirus recombinant that expresses the human cytomegalovirus major envelope 
glycoprotein and induces neutralizing antibodies. J Infect Dis, 1990. 162(5): p. 1177-81. 
118. 
Macagno, A., et al., Isolation of human monoclonal antibodies that potently neutralize human 
cytomegalovirus infection by targeting different epitopes on the gH/gL/UL128-131A complex. Journal of 
Virology, 2010. 84(2): p. 1005-13. 
119. 
Kim, S., et al., Human cytomegalovirus IE1 protein activates AP-1 through a cellular protein kinase(s). J Gen 
Virol, 1999. 80 ( Pt 4): p. 961-9. 
120. 
Johnson, R.A., et al., Domain mapping of the human cytomegalovirus IE1-72 and cellular p107 protein-
protein interaction and the possible functional consequences. J Gen Virol, 1999. 80 ( Pt 5): p. 1293-303. 
121. 
Pajovic, S., et al., Identification of a viral kinase that phosphorylates specific E2Fs and pocket proteins. Mol 
Cell Biol, 1997. 17(11): p. 6459-64. 
122. 
Gallez-Hawkins, G., et al., Use of transgenic HLA A*0201/Kb and HHD II mice to evaluate frequency of 
cytomegalovirus IE1-derived peptide usage in eliciting human CD8 cytokine response. J Virol, 2003. 77(7): p. 
4457-62. 
123. 
Meyer, H., G. Sutter, and A. Mayr, Mapping of deletions in the genome of the highly attenuated vaccinia 
virus MVA and their influence on virulence. J Gen Virol, 1991. 72 ( Pt 5): p. 1031-8. 

 
Page 73 of 81 
IRB#19065               
 
 
VERSION DATE:  08/23/2023               
124. 
Antoine, G., et al., The complete genomic sequence of the modified vaccinia Ankara strain: comparison with 
other orthopoxviruses. Virology, 1998. 244(2): p. 365-96. 
125. 
Chakrabarti, S., J.R. Sisler, and B. Moss, Compact, synthetic, vaccinia virus early/late promoter for protein 
expression. Biotechniques, 1997. 23(6): p. 1094-7. 
126. 
Carroll, M.W. and B. Moss, E. coli beta-glucuronidase (GUS) as a marker for recombinant vaccinia viruses. 
Biotechniques, 1995. 19(3): p. 352-4, 356. 
127. 
Wang, Z., et al., Modified H5 promoter improves stability of insert genes while maintaining immunogenicity 
during extended passage of genetically engineered MVA vaccines. Vaccine, 2010. 28(6): p. 1547-57. 
128. 
La Rosa, C., et al., MVA vaccine encoding CMV antigens safely induces durable expansion of CMV-specific T 
cells in healthy adults. Blood, 2017. 129(1): p. 114-125. 
129. 
Upfal, M.J. and S. Cinti, Smallpox vaccination and adverse cardiac events. Emerging Infectious Diseases, 
2004. 10(5): p. 961-2; discussion 962. 
130. 
Krishnan, A., et al., Programmed death-1 receptor and interleukin-10 in liver transplant recipients at high 
risk for late cytomegalovirus disease. Transpl Infect Dis, 2010. 12(4): p. 363-70. 
131. 
Aversa, F., et al., Successful engraftment of T-cell-depleted haploidentical "three-loci" incompatible 
transplants in leukemia patients by addition of recombinant human granulocyte colony-stimulating factor-
mobilized peripheral blood progenitor cells to bone marrow inoculum. Blood, 1994. 84(11): p. 3948-55. 
132. 
Aversa, F., et al., Full haplotype-mismatched hematopoietic stem-cell transplantation: a phase II study in 
patients with acute leukemia at high risk of relapse. J Clin Oncol, 2005. 23(15): p. 3447-54. 
133. 
Robinson, T.M., et al., Haploidentical bone marrow and stem cell transplantation: experience with post-
transplantation cyclophosphamide. Semin Hematol, 2016. 53(2): p. 90-7. 
134. 
Bashey, A., et al., T-cell-replete HLA-haploidentical hematopoietic transplantation for hematologic 
malignancies using post-transplantation cyclophosphamide results in outcomes equivalent to those of 
contemporaneous HLA-matched related and unrelated donor transplantation. J Clin Oncol, 2013. 31(10): p. 
1310-6. 
135. 
Kasamon, Y.L., et al., Nonmyeloablative HLA-haploidentical bone marrow transplantation with high-dose 
posttransplantation cyclophosphamide: effect of HLA disparity on outcome. Biol Blood Marrow Transplant, 
2010. 16(4): p. 482-9. 
136. 
Grosso, D., et al., A two-step approach to myeloablative haploidentical transplantation: low nonrelapse 
mortality and high survival confirmed in patients with earlier stage disease. Biol Blood Marrow Transplant, 
2015. 21(4): p. 646-52. 
137. 
Grosso, D., et al., A 2-step approach to myeloablative haploidentical stem cell transplantation: a phase 1/2 
trial performed with optimized T-cell dosing. Blood, 2011. 118(17): p. 4732-9. 
138. 
Blaise, D., et al., Haploidentical T Cell-Replete Transplantation with Post-Transplantation Cyclophosphamide 
for Patients in or above the Sixth Decade of Age Compared with Allogeneic Hematopoietic Stem Cell 
Transplantation from an Human Leukocyte Antigen-Matched Related or Unrelated Donor. Biol Blood 
Marrow Transplant, 2016. 22(1): p. 119-24. 
139. 
Kasamon, Y.L., et al., Outcomes of Nonmyeloablative HLA-Haploidentical Blood or Marrow Transplantation 
With High-Dose Post-Transplantation Cyclophosphamide in Older Adults. J Clin Oncol, 2015. 33(28): p. 3152-
61. 
140. 
Ljungman, P., et al., Donor cytomegalovirus status influences the outcome of allogeneic stem cell transplant: 
a study by the European group for blood and marrow transplantation. Clin Infect Dis, 2014. 59(4): p. 473-
81. 
141. 
Perruccio, K., et al., Transferring functional immune responses to pathogens after haploidentical 
hematopoietic transplantation. Blood, 2005. 106(13): p. 4397-406. 
142. 
Kanakry, C.G., E.J. Fuchs, and L. Luznik, Modern approaches to HLA-haploidentical blood or marrow 
transplantation. Nat Rev Clin Oncol, 2016. 13(1): p. 10-24. 

 
Page 74 of 81 
IRB#19065               
 
 
VERSION DATE:  08/23/2023               
143. 
Raiola, A.M., et al., Unmanipulated haploidentical bone marrow transplantation and posttransplantation 
cyclophosphamide for hematologic malignancies after myeloablative conditioning. Biol Blood Marrow 
Transplant, 2013. 19(1): p. 117-22. 
144. 
Lacey, S.F., et al., Characterization of cytotoxic function of CMV-pp65-specific CD8+ T- lymphocytes identified 
by HLA tetramers in recipients and donors of stem-cell transplants. Transplantation, 2002. 74(5): p. 722-732. 
145. 
Villacres, M.C., et al., Human immunodeficiency virus-infected patients receiving highly active antiretroviral 
therapy maintain activated cd8+ t cell subsets as a strong adaptive immune response to cytomegalovirus. 
J.Infect.Dis., 2001. 184(3): p. 256-267. 
146. 
Zaia, J.A., Prevention of cytomegalovirus disease in hematopoietic stem cell transplantation. Clin Infect Dis, 
2002. 35(8): p. 999-1004. 
147. 
Wu, Y., et al., Reactive impurities in excipients: profiling, identification and mitigation of drug-excipient 
incompatibility. AAPS PharmSciTech, 2011. 12(4): p. 1248-63. 
148. 
Wolfl, M., et al., Activation-induced expression of CD137 permits detection, isolation, and expansion of the 
full repertoire of CD8+ T cells responding to antigen without requiring knowledge of epitope specificities. 
Blood, 2007. 110(1): p. 201-210. 
149. 
Nakamura, R., et al., Ex vivo detection of CD8 T cells specific for H-Y minor histocompatibility antigens in 
allogeneic hematopoietic stem cell transplant recipients. Transpl Immunol, 2014. 30(4): p. 128-35. 
150. 
Gordon, C.L., et al., Tissue reservoirs of antiviral T cell immunity in persistent human CMV infection. J Exp 
Med, 2017. 
151. 
Almanzar, G., et al., Long-term cytomegalovirus infection leads to significant changes in the composition of 
the CD8+ T-cell repertoire, which may be the basis for an imbalance in the cytokine production profile in 
elderly persons. J Virol, 2005. 79(6): p. 3675-83. 
152. 
Jackson, S.E., et al., Diverse specificities, phenotypes, and antiviral activities of cytomegalovirus-specific 
CD8+ T cells. J Virol, 2014. 88(18): p. 10894-908. 
153. 
Lilleri, D., et al., Human cytomegalovirus-specific memory CD8+ and CD4+ T cell differentiation after primary 
infection. J Infect Dis, 2008. 198(4): p. 536-43. 
154. 
La Rosa, C., et al., Programmed death-1 expression in liver transplant recipients as a prognostic indicator of 
cytomegalovirus disease. J Infect Dis, 2008. 197(1): p. 25-33. 
155. 
La Rosa, C., et al., Primary response against cytomegalovirus during antiviral prophylaxis with valganciclovir, 
in solid organ transplant recipients. Transpl Int, 2011. 24(9): p. 920-31. 
156. 
DeYoung, M.P., et al., Tumor-specific p73 up-regulation mediates p63 dependence in squamous cell 
carcinoma. Cancer Res., 2006. 66(19): p. 9362-9368. 
157. 
Foley, B., et al., Human cytomegalovirus (CMV)-induced memory-like NKG2C(+) NK cells are transplantable 
and expand in vivo in response to recipient CMV antigen. J.Immunol., 2012. 189(10): p. 5082-5088. 
158. 
Foley, B., et al., Cytomegalovirus reactivation after allogeneic transplantation promotes a lasting increase 
in educated NKG2C+ natural killer cells with potent function. Blood, 2012. 119(11): p. 2665-2674. 
159. 
Lopez-Verges, S., et al., Expansion of a unique CD57(+)NKG2Chi natural killer cell subset during acute human 
cytomegalovirus infection. Proc.Natl.Acad.Sci.U.S.A, 2011. 108(36): p. 14725-14732. 
160. 
Kuijpers, T.W., et al., Human NK cells can control CMV infection in the absence of T cells. Blood, 2008. 112(3): 
p. 914-915. 
161. 
Paley, M.A., et al., Progenitor and terminal subsets of CD8+ T cells cooperate to contain chronic viral 
infection. Science, 2012. 338(6111): p. 1220-1225. 
162. 
Smith, C., et al., Endogenous antigen presentation impacts on T-box transcription factor expression and 
functional maturation of CD8+ T cells. Blood, 2012. 120(16): p. 3237-3245. 
163. 
Ribeiro-dos-Santos, P., et al., Chronic HIV infection affects the expression of the 2 transcription factors 
required for CD8 T-cell differentiation into cytolytic effectors. Blood, 2012. 119(21): p. 4928-4938. 
164. 
Hertoghs, K.M., et al., Molecular profiling of cytomegalovirus-induced human CD8+ T cell differentiation. 
J.Clin.Invest, 2010. 120(11): p. 4077-4090. 

 
Page 75 of 81 
IRB#19065               
 
 
VERSION DATE:  08/23/2023               
165. 
Krieg, A.M., CpG motifs in bacterial DNA and their immune effects. Annu.Rev.Immunol., 2002. 20: p. 709-
760. 
166. 
Davila, E., et al., Creating space: an antigen-independent, CpG-induced peripheral expansion of naive and 
memory T lymphocytes in a full T-cell compartment. Blood, 2002. 100(7): p. 2537-2545. 
167. 
Kuo, C.C., S.M. Liang, and C.M. Liang, CpG-B oligodeoxynucleotide promotes cell survival via up-regulation 
of Hsp70 to increase Bcl-xL and to decrease apoptosis-inducing factor translocation. J.Biol.Chem., 2006. 
281(50): p. 38200-38207. 
168. 
Team, R.D.C., R: A language and environment for statistical computing. 2011, Vienna: R Foundation for 
Statistical Computing. 
169. 
Frankel, P. and J. Longmate, Parametric models for accelerated and long-term survival: a comment on 
proportional hazards. Stat.Med., 2002. 21(21): p. 3279-3289. 
170. 
Ivanova, A., B.F. Qaqish, and M.J. Schell, Continuous toxicity monitoring in phase II trials in oncology. 
Biometrics, 2005. 61(2): p. 540-545. 
171. 
Przepiorka, D., et al., 1994 Consensus Conference on Acute GVHD Grading. Bone Marrow Transplant., 1995. 
15(6): p. 825-828. 
172. 
Bensinger, W.I., et al., Transplantation of bone marrow as compared with peripheral-blood cells from HLA-
identical relatives in patients with hematologic cancers. New England Journal of Medicine, 2001. 344(3): p. 
175-181. 
 
 
 
 

 
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APPENDIX A: ACUTE GVHD STAGING 
1994 Keystone Consensus Criteria 
Organ Staging of Clinical Acute GVHD 
Skin 
Lower GI 
Upper GI 
Liver (Total Bilb) 
0- No Rash 
 I- Maculopapular rash, 
<25% of body surface 
 II- Maculopapular rash, 
25-50% of body surface 
 III- Rash on >50% of body 
surface, or generalized 
erythroderma 
 IV- Generalized 
erythroderma with bullous 
formation and/or 
desquamation 
0-  ≤500 mL/day or <280 
mL/m2/day 
 I-  >500 but ≤1000 mL/day or 
280-555 mL/m2/day 
 II-  >1000 but ≤1500 mL/day 
or 556-833 mL/m2/day 
 III-  >1500 mL/day or 833 
mL/m2/day 
 IV-  Severe abdominal pain 
with or without ileus, or stool 
with frank blood or melena 
0-  No protracted 
nausea and vomiting 
 I-  Persistent nausea, 
vomiting, OR biopsy 
showing acute GVHD 
of stomach or 
duodenum 
0-   <2.0 mg/dL 
 I -    2.0-3.0 mg/dL 
 II-    3.1-6.0 mg/dL 
 III-    6.1-15 mg/dL 
 IV-    >15.0 mg/dL   
 
 
Overall Clinical Grading of Severity of Acute GVHD 
Grade 
Skin 
 
Gut 
 
Liver 
 I 
Stage I-II  
& 
None /Stage 0 
& 
None /Stage 0 
 II 
Stage III  
Or 
Stage I  
Or 
Stage I  
 III 
Stage 0-IV  
Or 
Stage II-IV  
Or  
Stage II-III  
 IV 
Stage IV  
Or  
Stage 0-IV  
Or  
Stage IV  
If KPS is ≤ 30%, or decreased ≥ 40% from baseline KPS, the status is Grade IV 
 
 
 
 
 
 

 
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APPENDIX B: CHRONIC GVHD GRADING 
Onset of Chronic GVHD  
*Karnofsky/Lansky score 
at time of diagnosis  
Progressive (acute GVHD progressed directly to chronic) 
Interrupted (acute GVHD resolved, then Chronic developed) 
De novo (acute GVHD never developed) 
Chronic GHVD Flare (symptoms reactivated within 30 days of drug tapering 
or discontinuation) 
Diagnosis 
of 
Chronic 
GVHD based on 
Histologic evidence/biopsy proven 
Clinical Evidence 
Both 
Unknown 
Maximum Chronic GVHD Limited-localized skin involvement and/or hepatic dysfunction due to 
chronic GVHD 
Extensive-generalized skin involvement; or, liver histology showing chronic 
aggressive hepatitis, bridging necrosis or cirrhosis; or involvement of eye: 
Schirmer’s test with <5mm wetting; or, involvement of minor salivary glands 
or oral mucosa demonstrated on labial biopsy; or, involvement of any other 
target organ 
Overall 
Severity 
of 
Chronic GVHD 
Mild-signs and symptoms of chronic GVHD do not interfere substantially 
with function and do not progress once appropriately treated with local 
therapy or standard systemic therapy (corticosteroids and/or cyclosporine 
or FK 506) 
Moderate-signs and symptoms of chronic GVHD interfere somewhat with 
function despite appropriate therapy or are progressive through first line 
systemic therapy (corticosteroids and/or cyclosporine or FK 506) 
Severe-signs and symptoms of chronic GVHD limit function substantially 
despite appropriate therapy or are progressive through second line therapy 
 
 
 

 
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APPENDIX C: KARNOFSKY PERFORMANCE SCALE 
Karnofsky Performance Status 
KPS 100 Normal; no complaints; no evidence of disease 
KPS 90 Able to carry on normal activity; minor signs or symptoms of disease 
KPS 80 Normal activity with effort; some sign or symptoms of disease 
KPS 70 Cares for self; unable to carry on normal activity or do active work 
KPS 60 Requires occasional assistance, but is able to care for most personal needs 
KPS 50 Requires considerable assistance and frequent medical care 
KPS 40 Disabled; requires special care and assistance 
KPS 30 Severely disabled; hospitalization is indicated, although death not imminent 
KPS 20 Very sick; hospitalization necessary; active support treatment is necessary 
KPS 10 Moribund; fatal processes progressing rapidly 
KPS 0 Dead 
 
 

 
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APPENDIX D: REAGENTS, EQUIPMENT AND SUPPLIES NECESSARY FOR VACCINE PREPARATION 
Reagents 
 
 Triplex vaccine vials containing 5.1x108  pfu/mL, fill volume approximately 1mL (Lot#0786-181-
0001-1) OR 9.1x108  pfu/mL, fill volume approximately 1 mL (Lot#0786-181-0002-1). 
 
PBS containing 7.5% lactose, fill volume 1mL 
 
Equipment 
 
Vortex 
 
Test tube cooling block 
 
NIST thermometer (kept in the IDSA refrigerator) or digital thermometer 
 
microfuge 
 
Supplies 
 
Sterile syringes 1mL and 3mL 
 
Sterile needles 
 
Small sealable amber plastic bag 
 
Alcohol swabs 
 
Container with Ice packs (provided by IDS with prepared dose) 
 
 

 
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APPENDIX E: SAE/UP REPORTING COVERSHEET 
NOTIFICATION OF UNANTICIPATED PROBLEM/SERIOUS ADVERSE EVENT 
For Use by Participating Institutions Only 
THIS FORM MUST BE EMAILED TO DCC@COH.ORG WITHIN 24 HOURS OF KNOWLEDGE OF ONSET OF SERIOUS ADVERSE EVENT OR 
UNANCTICIPATED PROBLEM  
COH IRB #19065- Participating Site IRB # ___________ 
 
From: 
Date: 
Phone No.: 
Email: 
 
Reporting Investigator: 
Event:  
Participant ID: 
Institution: 
Date Event Met Reporting Criteria (as defined in protocol):   
Type of Report:  Initial    Follow-up 
Toxicity Grade:   G1/mild    G2/moderate     G3/severe    G4/life threatening    G5 
Attribution to Vaccine:   Unrelated   Unlikely   Possible    Probable   Definite 
Historical/Known Correlation to Vaccine:  Expected    Unexpected   
Meets Definition of Serious AE:      Serious      Non-serious 
Meets Definition of Unanticipated Problem:      UP      Not a UP 
Has the event been reported to the following institution’s IRB?  __ No    __ Yes    Date: __ __ / __ __  / __ __ 
Signature of Investigator:_____________________________Date:______________ 
 
 

 
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APPENDIX F: REGISTRATION COVERSHEET 
COH IRB 19065: A PHASE II RANDOMIZED, PLACEBO-CONTROLLED TRIAL TO EVALUATE THE PROTECTIVE 
FUNCTION OF AN OPTIMIZED DOSE OF TRIPLEX VACCINE IN RECIPIENTS OF AN HAPLOIDENTICAL 
HEMATOPOIETIC STEM CELL TRANSPLANT 
 
Data Coordinating Center:  City of Hope 
1500 Duarte Road 
Duarte, CA 91010  
Tel:  626-256-4673 x 3968  
Email:  DCC@coh.org (use #secure# in subject line) 
 
 
 
 
 
 
Principle Investigator:___________________________ 
 
 
Participating Site:_______________________________ 
 
 
 
 
 
 
CRA/Study Coordinator:  _________________________  Contact Number:  ______________________________ 
Patient’s Initials: (F M L): 
Institution: 
Patient's DOB: 
Investigator/Treating Physician: 
Patient’s Zip Code: 
IRB approval valid until (date): 
Sex: 
______Male 
______Female 
Date Informed Consent was Signed: 
Race: 
___ 
Black 
___ 
Caucasian 
___ 
Asian 
___ 
American Indian 
___ 
Native Hawaiian/Pacific Islander 
___ 
Other ____________ 
Ethnicity: 
___ Hispanic 
 
___ Non-Hispanic 
 
___ Other 
______________ 
 
Projected Transplant Date: 
 
Diagnosis: ________________