A Prospective, Randomized, Open-label Clinical Trial to Assess the Safety and Immunogenicity of Simultaneous vs Sequential Administration of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine and Inactivated Influenza Vaccine in Pregnant Women - Pilot
Phase: PHASE4
Conditions: Pregnancy
Sponsor: Duke University

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A Prospective, Randomized, Open-label Clinical Trial to Assess the Safety and 
Immunogenicity of Simultaneous versus Sequential Administration of Tetanus Toxoid, 
Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine and Inactivated Influenza 
Vaccine in Pregnant Women – Pilot  
 
Short Title: Safety of Simultaneous Tdap and IIV in Pregnant Women  
 
 
 
Centers for Disease Control & Prevention  
Clinical Immunization Safety Assessment (CISA) Project  
 
 
Lead Site Principal Investigator: Geeta K. Swamy, MD 
Lead Site Sub-principal Investigator: Emmanuel B. Walter, MD, MPH 
 
Contributing Site Principal Investigator: Elizabeth Schlaudecker, MD 
Contributing Site Sub-principal Investigator: Steven Black, MD 
 
Centers for Disease Control and Prevention (CDC) Principal Investigator: Karen R. 
Broder, MD  
CDC Sub-principal Investigator: Patricia Wodi, MD 
 
 
 
 
NCT # (clinicaltrials.gov registry # NCT02783170) 
 
Version Number: 6.0 
 
5 December 2017 
 
 
 
 
 
 
 

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STATEMENT OF COMPLIANCE 
• 
This trial will be conducted in compliance with the protocol, the International 
Conference on Harmonization (ICH) Guideline E6-Good Clinical Practice (GCP), 
and the applicable guidelines and regulatory requirements from the United States 
(US) Code of Federal Regulations (CFR), 45 CFR Part 46. 
• 
All study personnel with subject contact have completed Human Subjects 
Protection Training. 
 
 
 

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TABLE OF CONTENTS 
 
Protocol Summary ........................................................................................................ 5 
1 
Background ........................................................................................................... 8 
1.1 Background ......................................................................................................... 8 
1.2 Summary & Rationale .......................................................................................... 9 
2 
Study Objectives ................................................................................................. 10 
2.1 Study Outcome Measures ................................................................................. 10 
2.1.1 Primary Outcome Measures ....................................................................... 10 
2.1.2 Secondary Outcome Measures .................................................................. 11 
3 
Study Design ....................................................................................................... 11 
3.1 Main study design .............................................................................................. 11 
3.2 Laboratory studies ............................................................................................. 11 
3.2.1 Serologic studies ........................................................................................ 11 
4 Study Enrollment and Withdrawal........................................................................... 13 
4.1 Subject Inclusion Criteria ................................................................................... 13 
4.2 Subject Exclusion Criteria .................................................................................. 13 
4.3 Recruitment ....................................................................................................... 14 
4.4 Reasons for and Handling of Withdrawals ......................................................... 15 
4.5 Termination of Study .......................................................................................... 15 
5 
Study Schedule, Procedures, & Evaluations ..................................................... 15 
5.1 Schedule of events ............................................................................................ 15 
5.2 Treatment Assignment Procedures .................................................................... 19 
5.2.1 Randomization ........................................................................................... 19 
5.2.2 Blinding ...................................................................................................... 19 
5.2.3 Vaccine Supply, Storage, and Administration ............................................. 19 
5.3 Reactogenicity Assessment ............................................................................... 20 
5.4 Safety Assessment ............................................................................................ 22 
5.5 Biospecimens Collection & Handling ................................................................. 23 
5.5.1 Serum ........................................................................................................ 23 
5.5.2 Placental Tissue ......................................................................................... 24 
6 
Laboratory Analyses ........................................................................................... 24 
6.1 Pertussis Laboratory Analysis ............................................................................ 24 
6.2 Tetanus and Diphtheria Laboratory Analysis ...................................................... 24 
6.3 Influenza Laboratory Analysis ............................................................................ 25 
6.4 Placental pathology and Chorioamnionitis Analysis ........................................... 25 
7 
Statistical Considerations ................................................................................... 26 
7.1 Analysis Plan ..................................................................................................... 26 
7.1.1 Study Populations ...................................................................................... 26 
7.1.2 Primary Objective 1 .................................................................................... 26 
7.1.3 Primary Objective 2 .................................................................................... 27 
7.1.4 Primary Objective 3 .................................................................................... 27 
7.1.5 Secondary Objective .................................................................................. 28 

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7.1.6 Secondary Objective 2 ............................................................................... 28 
7.1.7 Secondary Objective 3. .............................................................................. 28 
7.2 Data Management ............................................................................................. 28 
7.2.1 Research Electronic Data Capture (REDCap) ............................................ 29 
7.2.2 CDC Laboratory Management ................................................................... 30 
7.3 Role of the CDC Investigators in the Project ...................................................... 30 
8 
Human Subjects .................................................................................................. 30 
8.1 Human Subjects Involvement, Characteristics, and Design ............................... 30 
8.2 Sources of Material ............................................................................................ 31 
8.3 Potential Risks and Benefits .............................................................................. 31 
8.4 Adequacy of Protection Against Risks ............................................................... 33 
8.4.1 Protections against Risk ............................................................................. 33 
8.4.2 ClinicalTrials.gov Requirements ..................................................................... 33 
8.5 Human Subjects ................................................................................................ 33 
8.5.1 Vulnerable Subjects Research ................................................................... 33 
References ................................................................................................................... 35 
 
 

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PROTOCOL SUMMARY 
 
Title:  
A Prospective, Randomized, Open-label Clinical Trial to Assess 
the Safety and Immunogenicity of Simultaneous versus 
Sequential Administration of tetanus toxoid, reduced diphtheria 
toxoid, and acellular pertussis vaccine and inactivated influenza 
vaccine in Pregnant Women – Pilot  
Phase: 
Phase 4 
Population: 
80 adult pregnant women (18-45 years) at ≥ 26 weeks 0 days 
gestation through ≤ 32 weeks 0 days gestation who plan on 
receiving Tdap and IIV during the current pregnancy in 
accordance with the Advisory Committee on Immunization 
Practices (ACIP) and American College of Obstetricians & 
Gynecologists (ACOG) national recommendations.    
Clinical Sites: 
Two: Duke University (Lead); Cincinnati Children’s Hospital 
Medical Center (Contributor) 
Study Duration: 
24 months (4 months to recruit/enroll (per flu season), maximum 
of 26 weeks to follow (5.5 months) (per flu season), 4.5 months 
to perform analysis and laboratory assays (per flu season))  
Participant Duration: 
Up to 23 weeks depending upon gestational age at enrollment 
and delivery  
Description of Study 
Procedures: 
This is a pilot, prospective, randomized, open-label clinical 
trial. During the study, pregnant women will be randomized 
(1:1) to receive co-administration of a single intramuscular (IM) 
0.5 mL dose of US-licensed inactivated influenza vaccine (IIV) 
and a single intramuscular (IM) 0.5 mL dose of US-licensed 
Tetanus toxoid, reduced diphtheria toxoid and acellular 
pertussis vaccine adsorbed (Tdap) or sequential administration 
of the vaccines (IIV followed by Tdap ~ 21 days later).  
Vaccines will be administered by licensed study personnel.   
 
Prior Tdap/Td/TT and influenza vaccine history will be verified 
by medical record review when possible.  
 
Injection-site (local) and systemic reaction data will be 
assessed on vaccination day and during the 7 days following 
vaccination using either identical web-based or paper diaries, 
depending on study participant preference.  
 
Maternal serum samples will be collected for antibody titers 
relevant to the Tdap and Influenza at time points that include: 
prior to vaccination(s), ~22 days post vaccination(s), and at 

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delivery.  Additionally, cord blood serum will be analyzed for 
the same antibody titers.  Lastly, a subset of subjects will have 
infant blood collected prior to two-month vaccinations via heel 
stick. 
 
Pregnant women will be followed through delivery with 
comprehensive obstetric and neonatal outcomes obtained from 
medical record review.   
Objectives: 
Primary Objectives: 
• 
To assess proportions of reactogenicity events in 
pregnant women receiving Tdap and IIV simultaneously 
vs. sequentially 
• 
To assess maternal immune responses and cord blood 
antibody levels to pertussis antigens, tetanus and 
diphtheria toxoids, and influenza antigens in the women 
receiving Tdap and IIV simultaneously vs. sequentially 
• 
To assess the feasibility of conducting a larger clinical 
trial in pregnant women receiving Tdap and IIV 
simultaneously vs. sequentially 
 
Secondary Objectives: 
• 
To describe maternal and infant outcomes in pregnant 
women receiving Tdap and IIV simultaneously vs. 
sequentially 
• 
To evaluate clinical and histological chorioamnionitis in 
the women receiving Tdap and IIV simultaneously vs. 
sequentially 
• 
To build capacity to study immunogenicity of maternal 
vaccination in the CISA Project, in collaboration with 
the CDC laboratories. 
 
Exploratory Objectives: 
• 
To assess antibody levels to pertussis antigens at 2 
months of life before receipt of pediatric diphtheria and 
tetanus toxoids and acellular pertussis vaccine 
adsorbed (DTaP) in infants born to women receiving 
Tdap and IIV simultaneously vs. sequentially 
Outcome Measures: 
Primary:  
• 
Proportions of injection-site and systemic reactions will 
be compared in simultaneous and sequential groups   
• 
Measurement of serum antibody levels to pertussis 
antigens (pertussis toxin, filamentous hemagglutinin 

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and pertactin), diphtheria and tetanus toxoids, and 
influenza antigens in: 
• 
Maternal blood pre and post-vaccination in 
pregnant women 
• 
Maternal and infant cord blood obtained at 
delivery 
• 
Feasibility benchmarks to assess participant 
recruitment/retention and adequate, timely collection of 
data and biospecimens 
 
Secondary:  
• 
Proportions of maternal and infant outcomes, e.g. 
preterm birth, SGA, preeclampsia,  
• 
Proportions of clinical chorioamnionitis  
• 
Proportions of histologic chorioamnionitis on surgical 
pathology examination of placental tissue 
• 
Feasibility benchmarks for analyzing pertussis 
immunogenicity at the CDC laboratories: 
• 
Receipt of ≥95% of samples in testable 
condition and sufficient volume 
• 
Completion of testing of ≥95% of the testable 
samples 
Exploratory: 
• 
Measurement of serum antibody levels to pertussis 
antigens (pertussis toxin, filamentous hemagglutinin 
and pertactin in 2-month infant blood before receipt of 
pediatric DTaP 
Estimated Time to Complete 
Enrollment: 
Approximately 4 months for enrollment for both the 2016-17 
and 2017-18 flu seasons 

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1 BACKGROUND  
1.1 Background 
The Advisory Committee on Immunization Practices (ACIP) and American College of 
Obstetricians & Gynecologists (ACOG) currently recommend two licensed vaccines for 
routine administration during pregnancy: inactivated influenza vaccine (IIV) for women 
who will be pregnant during influenza season and tetanus toxoid, reduced diphtheria 
toxoid and acellular pertussis vaccine (Tdap) during every pregnancy.1-5 
Pregnant women are at high risk for influenza-related morbidity and mortality due to 
changes in immunology and cardiorespiratory physiology. Influenza-infected pregnant 
women have higher rates of hospitalization, cardiopulmonary complications, and death 
compared to the general public.6-11 Further, influenza is associated with adverse birth 
outcomes such as preterm birth and fetal demise.12 Complications are even higher 
during pandemics, as seen in the 2009 outbreak when the preterm birth rate rose 
threefold among infected pregnant women and 5% of all related deaths occurred in 
pregnant women, yet they only encompass 1% of the total population.13 The Advisory 
Committee on Immunization Practices (ACIP) and American College of Obstetricians & 
Gynecologists (ACOG) recommend inactivated influenza vaccine (IIV) for all women who 
will be pregnant during influenza season at any time during pregnancy.3,4 Immunization 
of pregnant women is an effective way to prevent influenza in both mothers and their 
infants. Initial recommendations for IIV administration during pregnancy were 
extrapolated from the documented efficacy and safety of IIV in non-pregnant adults. Until 
the 2009 pandemic, there were only a few small-scale studies on the safety and 
immunogenicity of maternal influenza vaccination. Recent large cohort studies and 
randomized controlled trials have supported the presumed safety and effectiveness of 
IIV in pregnancy.4,12,14-17  
Pertussis, a respiratory infection caused by Bordetella pertussis bacteria, has been on 
the rise in the US over the last three decades after many years of effective disease 
control and prevention.18-20  Although increasing disease incidence has been 
documented among all age groups, pertussis has the greatest impact on infants <12 
months of age as they are at greatest risk for hospitalization, subsequent complications 
and death.18,19,21-23 Given that infants cannot be vaccinated against pertussis until 2 
months of age and protection against pertussis is not established until after 6 months of 
age following at least 2 to 3 pediatric diphtheria and tetanus toxoids and acellular 
pertussis vaccine adsorbed (DTaP) vaccine doses,24 alternative strategies are required 
for prevention of pertussis during infancy. After failed efforts to “cocoon” 25,26 infants or 
diminish their risk of exposure to pertussis by vaccinating adolescents and adults and 
demonstrated safety of antenatal Tdap administration in small studies, ACIP 
recommendations were updated in 2013 to administer Tdap vaccine during every 
pregnancy, preferable between 27 – 36 weeks gestation to maximize passive antibody 
transfer to the infant.2  
The Centers for Disease Control and Prevention (CDC), American Academy of 
Pediatrics, and the Immunization Action Coalition all recommend that multiple 
inactivated vaccines can be administered at the same time, citing evidence that it does 
not diminish antibody response or increase reactogenicity.27,28  Further, simultaneous 
administration of vaccines is more convenient and efficient for patients and providers. 
However, the simultaneous administration of vaccines during pregnancy such as IIV and 
Tdap has not been studied in a prospective manner to date. Funded by the CDC, the 
Vaccine Safety Datalink (VSD) assessed the safety of simultaneous Tdap and IIV in 
pregnant women using a large-linked database.29  In the VSD study Tdap and IIV were 

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administered simultaneously in 8464 pregnancies and sequentially (in any order) in 
28,380 pregnancies.  The VSD study concluded that simultaneous administration of 
Tdap and IIV vaccines during pregnancy was not associated with a higher risk of 
medically attended adverse acute outcomes or birth outcomes compared with sequential 
vaccination.  While this is certainly informative given the current paucity of data, it did not 
provide data on reactogenicity events that did not lead to a medical visit, such as 
maternal fever or injection-site pain. Another limitation of a retrospective study like the 
VSD analysis is that it did not allow for assessment of immunogenicity, or vaccine-
induced antibody response and seroprotection against the vaccine-preventable disease. 
Some investigators on our study team participated in a randomized, placebo-controlled 
trial of Tdap given at 32 weeks gestation vs. immediately postpartum in which we 
followed infants for the first year of life. We found that antenatal Tdap resulted in high 
pertussis antibody levels in infants during the first 2 months of life and did not 
substantially affect infant immune responses to pediatric DTaP.30 Such data have been 
used to support the ACIP recommendation to administer Tdap during every pregnancy. 
However, recent studies raise concerns about the impact on pertussis immunogenicity 
following co-administration of IIV and Tdap. Two studies in non-pregnant adults suggest 
that simultaneous vs. sequential administration (IIV followed by Tdap 4-6 weeks later) is 
safe and well-tolerated.31,32 However, one of the studies demonstrated higher reports of 
injection-site pain after simultaneous administration.31 Furthermore, both studies 
suggested a diminished antibody response to pertussis antigens following simultaneous 
administration of IIV and Tdap as compared to sequential dosing, and some 
investigators on our study team have demonstrated reduced antibody responses to 
influenza vaccine (as measured by hemagglutinin inhibition) in pregnant women 
compared to non-pregnant women.33 This suggests that decreased immune responses 
may be exacerbated in pregnant women, though the clinical importance remains unclear 
in the adult population.31,32  These findings raise questions about the potential impact of 
simultaneous administration during pregnancy. Given that the primary motivation for 
administering Tdap during pregnancy is to boost maternal antibodies against pertussis 
and attempt to achieve the highest possible antibody titer at the time of delivery, 
diminished anti-pertussis antibody production could result in a shorter duration of 
protection against pertussis in vulnerable young infants. 
Another unanswered question in maternal immunization concerns a questionable small 
increased risk for clinical chorioamnionitis following both Tdap and IIV administration 
during pregnancy identified through VSD analyses.15,34 At present, these findings remain 
unexplained as chorioamnionitis is a polymicrobial infection of the intra-amniotic cavity 
that affects 1-2% of term and 5-10% of preterm pregnancies and thus unlikely to result 
from a single vaccination given weeks to months earlier than delivery. 35,36 Further, the 
diagnosis was based on ICD-9 coding and not strict definitions of clinical 
chorioamnionitis combined with the lack of an increase in preterm birth which is highly 
intertwined with chorioamnionitis. While it is possible that these findings are due to 
chance, further evaluation of a possible association could help to resolve the issue. 
1.2 Summary & Rationale 
Given the limited data on the safety and immunogenicity of simultaneously administered 
IIV and Tdap during pregnancy, a prospective randomized clinical study could provide 
much-needed data on the maternal and infant risks and benefits. There are currently no 
published or registered randomized trials of simultaneous vs. sequential administration 
of IIV and Tdap during pregnancy. Such data would aid policymakers, clinicians, and 
pregnant women in making vaccination decisions during influenza season while 

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identification of a potential clinically-relevant reduction in pertussis antibody levels 
following simultaneous IIV and Tdap administration may warrant the consideration for 
altered guidelines for administration. Moreover, generation of data on simultaneous 
vaccination during pregnancy will likely be of great importance as the maternal 
immunization platform continues to develop and very possibly include vaccines against 
group B Streptococcus and respiratory syncytial virus.37-39 
 
2 STUDY OBJECTIVES 
Primary Objectives: 
• 
To assess proportions of reactogenicity events in pregnant women receiving 
Tdap and IIV simultaneously vs. sequentially 
• 
To assess maternal immune responses and cord blood antibody levels to 
pertussis antigens, tetanus and diphtheria toxoids, and influenza antigens in the 
women receiving Tdap and IIV simultaneously vs. sequentially 
• 
To assess the feasibility of conducting a larger clinical trial in pregnant women 
receiving Tdap and IIV simultaneously vs. sequentially 
 
Secondary Objectives: 
• 
To describe maternal and infant outcomes in pregnant women receiving Tdap 
and IIV simultaneously vs. sequentially 
• 
To evaluate clinical and histological chorioamnionitis in the women receiving 
Tdap and IIV simultaneously vs. sequentially 
• 
To build capacity to study immunogenicity of maternal vaccination in the CISA 
Project, in collaboration with the CDC laboratories. 
 
Exploratory Objectives: 
• 
To assess antibody levels to pertussis antigens at 2 months of life before receipt 
of pediatric diphtheria and tetanus toxoids and acellular pertussis vaccine 
adsorbed (DTaP) in infants born to women receiving Tdap and IIV 
simultaneously vs. sequentially 
2.1 Study Outcome Measures 
2.1.1 Primary Outcome Measures:  
• 
Proportions of injection-site and systemic reactions will be compared in 
simultaneous and sequential groups   
• 
Measurement of serum antibody levels to pertussis antigens (pertussis toxin, 
filamentous hemagglutinin, and pertactin), diphtheria and tetanus toxoids, and 
influenza antigens in: 
• 
Maternal blood pre and post-vaccination in pregnant women 
• 
Maternal and infant cord blood obtained at delivery 
• 
Feasibility benchmarks to assess participant recruitment/retention and adequate, 
timely collection of data and biospecimens  
 

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2.1.2 Secondary Outcome Measures: 
 
• 
Proportions of maternal and infant outcomes, e.g. preterm birth, SGA, 
preeclampsia 
• 
Proportions of clinical chorioamnionitis  
• 
Proportions of histologic chorioamnionitis on surgical pathology examination of 
placental tissue 
• 
Feasibility benchmarks for analyzing pertussis immunogenicity at the CDC 
laboratories: 
• 
Receipt of ≥95% of samples in testable condition and sufficient volume 
• 
Completion of testing of ≥95% of the testable samples 
 
2.1.3 Exploratory Outcome Measures: 
 
• 
Measurement of serum antibody levels to pertussis antigens (pertussis toxin, 
filamentous hemagglutinin and pertactin), in 2-month infant blood before receipt 
of pediatric DTaP 
3 STUDY DESIGN 
3.1 Main study design 
This pilot study is a prospective, randomized open-label clinical trial of approximately 80 
healthy pregnant women enrolled at Duke University Medical Center (Lead Contractor) 
and Cincinnati Children’s Hospital (Contributing Contractor) who will be followed after 
they receive simultaneous or sequential single 0.5 mL intramuscular (IM) dose of US-
licensed inactivated influenza vaccine (quadrivalent Fluzone) and single 0.5 mL 
intramuscular (IM) dose of US-licensed tetanus toxoid, reduced diphtheria toxoid and 
acellular pertussis vaccine (Tdap, Boostrix).  In each study participant, the Tdap and IIV 
vaccine that is administered will be produced by different manufacturers unless there are 
manufacturing issues or vaccine shortages that necessitate acquisition of Tdap and IIV 
from the same manufacturer. 
 
Pregnant women 18-45 years of age and 26-32 weeks gestation will be enrolled over a 
period of approximately 4 months per flu season. The purpose of the study is to compare 
the rates of injection-site and systemic reactions and the immune response following 
simultaneous administration of IIV and Tdap or sequential administration of IIV followed 
by Tdap in pregnant women, and to assess rates of adverse pregnancy (maternal and 
infant) outcomes including, but not limited to, preterm birth, small for gestational age 
(SGA), and chorioamnionitis. Maternal and infant outcomes will be collected by medical 
record review from enrollment through hospital discharge following delivery.  
 
3.2 Laboratory studies 
3.2.1 Serologic studies – We will evaluate pre- and post-vaccination serologic 
responses in both simultaneous and sequential vaccination groups.  A 
microsphere based multiplex antibody capture assay to determine levels of IgG 
to pertussis toxin, filamentous hemagglutinin, pertactin, and fimbrae (only for 
2016-17 influenza season) in the serum will be performed by the laboratory at the 
CDC according to CDC protocol MPIR-4301.  Tetanus and diphtheria toxoid IgG 
levels will be measured by an enzyme linked immunoassay (ELISA) at the Duke 
Human Vaccine Institute (Moody lab).  In addition, IgG levels will be measured 

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for the for the specific viral strains included in the 2016-2017 and 2017-2018 
quadrivalent IIV (depending upon vaccine availability) using hemagglutination 
inhibition assays at the Duke RBL Virology Unit. Venous blood (approximately 15 
mL of blood) will be collected from each subject before and 21(+7) days after 
each vaccination. Additionally, maternal and cord blood (approximately 15mL of 
blood each) will be collected at delivery for serological analysis in both 
simultaneous and sequential vaccination groups.  An assessment of placental 
antibody transfer (maternal:cord antibody ratio) will be determined. Prior to the 2-
month infant vaccination visit, a blood sample (up to 0.5 mL) will be obtained via 
heel stick on a subset of 10 infants at each site (20 total). The blood sample will 
be used to form 5 dried blood spots (DBS) and sent to the CDC lab to determine 
levels of IgG to pertussis toxin, filamentous hemagglutinin, and pertactin.   
   
3.2.2 Placental pathology – Routine placental pathology includes gross and 
microscopic evaluation of the placenta (including its weight), umbilical cord 
(including length, diameter, number of vessels, coiling, and insertion point) and 
fetal membrane characteristics. Histologic chorioamnionitis is diagnosed using 
standard hematoxylin and eosin (H & E) staining to identify inflammatory cells 
(neutrophils, lymphocytes, eosinophils, etc.) as infiltration of the chorionic plate 
by neutrophils is diagnostic of chorioamnionitis. Chorioamnionitis is staged as per 
the grading system described in Section 6.4 below.   
 
3.2.3 Feasibility assessment - Feasibility for conducting a larger-scale study of 
simultaneous vs. sequential administration of IIV and Tdap in pregnancy will be 
assessed through pre-specified benchmarks for participant recruitment and 
retention, data collection, and maternal and infant biospecimen collection as 
described in Section 5.5 below.  
 
3.2.4 Future studies - In addition to the specified analyses described thus far, there 
may be other tests or assays that have yet to be identified that may be important 
for interpreting our study findings or of relevance to maternal-infant health 
outcomes.  Therefore, participants will be offered, through an opt-in/opt-out 
strategy to allow for the storage of any remaining blood (serum/plasma) after all 
specified analyses have been completed.  Additional laboratory assays may test 
for antibodies against other bacteria or viruses, markers of inflammation, or used 
in research on the health of mothers and infants. Specimens banked for use in 
other studies will be linked to information (including identifying information) that 
participants provided to the study. Participants will not receive results of any 
future testing of their specimens.   
In addition, participants will be offered, again through an opt-in/opt-out strategy, 
to allow study staff to contact them in the future to take part in other research 
studies.    
 
3.2.5 Investigational New Drug (IND) Exemption – Upon completion of Duke 
University’s “Checklist to Determine if an Investigational New Drug (IND) 
Application is Required” it was determined that the study meets criteria for IND 
exemption.   
 

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4 STUDY ENROLLMENT AND WITHDRAWAL  
4.1  Subject Inclusion Criteria 
Subjects who meet all of the following criteria will be eligible to participate in this 
interventional study.   
1. Pregnant, as determined by medical history; 18 – 45 years of age inclusive 
2. Intention of receiving Tdap and IIV vaccines based on ACIP recommendations   
3. Willing to provide written informed consent prior to initiation of any study 
procedures 
4. Singleton gestation ≥ 26 weeks 0 days gestation - ≤32 weeks 0 days gestation at 
the time of Visit 1 vaccination based on reconciliation of last menstrual period 
and ultrasound dating. Estimated due date (EDD) and Gestational Age (GA) - 
EDD will be based on reconciliation of a “sure” first day of the last menstrual 
period (LMP) and earliest dating ultrasound. If the LMP is uncertain, then the 
earliest dating ultrasound will be used to determine EDD and GA. If the 
ultrasound derived-EDD is in 
agreement with sure-LMP derived 
EDD (Table 1), then the LMP-derived 
EDD is used to determine GA. If the 
ultrasound derived EDD is not in 
agreement with the LMP-derived 
EDD, the ultrasound-derived EDD is 
used to determine GA.  
5. English or Spanish literate 
6. Intention of being available for entire study period and complete all relevant study 
procedures, including follow-up phone calls and collection of delivery information.   
 
4.2 Subject Exclusion Criteria 
Subjects who meet any of the following criteria will not be eligible to participate in 
this study: 
1.  
a. For subjects enrolling during the 2016-2017 influenza season:  IIV/LAIV 
receipt during 2016-2017 influenza season prior to study enrollment 
b. For subjects enrolling during the 2017-2018 influenza season:  IIV/LAIV 
or recombinant influenza vaccine (RIV) receipt during 2017-2018 
influenza season prior to study enrollment 
2. Tdap/Td/TT receipt during current pregnancy prior to study enrollment 
3. Has immunosuppression as a result of an underlying illness or treatment, or use 
of anti-cancer chemotherapy or radiation therapy within the preceding 36 
months. 
4. Has an active neoplastic disease (excluding non-melanoma skin cancer), a 
history of any hematologic malignancy, current bleeding disorder, or taking 
anticoagulants (daily low dose aspirin may be acceptable). 
5. Has a history of receiving immunoglobulin or other blood product (with exception 
of Rhogam) within the 3 months prior to enrollment in this study. 
6. Known to have pre-existing diabetes mellitus or an autoimmune disorder.   
7. Febrile illness within the last 24 hours or an oral temperature > 100.4°F (> 
38.0°C) prior to IIV or Tdap administration 
Table 1. Ultrasound Parameters for Using Sure LMP to 
Determine Gestational Age 
Gestational age at first 
ultrasound by LMP 
Ultrasound agreement 
with LMP 
< 19 weeks 6 days 
± 7 days 
20 weeks to 29 weeks 6 days 
± 14 days 
> 30 weeks 
± 21 days 

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8. Contraindication to IIV receipt including history of severe allergic reaction after a 
previous dose of any influenza vaccine; or to a vaccine component, including 
egg protein 
9. Contraindication to Tdap receipt including history of severe allergic reaction after 
a previous dose of any tetanus toxoid-, diphtheria toxoid-, or pertussis antigen-
containing vaccine or encephalopathy within 7 days of administration of a 
previous dose of a pertussis antigen-containing vaccine that is not attributable to 
another identifiable cause  
10. Arthus-type hypersensitivity reaction following a prior dose of a tetanus toxoid-
containing vaccine within the last 10 years    
11. Any condition that may interfere with assessment of local injection site reactions, 
e.g. lymphadenectomy or obscuring tattoos 
12. History of Guillain-Barré syndrome within 6 weeks of a prior dose of any tetanus 
toxoid-, diphtheria toxoid- or pertussis antigen-containing vaccine or influenza 
vaccine 
13. Known or suspected impairment of immunologic function including infection with 
HIV, hepatitis B or C 
14. Use of immunosuppressive or cytotoxic drugs except receipt of oral or 
parenteral (intravenous, subcutaneous or intramuscular) corticosteroids 30 or 
more days prior to enrollment. Persons who have used oral or parenteral 
corticosteroids within 12months prior to enrollment may be enrolled if the 
longest course of therapy was less than 14 consecutive days and no dose was 
given within 30 days of enrollment. Intraarticular, bursal, tendon, or epidural 
injections of corticosteroids are permissible if the most recent injection was 30 or 
more days prior to enrolment. Persons applying topically corticosteroid in either 
upper arm (i.e. injection site) may be enrolled 1 or more days after their therapy 
is completed. Corticosteroids administered topically at non-injection sites, by 
inhalation or intranasally are permissible 
15. Receipt of any licensed vaccine within 14 days prior to study vaccination or 
planning receipt of any vaccines (except study vaccines) prior to Visit 7 follow 
up. 
16. Receipt of live vaccine during current pregnancy.  
17. High risk for preterm birth (active preterm labor, short cervix, cervical cerclage, 
receipt of antenatal corticosteroids for fetal lung maturity prior to Visit 1) 
18. Antenatal ultrasound diagnosis of fetal growth restriction, defined as < 10th 
percentile estimated fetal weight for gestational age 
19. Known fetal congenital anomaly, e.g. genetic abnormality or malformation based 
on antenatal ultrasound  
20. Any condition which, in the opinion of the investigators, may pose a health risk 
to the subject or interfere with the evaluation of the study objectives. 
21. Anyone who is a relative of any research study personnel 
22. Anyone who is an employee of any research study personnel 
23. Anyone who is already enrolled or plans to enroll in another clinical trial with an 
investigational product. Co-enrollment in observational or behavioral intervention 
studies are allowed at any time. 
24. Previous participation in the study.   
4.3 Recruitment 
Pregnant women at ≥ 26 weeks 0 day- ≤ 32 weeks 0 days gestation, 18-45 years old, 
who are planning to receive Tdap and IIV during their current pregnancy will be recruited 
at prenatal clinics whose patients deliver at Duke University Hospital or University of 

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Cincinnati Medical Center. Pregnant women will be pre-screened for eligibility via 
medical record review. The study will be introduced to a potential subject by a member 
of their care team. Potential subjects ≥ 20 weeks 0 days gestation will be approached by 
a member of the research team for study enrollment. Medical and obstetric history, 
including prior Tdap/Td/TT and influenza vaccine history, will be obtained via participant 
self-report with verification by chart review whenever feasible (including medical records, 
employee health records, immunization registry records, and pharmacy records). Study 
staff will attempt to recruit 10 infants born to women in this study from each site to 
assess infant pertussis antibody levels prior to 2-month vaccinations.  To the extent 
feasible each site will preferentially recruit 5 infants for each assignment group 
(simultaneous vs. sequential).  
4.4 Reasons for and Handling of Withdrawals 
The following may be reason for study withdrawal: 
• 
As deemed necessary by the principal investigator (PI).  
• 
Subject withdrawal of consent. 
• 
Loss to follow-up. 
• 
Termination of the study by the sponsor. 
 
Subjects may withdraw their consent for study participation at any time and for any 
reason, without penalty. Subjects who withdraw from the study prior to randomization 
vaccine will be replaced. Subjects who withdraw from the study after receiving vaccine 
will not be replaced. Every attempt should be made to collect all data specified by the 
protocol, including collection of pregnancy outcome/safety data via medical record 
review for subjects who request withdrawal from study interventions/procedures.   
4.5 Termination of Study  
This study may be terminated for safety concerns of the principal investigators from the 
Lead or Contributing sites, CDC, or participating IRBs.   
 
5 STUDY SCHEDULE, PROCEDURES, & EVALUATIONS 
5.1 Schedule of events 
Pregnant women meeting the proposed eligibility criteria (Section 4.1-4.2) will be 
recruited. Written informed consent (Appendix I) will be obtained from study participants 
prior to conducting any study procedures. Table 2 describes the proposed schedule of 
study visits with further details below.  
Table 2:  Study Visit Schedule 
Procedure 
Screening 
Visit* 
Day -28 to 1 
Visit 1 
Day 1 
Visit 2 
Day 4 + 1 
Visit 3 
Day 9 + 3 
Visit 4 
Day  22 + 7 
Visit 5 
Day  25 – 32 
+ 1 
Visit 6 
Day  30 – 
37 + 3 
Visit 7 
Day 43 -50 + 
7 
Visit 8 
Delivery 
Visit 9 
Infant Blood 
Draw 
Unscheduled 
Visit 
 
Type of contact 
Chart 
Abstraction/ 
Clinic 
Clinic 
Phone/ 
Email/ 
Text 
Phone/ 
Email/ 
Text 
Clinic 
Phone/ 
Email/ Text 
Phone/ 
Email/ Text 
Clinic/ 
Phone/Email/ 
Text 
Hospital/ Chart 
Abstraction 
Clinic 
Clinic 
Informed consent & 
Medical Release of 
Information 
X 
 
 
 
 
 
 
 
 
Xe 
 
Review Eligibility Criteria 
X 
X 
 
 
 
 
 
 
 
 
 
Review eligibility criteria 
for Tdap vaccination 
 
 
 
 
Xa 
 
 
 
 
 
 
Data Collection b 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
Influenza and Td/TT/Tdap 
Vaccination History 
X 
  
 
 
 
 
 
 
 
 
 
Vital signs (temperature, 
heart rate, respiratory rate 
and blood pressure) c  
 
X 
 
 
Xa 
 
 
 
 
 
X 

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Collection of Cord Blood 
& Placenta 
 
 
 
 
 
 
 
 
X 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
 
Vaccination 
 
X 
 
 
Xa 
 
 
 
 
 
 
Dispense and review 
instructions for  Memory 
aid supplies & (REDCap 
or paper) 
 
X 
 
 
X 
 
 
 
 
 
 
Complete Memory aid 
form (REDCap or paper) 
 
X 
X 
X 
X 
X 
X 
 
 
 
 
Reactogenicity (local & 
systemic) 
 
 
X 
X 
 
X 
X 
 
 
 
 
Concomitant medications 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
Obtain solicited & 
unsolicited adverse 
events 
 
X 
X 
X 
X 
X 
X 
 
 
 
X 
Obtain medically-attended 
events and serious 
adverse events  
 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
Infant Data Collectiond 
 
 
 
 
 
 
 
 
 
X 
 
Infant Blood Sample  
(DBS) 
 
 
 
 
 
 
 
 
 
X 
 
* Screening visit may occur simultaneously with Visit 1 
a Procedures for subjects in sequential group only 
b Data collection includes demographic information, medical and obstetric history, current pregnancy status. Changes in baseline medical status such as worsening or new onset 
condition will be capture as adverse events   
c Vital signs measured prior to vaccinations during Visit 1 and Visit 4 
d Data collection includes pertussis-specific medical history 
e Informed consent to be completed prior to Visit 9 blood draw 
 
Screening Visit, Study Day -28 to 1 (Chart Abstraction & Clinic Visit – may occur 
simultaneously with Visit 1) 
• Obtain written informed consent (Appendix I) and release of medical record 
information 
• Review and confirm study eligibility 
• Obtain information on preferred method of contact for follow-up (telephone, email 
or reminder) 
• Obtain demographic data 
•  Obtain month/year of prior history of influenza (IIV or LAIV) vaccines for the past 2 
years 
• Obtain month/year of any prior history of Tdap 
• Obtain month/year of prior history of Td/TT vaccines in the past 10 years 
• Obtain medical and obstetric history and current pregnancy status  
• Obtain current concomitant medication use 
 
Visit 1, Study Day 1 (Vaccination Day) - Screening, Enrollment, and Randomization 
(Clinic Visit) 
• If Screening Visit occurred prior to Visit 1, review and confirm eligibility and all data 
collected during Screening Visit 
• Obtain vital signs including oral temperature prior to vaccination 
• Obtain 15mL blood sample prior to vaccination for serologic analysis (Section 6) 
• Randomize study participant to simultaneous or sequential vaccine administration 
(Section 5.2.1) 
• Administer assigned study products – Trained, licensed research staff will administer 
either IIV alone or IIV + Tdap as described in Section 5.2.3. Ensure participants 
receive corresponding Vaccine Information Sheets (VIS) during visit. 
• Dispense memory aid (Appendix B and C), thermometer, and ruler (in order to 
standardize measurements). Review instructions for use of thermometer, ruler, and 

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memory aid (Appendix A) completion. 
• Confirm preferred method of contact for follow-up (telephone, text or email 
reminder) 
• Confirm date of next scheduled prenatal appointment 
• Record any AEs and SAEs during post-vaccination monitoring  
 
Visit 2, Study Day 4 (window Days 3 – 5) Phone Call/Email/SMS Text Follow-Up 
Study staff will contact study participants (Appendix F) to review the memory aid data 
and record any adverse events (AEs), serious AEs (SAEs), concomitant medications, 
and current medical/pregnancy status as described in Section 5.1. Participants will be 
reminded that they will be contacted again after Day 8.  
For participants who choose to utilize REDCap web-based system for entry of 
memory aid information, study staff will review REDCap system to confirm data 
capture and assess for any AEs, SAEs, and concomitant medications. Subjects who 
chose to utilize REDCap will be called if they have not entered their information to remind 
them to enter their information.    
 
Visit 3, Study Day 9 (window Days 9 – 12) Phone Call/Email/SMS Text Follow-Up 
Study staff will contact study participants (Appendix F) to review the memory aid data 
and record any AEs, SAEs, concomitant medications, and current medical/pregnancy 
status as described in Section 5.1.  Participants who are lost to follow-up by phone 
contact will continue to be called on a weekly basis until approximately Day 45 following 
vaccination for safety assessment. Study staff will also attempt to follow up with 
participants at subsequent scheduled prenatal appointments which should be within 2-4 
weeks from enrollment visit based on routine prenatal care guidelines. 
 
For participants who choose to utilize REDCAP web-based system for entry of 
memory aid information, study staff will review REDCAP system to confirm data 
capture and assess for any AEs, SAEs, and concomitant medications.  Participants who 
are lost to follow-up by phone contact will continue to be called on a weekly basis until 
approximately Day 45 following vaccination for safety assessment.  
 
Visit 4, Study Day 22 (window Days 22 – 29) Clinic Visit 
• For study participants in the sequential study group, review exclusion criteria listed in 
section 4.2 for Tdap vaccination 
• Obtain vital signs including oral temperature prior to vaccination for study participants 
in the sequential group. 
• Study staff will review the memory aid data and record any AEs, SAEs, concomitant 
medications, and current medical/pregnancy status as described in Section 5.1  
• Obtain 15mL blood sample for serologic analysis (Section 6).  Study participants in 
sequential group to have blood sample obtained prior to vaccination.   
• For subjects in the sequential study group, trained, licensed research staff will 
administer Tdap as described in Section 5.2.3. Ensure participants receive Tdap 
Vaccine Information Sheets (VIS) during visit. 
• Confirm subjects still have previously dispensed thermometer and ruler; if not, 
provide new supplies. Review instructions for use of thermometer, ruler, and 
memory aid (Appendix A) completion. All subjects will complete the memory aid 
(Appendix D and E) again to allow for the collection of “mock” data in the 
simultaneous group for comparison with the sequential group.  Simultaneous group 
will only provide information for systemic reactions and oral temperature.   

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• Confirm preferred method of contact for follow-up (telephone or email reminder) 
• Confirm date of next scheduled prenatal appointment 
 
Visit 5, Study Day 25 - 32 (window Days 24 – 33) Phone Call/Email/SMS Text 
Follow-Up 
Study staff will contact study participants (Appendix F) to review the memory aid data 
and record any AEs, SAEs, concomitant medications, and current medical/pregnancy 
status as described in Section 5.1. Participants will be reminded that they will be 
contacted again after Day 29.  Participants who are lost to follow-up by phone contact will 
continue to be called on a weekly basis following vaccination until approximately Day 45 
for safety assessment. Study staff will also attempt to follow up with participants at 
subsequent scheduled prenatal appointments which should be within 2-4 weeks from 
enrollment visit based on routine prenatal care guidelines. 
 
Visit 6, Study Day 30 - 37 (window Days 30 – 40) Phone Call/Email/SMS Text 
Follow-Up 
Study staff will contact study participants (Appendix F) to review the memory aid data 
and record any AEs, SAEs, concomitant medications, and current medical/pregnancy 
status as described in Section 5.1.  Participants who are lost to follow-up by phone 
contact will continue to be called on a weekly basis until approximately Day 45 following 
vaccination for safety assessment. Study staff will also approach participants at follow-up 
prenatal appointments which should be within 2-4 weeks based on routine prenatal care 
guidelines. 
 
Visit 7, Study Day 43 - 50 (window Days 43 – 57) Clinic Visit for sequential group, 
Phone Call/Email/Text for simultaneous group 
• This review will be done by phone call/email/text for study participants (Appendix F) in the 
simultaneous group and in clinic for participants in the sequential group.  Study staff will 
review the memory aid data and record any AEs, SAEs, concomitant medications, and 
current medical/pregnancy status as described in Section 5.1. Obtain 15mL blood 
sample for serologic analysis for sequential group only (Section 6) 
 
Visit 8, Delivery Visit, Medical Record Review/Phone Call/Hospital 
Study staff will screen the inpatient census for the site-specific Labor & 
Delivery/Birthing Centers daily to identify study participants admitted for delivery. 
Electronic medical records will be comprehensively reviewed for detailed 
information about maternal health events during pregnancy and maternal and infant 
outcomes as defined by the American College of Obstetrics & Gynecology’s 
REVITALIZE Obstetric Data Definitions.40 Concomitant medications during 
delivery hospitalization will be limited to those that are relevant to pregnancy 
outcomes of interest, e.g. antenatal corticosteroids, or tocolytics in the setting of 
preterm labor/preterm birth, magnesium in the setting of preeclampsia, antibiotics in 
the setting of Group Beta Streptococcus (GBS) prophylaxis or chorioamnionitis, etc.  
Maternal blood and infant cord blood will be collected at this visit. Placentas will be 
sent for clinical pathology examination.   
 
In order to capture and follow all participants, as a separate plan of follow up, study 
participants who are not identified via medical record review at delivery will be contacted 
by phone approximately 2 weeks after their estimated due date to determine if delivery 

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occurred elsewhere. If so, maternal and infant medical records will be requested from 
the delivery hospital for data collection.   
 
Visit 9, Infant Follow up Clinic Visit 
At Visit 9, infants must be ≥ 6weeks and ≤ 12 weeks of age and not have received any 
dose of DTaP. Study staff will obtain a blood sample via heel stick (up to 0.5 mL) prior to 
the infant receiving 2-month vaccination series to collect 5 dried blood spots (DBS).  
Study staff will recruit 10 infants born to women in this study from each site and will 
attempt to preferentially recruit 5 infants for each assignment group (simultaneous vs. 
sequential) at each site. Dried blood spot cards will be sent to the CDC for testing. 
 
Additionally, study staff will collect information about pertussis symptoms, diagnosis and 
exposure in the infants. The study staff will also assess to ensure the child does not 
have an increased risk for bleeding or infection after a heel stick.   
Unscheduled Clinic Visit 
• Unscheduled visits would be conducted for study participants with severe local or 
systemic reactions with assessment including vital signs, direct measurement of the 
extent of local reactions, and photographs of local reactions.  Providers will be 
informed of the reactions in their patients and direct care as needed. Study staff will 
review the memory aid data (if applicable) and record any AEs, SAEs, concomitant 
medications, and current medical/pregnancy status as described in Section 5.1.   
5.2 Treatment Assignment Procedures 
This is a pilot, open-label, prospective, randomized study involving pregnant women who 
are to receive Tdap and IIV vaccines.  The specific vaccines administered are based on 
availability from manufacturers prior to the 2016-2017 and 2017-2018 influenza seasons.  
 
5.2.1 Randomization 
Participants will be randomized (1:1) to receive either IIV and Tdap simultaneously or 
sequentially (IIV followed by Tdap) using a permuted block randomization scheme 
stratified by Lead and Contributing sites. The project statistician at Duke University will 
generate permuted block randomization schemes which will be uploaded to REDCap. 
The randomization schedule will not be available to the study staff, so the next 
randomization allocation will not be known before randomization occurs. Following 
confirmation of study eligibility criteria during Visit 1, participant randomization will be 
through REDCap with treatment allocation recorded on the CRF.  
 
5.2.2 Blinding 
This study will be open label and study staff and subjects will not be blinded.  Laboratory 
and pathology staff will be blinded to treatment arm assignment.    
 
5.2.3 Vaccine Supply, Storage, and Administration 
In order to ensure adherence to study randomization assignment, US licensed IIV and 
Tdap vaccines will be administered as study procedures. Licensed Tdap and IIV (single 
dose vials or prefilled syringes) will be purchased for study administration and 
maintained at the study sites in a research-specific medication refrigerator at 2-8°C in 
accordance with package insert guidelines. Vaccine brand will be uniform across sites 
for both Tdap and IIV.  The vaccine brands used for the study will be Boostrix® (GSK) 
[Tdap vaccine] and Fluzone Quadrivalent® (Sanofi) [influenza vaccine]. 

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Pregnant women meeting eligibility criteria for the study will either receive 1) a single 
intramuscular (IM) 0.5 mL dose of IIV vaccine and single IM 0.5 mL dose of Tdap 
vaccine (simultaneous vaccination group) or 2) a single IM 0.5 mL dose of IIV vaccine 
followed by a single IM 0.5 mL dose of Tdap vaccine 22-29 days later (sequential 
vaccination group).  Both vaccines will be administered by a licensed provider (RN, NP, 
PA, MD) following randomization assignment within the electronic data capture system.  
The study team will ensure that the vaccines will not be administered in the same arm. 
The vaccine manufacturer, lot number, expiration date, site of administration, and 
date/time of administration will be recorded on the case report form (CRF) and on the 
study product accountability log. Following administration, used study syringes will be 
disposed of according to standard operating procedure. Emergency management 
supplies will be available for initial treatment of an allergic reaction if needed.  
 
The vaccine injection site(s) will be reviewed prior to subject leaving the clinic at least 20 
minutes after vaccination takes place, which is consistent with current ACIP 
recommendations that individuals be observed for 15 minutes post-vaccination.41  The 
site(s) will be scored for evidence of local reactogenicity as listed below in Tables 3 and 
4.  
 
5.3 Reactogenicity Assessment 
Frequency and occurrence of local and systemic reactogenicity, solicited and unsolicited 
AEs, SAEs, concomitant medication use, and unscheduled medical care will be 
assessed immediately after vaccination (day 1) through post-vaccination Day 8 (day 1-8) 
using a standard memory aid (Appendix B-E). At the time of study enrollment, 
participants will be given an oral digital thermometer and instructed on completing the 
memory aid to document oral temperatures and post-injection symptoms, daily.  A study 
staff member will review each portion of the memory aid with the subject in order to 
familiarize the subject with the form.  The subject will be given the choice of either 
entering their data into REDCap daily or utilizing a traditional paper memory aid.  
Subjects will be instructed to notify study staff promptly using the 24-hour contact 
number provided in the memory aid in the event of any severe (Grade 3) local or 
systemic reactions.    
 
Beginning on the evening of Study Visit 1 (Day 1) following vaccination, participants will 
record their oral temperature using the study-supplied thermometer, the occurrence of 
AEs, and concomitant medication use for the next 7 days (Day 1 – 8). Temperature will 
be recorded at roughly the same time each day. If a temperature ≥ 100.0°F (37.8°C) is 
recorded, a second measurement will be taken within 20 minutes. If more than one 
temperature is taken on the same day, the highest temperature should be recorded. 
Solicited adverse events (local and systemic), which will be classified as mild, moderate, 
or severe as described in Tables 3 and 4, will be reviewed and recorded during Visits 2-
3 and 5-6.  
 
Each day, women will record reactogenicity data either on paper or directly into the 
REDCap system through 7 days post-vaccination.  All subjects will be provided with a 
paper memory aid (Appendix B-E) to record their reactogenicity data for ease of recall 
when entering into REDCap or recalling to research staff over the phone.  We have 
selected a reactogenicity period of vaccination day and the next seven days based on 
pre-licensure studies of Tdap and IIV vaccines in adults and adolescents which suggest 

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that the onset of solicited, local adverse events is highest during days 1 through 4 post-
vaccination. Moreover, pre-licensure data indicate a low incidence of late onset reactions 
(> 3 days post-vaccination). 42 Contemporary evaluations of booster doses of both 
licensed Tdap vaccines (i.e., Boostrix and Adacel) have used either 4- or 7-day periods 
for assessments of reactogenicity citing that most local and systemic reactions occur 
within the first 48 hours after vaccination. 43    
 
Women using REDCap will receive an email soliciting their record of events (daily link is 
sent via email for subjects to complete). The REDCap system provides real-time reports 
regarding who has responded.  Local and systemic reactogenicity will be measured as 
described in Tables 3 and 4 and subjects will contact the study team if they have any 
severe solicited symptoms or experience an SAE. AEs and SAEs will be reviewed in 
REDCap or by phone follow-up. For severe symptoms in REDCap, study team will 
follow-up with the subject by phone to gather more information about the symptoms. 
 
 
Participants will also be queried during Visits 2-3 and Visits 5-6 on common post-
vaccination local and systemic symptoms as described in Tables 3 and 4.  
Participants using the paper diary will be contacted at Visits 2-3 and Visits 5-7 to review 
and document the information recorded in their diary. They will also be encouraged to 
report unsolicited adverse events in an open-ended question format, e.g. “How are you 
doing? Are you having any medical or clinical problems? If so, please tell me about 
them.” Participants who report severe solicited adverse events or express any concern 
about symptoms/unsolicited events will be encouraged to follow up with their ObGyn or 
primary care provider. Study staff will assist with coordination of referral appointments as 
necessary. Medical records will be obtained and reviewed for any unscheduled medical 
appointment through post-vaccination Day 8. The same procedures for solicited adverse 
events will follow the second vaccination for the sequential group and be performed 
around the same time period for the simultaneous group in a “mock” fashion (Visits 4-6, 
with the exception of solicited injection site reaction). After Visit 4, solicited injection site 
reactions will not be recorded by participants in the simultaneous group.  After the 
reactogenicity assessment period, only medically-attended adverse events will be 
collected.   
 
Table 3: Injection-site Reactogenicity 
Symptom 
Mild (Grade 1) 
Moderate (Grade 2) 
Severe (Grade 3) 
Pain (without 
touching) 
Noticeable but does not 
interfere with activity  
Interferes with activity  but did 
not necessitate medical visit 
or absenteeism   
Prevents daily activity  and/or 
resulted in medical visit and/or 
absenteeism 
 Pain upon 
touching 
(Tenderness) 
Noticeable but does not 
interfere with activity  
Interferes with activity but did 
not necessitate medical visit 
or absenteeism    
Prevents daily activity  and/or 
resulted in medical visit  and/or  
absenteeism 
Swelling  
(Induration) 
<10 mm 
10-34 mm   
>=35 mm  
Redness 
(Erythema)   
<10 mm 
10-34 mm   
>=35 mm  

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Table 4: System Reactogenicity 
Systemic 
Mild (Grade 1) 
Moderate (Grade 2) 
Severe (Grade 3) 
Oral Temperature 
(°C/°F)** 
≥ 37.8 - < 38.7° C  
≥ 100.0 - < 102.0 °F 
 ≥ 38.8 - < 39.4° C  
≥ 102.0 - < 103.0° F 
≥ 39.5° C  
≥ 103.1° F  
Fatigue  
(Malaise)  
Noticeable but does 
not interfere with 
activity  
Interferes with activity but did not 
necessitate medical visit or 
absenteeism 
Prevents daily activity 
and/or resulted in medical 
visit and/or absenteeism  
Body Aches 
(Myalgia) 
Noticeable but does 
not interfere with 
activity  
Interferes with activity but did not 
necessitate medical visit or 
absenteeism 
Prevents daily activity 
and/or resulted in medical 
visit and/or absenteeism  
Headache 
Noticeable but does 
not interfere with 
activity  
Interferes with activity but did not 
necessitate medical visit or 
absenteeism 
Prevents daily activity 
and/or resulted in medical 
visit and/or absenteeism  
Chills/shivering 
(Feverishness) 
Noticeable but does 
not interfere with 
activity  
Interferes with activity but did not 
necessitate medical visit or 
absenteeism 
Prevents daily activity 
and/or resulted in medical 
visit and/or absenteeism  
Joint Pain 
(Arthralgia) 
Noticeable but does 
not interfere with 
activity 
Interferes with activity but did not 
necessitate medical visit or 
absenteeism 
Prevents daily activity 
and/or resulted in medical 
visit and/or absenteeism  
Nausea 
Noticeable but does 
not interfere with 
activity 
Interferes with activity but did not 
necessitate medical visit or 
absenteeism 
Prevents daily activity 
and/or resulted in medical 
visit and/or absenteeism  
Vomiting 
Noticeable but does 
not interfere with 
activity 
Interferes with activity but did not 
necessitate medical visit or 
absenteeism 
Prevents daily activity 
and/or resulted in medical 
visit and/or absenteeism 
Diarrhea 
Noticeable but does 
not interfere with 
activity 
Interferes with activity but did not 
necessitate medical visit or 
absenteeism 
Prevents daily activity 
and/or resulted in medical 
visit and/or absenteeism 
Abdominal Pain 
Noticeable but does 
not interfere with 
activity 
Interferes with activity but did not 
necessitate medical visit or 
absenteeism 
Prevents daily activity 
and/or resulted in medical 
visit and/ or absenteeism 
Body Rash 
Noticeable but does 
not interfere with 
activity 
Interferes with activity but did not 
necessitate medical visit or 
absenteeism 
Prevents daily activity 
and/or resulted in medical 
visit and/ or absenteeism 
** Oral temperature, no recent hot/cold beverages or smoking 
 
5.4 Safety Assessment 
Both IIV and Tdap administration for pregnant women are recommendations for routine 
clinical care during pregnancy such that we do not anticipate having a significant issue 
with SAEs. However, we will monitor study participants for medically-attended events 
and SAEs during the protocol-defined surveillance period of vaccination through 
delivery. Subjects will be followed for SAEs up to the 6-week postpartum visit.  
Significant infant complications or SAEs identified during the delivery visit will be 
followed up to the 2 month Well Child Visit.    
 
An SAE is defined as an AE that meets one of the following conditions: 
• Results in death (maternal, fetal, or infant) during the study period  

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• Is life-threatening (defined as immediate risk of death at the time of the event) 
• Requires inpatient hospitalization prolongation of hospitalization during the study period 
(other than routine hospital admission for labor & delivery)  
• Results in congenital anomaly or birth defect 
• Results in a persistent or significant disability/incapacity 
• Any other important medical event that may not result in death, be life threatening, or 
require hospitalization, may be considered an SAE when, based upon appropriate 
medical judgment, the event may jeopardize the subject and may require medical or 
surgical intervention to prevent one of the outcomes listed above. Examples of such 
medical events include allergic bronchospasm requiring intensive treatment in an 
emergency room or at home, blood dyscrasias or convulsions that do not result in 
inpatient hospitalization, or the development of drug dependency or drug abuse. 
SAEs will be reported to the CDC, Duke, and Cincinnati Children’s IRBs within 48 hours 
of study staff awareness of the event. If indicated, SAEs will be reported to the CDC’s 
Vaccine Adverse Event Reporting system (VAERS).  
Given that this is a pilot study involving vaccines that are included as part of routine 
clinical care, there will not be a designated data safety monitoring board for this pilot 
study. If deemed necessary, we will designate an independent safety monitor with 
relevant expertise, in collaboration with the CDC. 
 
5.5 Biospecimens Collection & Handling 
 
5.5.1 Serum   
Maternal and cord blood specimens will be collected during study visits as described in 
Table 1. All blood samples will be collected, processed, and frozen according to the 
standard operating procedures and not contain personal identifiers.  Serum aliquots will 
be frozen and stored at each site until planned laboratory analyses. A portion of serum 
aliquots from each subject’s blood draw visits will be sent to the CDC for Pertussis 
assays once all study samples have been collected for all subjects. Remaining frozen 
serum aliquots will be stored and then shipped to the lead site for influenza, tetanus, and 
diphtheria assays.  Please refer to the study’s manual of operations for specifics of 
sample shipping to CDC and Duke University. 
 
The Study site(s) will process and ship these samples to CDC using standard 
procedures, in accordance with specimen transport policies 
(http://www.cdc.gov/laboratory/specimen-submission/shipping-packing.html).  The study 
site(s) will use the CDC File Accessioning Form to send the specimen data via e-mail to 
Peter Browning (isk8@cdc.gov) or designee.  All samples will be barcode labelled and 
contain a unique ID and date and time of sample collection.  No personal identifiers will 
be included on the samples or CDC File Accessioning Form.   
 
Any unused serum samples will be returned to the study site(s) after all assays have 
been completed.   
 

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5.5.2 Placental Tissue 
The study team will work with labor and delivery staff to ensure placentas from 
study subjects are sent for pathological evaluation for chorioamnionitis. The results 
from the pathology reports will be entered into REDCap.   
Following delivery of all subjects, placental histological slides will be over-read for 
histological diagnosis of chorioamnionitis. Over-reading will be performed by a 
single board-certified pathologist with expertise in placental pathology at Duke 
University. The pathologist will be blinded to study details including randomization 
arm assignment.  Chorioamnionitis will be assessed using the grading scale 
described in Table 5.  If a clinically-significant discrepancy is noted between the 
original pathology report regarding chorioamnionitis and the over-read by the 
blinded pathologist, then another independent pathologist will review the pathology 
slides in question to allow for adjudication of the discrepant results.    
5.5.3 Infant Dried Blood Spots 
The study team will obtain a blood sample via heel stick on a subset of 10 infants at 
each site (20 total) to collect 5 dried blood spots to determine levels of IgG to pertussis 
toxin, filamentous hemagglutinin, and pertactin (the pertussis antigens in the Boostrix® 
vaccine) at the CDC. DBS punch cards will be adequately dried with desiccant provided 
by the CDC and shipped to the CDC for pertussis testing. CDC pertussis laboratory will 
destroy unused DBS after all assays and the study have been completed. 
 
6 LABORATORY ANALYSES 
6.1 Pertussis Laboratory Analysis   
Quantification of antibodies against pertussis toxin (PTx), pertactin (PRN), filamentous 
hemagglutinin (FHA), and fimbrial antigen 2/3 (Fim2/3) in a microsphere based multiplex 
antibody capture assay according to CDC protocol MPIR-4301. Antibody to fimbrial 
antigen 2/3 will only be done on samples collected in 2016-2017 influenza season.  All 
specimens will be run in duplicate by 2 independent operators. Briefly, each of the 5 
antigens are conjugated to spectrally distinct fluorescent microspheres (Luminex 
XMAP™, Austin, TX). The microspheres are incubated with serum for 40 minutes at 
room temperature, washed, then incubated for 20 minutes with a fluorescently labelled 
anti-human antibody. The beads are then washed again and read using a Luminex 
instrument. Antibody levels are quantified by interpolation to a WHO reference standard. 
Samples that read higher than the useable range of the reference standard are repeated 
at a higher starting dilution. The independent results are compared, and if the coefficient 
of variation (CV) is below 30% the mean is reported. If the CV is greater than 30%, up to 
2 additional runs are performed and the median is reported. 
 
6.2 Tetanus and Diphtheria Laboratory Analysis  
Quantification of antibodies against diphtheria and tetanus toxoids will be performed by 
ELISA using kits containing an internal standard (AbCam, Cambridge, MA) per the 
manufacturer's directions. Briefly, wells pre-coated with diphtheria or tetanus antigen are 
incubated with dilution media as a blank, control specimens that contain a defined 
amount of anti-diphtheria or anti-tetanus antibody, or an unknown test sample. All 
specimens are run in duplicate. Primary antibody is allowed to bind for 1 hour at 37°C, 
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Plates are washed again and substrate added; this is incubated for 15 min at room 
temperature in the dark, followed by reading on a microtiter plate reader at 450 nm. The 
values from replicate wells are averaged, the background of blank wells subtracted from 
all other wells, and a dilution curve created using the known controls. Optical density 
readings are then compared to the standard curve and an absolute value for binding 
antibodies in international units is calculated. For specimens that have optical density 
readings higher than the standard curve range, a dilution of the serum/plasma sample is 
assessed in a repeat assay. 
 
6.3 Influenza Laboratory Analysis 
We intend to utilize the 2016-2017 and 2017-2018 quadrivalent Fluzone (Sanofi) as the 
IIV study product. As such, reference wild-type, reassortant, or vaccine virus strains 
representative of the specific viral antigens included in the 2016-2017 and 2017-2018 
influenza vaccines will be used to evaluate the relative levels of all four influenza strain-
specific antibodies in maternal serum pre- and post-vaccination (60 subjects, 240 
samples total). To accomplish these activities all patient samples will be interrogated for 
influenza antibodies against the strains of interest using the influenza hemagglutination 
inhibition assay (HI).  This assay is considered the “gold-standard” measure by which to 
evaluate seroconversion/seroprotection in response to seasonal influenza vaccination. 
This assay will be performed in accordance with the RBL Virology Unit’s fully optimized 
and approved SOP (RVUSOP004 Influenza HI of Serum Samples).  Briefly, test samples 
will be assayed by HAI as duplicate 2-fold dilution series starting at 1:10.  Serum 
dilutions are then incubated with a concentration of virus verified to possess a known 
potential for red blood cell (RBC) agglutination.  The presence of virus-specific 
antibodies is visualized via incubation of the virus-serum mixture with a RBC solution; 
the endpoint titer for a given dilution series is then expressed as the reciprocal of the 
final dilution in which complete HI is observed.  By convention, seronegative samples 
are defined as having an endpoint HI titer < 1:40 and seropositive samples as having an 
endpoint titer of ≥ 1:40; and seroconversion as a 4-fold change in endpoint titer relative 
to pre-immunization baseline or a change from <1:10 to ≥1:40. 
 
6.4 Placental pathology and Chorioamnionitis Analysis 
Placentas from subjects will be sent to the surgical pathology department at each site in 
accordance with standard clinical care following delivery (sent in-total in a specimen 
container with formalin for fixation). Routine placental pathology will be performed and 
pathologists will be unaware of study group at the time of placental evaluation. Routine 
pathology reporting includes gross and microscopic evaluation of the placenta including 
weight, umbilical cord including length, diameter, number of vessels, coiling, and 
insertion point, fetal membrane characteristics. 
 
Histologic chorioamnionitis is diagnosed using standard hematoxylin and eosin (H & 
E) staining to identify inflammatory cells (neutrophils, lymphocytes, eosinophils, etc.) 
as infiltration of the chorionic plate by neutrophils is diagnostic of chorioamnionitis. 
Chorioamnionitis is staged as per the grading system described below. 
 
Table 5: Histologic Chorioamnionitis Grading Scheme 
Stage 1 – Mild  
Stage 2 - Moderate 
Stage 3 - Severe 
Acute subchorioamnionitis 
or acute chorioamnionitis 
Acute chorioamnionitis 
Necrotizing chorioamnionitis 

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Characterized by neutrophils 
in subchorionic fibrin or 
interface between decidua 
and chorion 
Neutrophils in 
connective tissue plane 
between chorion and 
amnion 
Necrosis, amnion sloughing, thickening of 
amnion basement membrane and 
neutrophilic karyorrhexis, Multifocal 
abscesses may be present as well as 
funisitis (identification of neutrophils in the 
umbilical cord connective tissue) 
 
For microscopic evaluation of chorioamnionitis, we use the 2003 Pediatric Pathology 
Society consensus recommendations to diagnose and stage chorioamnionitis (Redline, 
Raymond W., et al. "Amniotic infection syndrome: nosology and reproducibility of 
placental reaction patterns." Pediatric and Developmental Pathology 6.5 (2003): 435-
448.).   
 
7 STATISTICAL CONSIDERATIONS 
 
In collaboration with the CDC and Cincinnati sites, the research team at Duke will 
oversee the statistical analysis. This pilot study is not designed based on statistical 
considerations regarding power/sample size in relation to group comparisons. Therefore, 
descriptive statistics and confidence intervals for continuous variables will be presented 
(e.g., mean, standard deviation, median, interquartile range, and confidence 
boundaries). Categorical variables will be summarized with frequencies, percentages, 
and exact confidence boundaries.  
For analysis, data will reside on a secure Duke server maintained by Duke Health 
Technology Solutions (DHTS).  For the study, a database will be developed and a 
dataset for the study without personal identifiers will be made available to the CDC upon 
request. 
7.1 Analysis Plan 
 
7.1.1 Study Populations – There will be two study populations for this study.  The 
Intent-to-Treat (ITT) and Safety populations.  The ITT Population includes any 
participant that was enrolled and randomized into the study.  The Safety 
Population is a subset of the ITT Population excluding those participants that 
never received the study intervention (either the influenza or Tdap vaccine). 
Statistical analyses will be performed for both study populations, or the ITT 
Population only if no participants are excluded for the Safety Population.   
 
7.1.2 Primary Objective 1 - To assess proportions of reactogenicity events in pregnant 
women receiving Tdap and IIV simultaneously vs. sequentially   
 
Reactogenicity will be assessed for 7 days following each vaccination visit, as described 
in Section 5.3. The proportion of women and a 95% exact binomial confidence interval 
will be presented by treatment group, symptom, and grade level (mild/moderate/severe) 
for women with injection site reactogenicity within 7 days post-vaccination. This will be 
presented for each of the four reactogenicity outcomes, using the highest grade reported 
per woman. A 95% confidence interval of the difference in proportions between the 
treatment groups will also be presented. Systemic reactogenicity will be presented in a 
similar fashion. For adverse events, the proportion of women and a 95% exact binomial 

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confidence interval of adverse events, as well as the total number of adverse events, will 
be presented by treatment group, severity, and relatedness 
 
7.1.3 Primary Objective 2 - To assess maternal immune responses and cord blood 
antibody levels to pertussis antigens, tetanus and diphtheria toxoids, and 
influenza antigens in the women receiving Tdap and IIV simultaneously vs. 
sequentially 
7.1.3.1 
Pertussis antigens - Geometric mean titers (GMTs) will be calculated along 
with 95% confidence intervals for the two treatment groups for each pertussis 
antigen tested.  A 95% confidence interval of the difference in GMTs between 
the treatment groups will also be presented. 
7.1.3.2 
Tetanus and diphtheria antigens - The proportion of subjects with 
seroprotection, defined as > 0.1 IU/mL post-vaccination for both tetanus and 
diphtheria ELISAs, in the two treatment groups will be presented along with 
95% exact binomial confidence intervals. Ninety-five percent confidence 
intervals of these differences in proportions between the treatment groups will 
also be presented. Given there is no acceptable definition of seroconversion 
with these assays, we will evaluate the data to derive a potential post hoc 
definition for seroconversion.   
7.1.3.3 
Influenza antigens - The proportion of subjects with seroprotection (pre- and 
post-immunization) and seroconversion (4-fold change in endpoint titer 
relative to pre-immunization baseline or a change from <1:10 to ≥1:40) in the 
two treatment groups will be presented along with 95% exact binomial 
confidence intervals. A 95% confidence interval of the difference in 
proportions between the treatment groups will also be presented. The GMTs 
for each influenza antigen and 95% confidence boundaries will be presented 
for both treatment groups. A 95% confidence interval of the ratios in GMTs 
between the treatment groups will also be presented. 
Outcomes listed in Primary Objective 2 may be analyzed using a regression model to 
adjust for covariates such as BMI or race.  This will be performed as a secondary 
analysis if normality assumptions for model based analyses are met. 
 
7.1.4 Primary Objective 3 – To assess the feasibility of conducting a larger clinical trial 
in pregnant women receiving Tdap and IIV simultaneously vs. sequentially 
 
Feasibility will be assessed based on the following benchmarks for recruitment and 
retention in Table 6, as well as adequate and timely collection of data and 
biospecimens. 
Table 6: Proposed Feasibility Benchmarks  
Benchmark  
Completion Target 
Recruitment and randomization 
30-50* subjects during 4 month enrollment period 
Retention  
98% completion of all in-person and delivery visits 
Data collection  
> 95% collection of reactogenicity data 
Biospecimen collection – maternal 
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7.1.5 Secondary Objective 1 – To describe maternal and infant outcomes in pregnant 
women receiving Tdap and IIV simultaneously vs. sequentially 
 
The proportion and 95% exact binomial confidence interval will be presented by 
treatment group for adverse birth outcomes such as preterm birth, low birthweight and 
SGA. A 95% confidence interval of the difference in proportions between the treatment 
groups will also be presented.   
 
7.1.6 Secondary Objective 2 – To evaluate clinical and histological chorioamnionitis in 
the women receiving Tdap and IIV simultaneously vs. sequentially  
 
The proportion and 95% exact binomial confidence interval will be presented by 
treatment group for histological and clinical chorioamnionitis. A 95% confidence interval 
of the difference in proportions between the treatment groups will also be presented.   
 
7.1.7 Secondary Objective 3 – To build capacity to study immunogenicity of maternal 
vaccination in the CISA Project, in collaboration with the CDC lab as described in 
Table 7.  
 
7.1.8 Exploratory Objective 1 - To assess antibody levels to pertussis antigens at 2 
months of life in infants born to women receiving Tdap and IIV simultaneously vs. 
sequentially 
 
Geometric mean titers (GMTs) will be calculated along with 95% confidence intervals for 
the two treatment groups for each pertussis antigen tested.  A 95% confidence interval 
of the ratio in GMTs between the treatment groups will also be presented as well as for 
the infant cord blood versus the 2-month blood draw.   
 
 
 
7.2 Data Management 
The amount of data that will be collected for the proposed project will be substantial and 
will require a sophisticated, practical and flexible system that can accommodate different 
modes of data collection and several separate linked surveys. The novel Vanderbilt-
designed resource developed specifically for online collection of research information, 
Biospecimen collection – delivery 
≥ 95% collection of maternal blood, umbilical cord blood, and 
placental pathology 
*enrollment target will depend upon whether additional enrollment occurs at the Cincinnati Site 
Table 7: Feasibility Benchmarks for CDC lab 
Benchmark  
Completion Target 
Quality of blood specimens submitted 
to the CDC lab for serologic response 
to pertussis antigen 
Receipt of ≥95% of blood samples in testable condition  
  
Quantity  of blood specimens 
submitted to the CDC lab for serologic 
response to pertussis antigen 
Receipt of ≥95% of blood samples with sufficient volume for 
testing 
  
Completion of testing  
Completion of testing of ≥95% of testable blood samples. 
  

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the Research Electronic Data Capture (REDCap) platform, will be used to design study 
forms, including the reaction forms, and short customized questionnaires to collect 
information from study subjects. This system will be used by Duke for data management.  
All electronic linkages will fulfill regulations for protection of human subjects and 
requirements to minimize the risk of breach of confidentiality. After initial set-up, the work 
load required for electronic data collection will be substantially reduced (description of 
REDCap resources below).44 Duke investigators have previously used the REDCap 
system for collection and analysis of large quantities of data. Participants will be given 
the option to fill out their reactogenicity diary either directly in the REDCap system or on 
paper. Participants who choose the paper form will receive phone calls (Visits 2, 3, 5, 
and 6) to collect the information recorded on their diary card, which will then be entered 
by study personnel onto REDCap. Participants who choose to enter the information 
directly into REDCap will receive phone calls if they fail to enter their information. All 
study-related documents containing protected health information, e.g. enrollment logs, 
case report forms, memory aids (Appendix B-E) completed by study participants, will be 
maintained in secure research offices at Duke, which are accessible to research staff 
only.  
 
The study team will utilize a secure, encrypted, file transfer method for sharing study 
documents and data with the CDC Pertussis laboratory and study teams.  No personal 
identifiers will be included in any shared documents or datasets.   
 
7.2.1 Research Electronic Data Capture (REDCap)  
Investigators within the NIH-funded Clinical and Translational Research Unit at 
Vanderbilt have developed REDCap (http://project-redcap.org/), to collect and manage 
data for diverse clinical and translational research studies. REDCap was designed 
around the concept of giving research teams an easy method to specify project needs 
and rapidly develop secure, web-based applications for collection, management and 
sharing of research data. REDCap accomplishes these key functions through use of a 
single study metadata table referenced by presentation-level operational modules. 
Based on this abstracted programming model, databases are developed in an efficient 
manner with little resource investment beyond the creation of a single data dictionary. 
The concept of metadata-driven application development is well established, and the 
critical factor for successful data collection lies in creating a simple workflow 
methodology allowing research teams to autonomously develop study-related metadata 
in an efficient manner.44 Of particular interest for this project, a subcomponent of 
REDCap, the REDCap Survey is designed for studies where data are collected directly 
from the research participant. This will be used with the web-based reaction forms that 
will be completed by the study subjects.  Both products include secure institutional data 
hosting and include full audit-trails in compliance with HIPAA security requirements. The 
REDCap Consortium is comprised of 647 active institutional, including CCHMC. The 
REDCap currently supports 68,000 projects with over 89,000 users spanning numerous 
research focus areas across the consortium.  The current project will use this software 
application for the design of electronic forms to collect information from study 
participants, to link the baseline data, sample collection date, and laboratory results in an 
automated database family, to perform data cleaning and data quality assurance 
efficiently, and to design an analytical dataset for the analysis of the project data.  
 
Data will be entered into the REDCap database by members of the study team, from 
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as part of study procedures.  Study investigators will be responsible for assuring that all 
paper records are securely stored according to the requirements of their IRBs.  The 
study investigators will be responsible for assuring the accuracy of the data entered from 
the paper forms into REDCap.  Only the assigned identifiers will be used in REDCap. 
Therefore, personal health identifiers will not appear in the REDCap database. 
 
In order to perform data cleaning and data quality assurance efficiently, numerous built-
in filters and checks for consistency of the data including range and limit checks, 
branching logic and pull down menus to limit choices for categorical variables to a pre-
specified list will be implemented and performed automatically to minimize data entry 
error. The data will be randomly sampled and checked against source records on a 
regular basis. The data and related analytical datasets will also be stored at the lead and 
contributing sites with secured password-protected computers. Coded data without 
personal identifiers will be made available to the CDC and transferred using a secure 
transfer method as described in Section 7.2.  
 
7.2.2 CDC Laboratory Management   
The CDC lab will send results back to Duke University using secure data transfer 
methods. CDC will send any remaining serum samples back to the site(s) after 
completing the pertussis testing or disposed at the request of the Sponsor. CDC 
pertussis laboratory will destroy unused DBS after all assays and the study have been 
completed. CDC laboratory staff will be blinded to the vaccination status of the samples 
being tested.  
7.3 Role of the CDC Investigators in the Project 
This study is funded by a CDC contract with Duke University and Cincinnati as Task 
Orders in the CISA Project Contract; the National Vaccine Program Office (NVPO) has 
also provided funding.   The Duke University PI (Geeta Swamy) will oversee the study in 
partnership with the Cincinnati PI (Elizabeth Schlaudecker).  The NVPO and CDC staff 
will collaborate with both sites to develop the protocol, conduct the study, ensure the 
study is aligned with US Department of Health and Human Services (CDC and NVPO) 
public health priorities, and analyze the data and disseminate the results. CDC may 
receive access to coded data not containing any directly identifying information.  The 
CDC lab will conduct pertussis immunogenicity testing for the maternal serological 
samples and infant DBS collected in the study.   
 
8    HUMAN SUBJECTS  
8.1 Human Subjects Involvement, Characteristics, and Design 
 
Duke and Cincinnati investigators will be responsible for submitting the protocol, 
informed consent (Appendix I), memory aids (Appendix B-E), recruitment letters, flyers 
(Appendix G-H), and any written or verbally conveyed materials (Appendix A and F) 
specific to this project to their institutional review boards.  CDC staff will be responsible 
for submitting materials to the CDC IRB for review and approval.   
 
To facilitate subject recruitment at the practices, we will request a waiver of consent and 
HIPAA authorization for ascertainment (identification, selection) and/or recruitment of 
potential subjects while recording identifiable private health information (PHI) prior to 
obtaining the subject’s consent.  This information will be obtained from review of the 

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electronic scheduling and medical record systems in the clinics in order to determine 
eligibility for study enrollment. We will review information only the minimum amount of 
information necessary to determine eligibility, i.e. date of birth, current pregnancy status, 
pregnancy history, medical and surgical history, ultrasounds pertaining to current 
pregnancy, and recent laboratory test results. The PHI collected prior to consent will be 
used to recruit and screen only. Use of PHI in this manner involves no more than 
minimal risk to subjects and no information will leave the study sites. 
 
Continuing reviews will be submitted to the IRBs on an annual basis.  Protocol 
deviations or concerns about study integrity will be reported promptly to the overseeing 
IRB in accordance with institutional requirements. 
 
8.2 Sources of Material 
Medical history and immunization history will be obtained from the medical record and 
from patient report.  Demographic information will be obtained from the medical record 
and patient report.  Subjects will record solicited adverse reactogenicity events and any 
medical intervention sought on the day of and 7 days following vaccinations (or 7 days 
following mock vaccination) on the memory aid (Appendix B-E).  Memory aid information 
will be reported to the study team during a telephone call or in the web-based REDCap 
system. The research staff will assess one or more of the following:  weight, height, 
temperature, blood pressure, and pulse.   
8.3 Potential Risks and Benefits 
Tdap and IIV are FDA licensed vaccines approved for use in non-pregnant individuals 
and are not contraindicated for use in pregnant women. Both vaccines are standard 
clinical practice and recommended by the CDC and ACOG during pregnancy.  
Participants will be provided with the CDC Vaccine Information Statements (VIS) for IIV 
and Tdap.  
 
IIV risks include minor problems such as soreness, redness, swelling, or pain where the 
shot was given, hoarseness, sore, red or itchy eyes, cough, fever, aches, headache, 
itching, fatigue, all of which usually occur within 1-2 days of vaccination and are self-
limiting. Syncope (fainting) can occur in association with administration of injectable 
vaccines. More serious problems including a small increased risk of Guillain-Barré 
Syndrome estimated at 1 or 2 additional cases per million people vaccinated. This is 
much lower than the risk of severe complications from influenza infection, which can be 
prevented by IIV.  In addition, any medication can cause a severe allergic reaction, or 
anaphylaxis, which is estimated at ~ 1 in a million doses of IIV 
(http://www.cdc.gov/vaccines/hcp/vis/vis-statements/tdap.html and 
http://www.cdc.gov/vaccines/hcp/vis/vis-statements/flu.html). 
 
Tdap risks include mild problems such as redness, swelling, and pain where the shot 
was given, redness or swelling where the shot was given, fever, chills, sore joints, 
headache, body aches, fatigue, nausea, vomiting, diarrhea, stomach ache, rash, and 
swollen glands, all of which usually occur within 1-2 days of vaccination and are self-
limiting. Moderate problems include higher severity of mild problems and swelling of the 
entire arm in which the injection was given. Rarely, local injection site symptoms limit the 
ability to perform usual activities and require medical attention. 
 
Problems that could happen after any injected vaccine:  

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• 
People sometimes faint after a medical procedure, including vaccination. Sitting 
or lying down for about 15 minutes can help prevent fainting, and injuries caused 
by a fall. Subjects should inform their doctor should they feel dizzy, or have vision 
changes or ringing in the ears.  
• 
Some people get severe pain in the shoulder and have difficulty moving the arm 
where a shot was given. This happens very rarely.  
• 
Any medication can cause a severe allergic reaction. Such reactions from a 
vaccine are very rare, estimated at about 1 in a million doses, and would happen 
within a few minutes to a few hours after the vaccination. As with any medicine, 
there is a very remote chance of a vaccine causing a serious injury or death. 
 
There is a small risk of infection around the heel stick where the blood was collected.  
Maternal subjects may also experience dizziness or fainting. Each maternal subject will 
be asked to have up to 3 blood samplings with the total volume not to exceed 45mL. For 
infants participating in the 2-month study procedure, the volume of blood collected will 
be no more than 0.5 ml.  There is no risk to the subject or their newborn for collection of 
cord blood, as the cord blood is drawn from the umbilical cord/placenta after the baby is 
not attached to it.  
 
Randomized controlled trials of IIV during pregnancy have demonstrated efficacy in 
preventing maternal influenza infection as well as infant influenza infection for the first 6 
months of life.45,46  Further, these trials have not demonstrated any concerns for 
maternal-fetal-infant safety. Studies of Tdap during pregnancy have demonstrated an 
appropriate maternal immune response but have been too small to evaluate efficacy.30 A 
recent large scale observational study of Tdap during pregnancy, demonstrated a 
reduction in neonatal/infant pertussis, which has been further supported by a recent 
retrospective case-control study. 47,48 Studies of Tdap in pregnancy have not 
demonstrated any concerns for maternal-fetal-infant safety. However, as with any 
vaccines we cannot assure or guarantee protection against influenza, tetanus, 
diphtheria, or pertussis given the potential for mismatch between circulating influenza 
vaccine strains and those included in the 2016-2017 and 2017-2018 vaccines and 
variation in individual immune responses.   
 
The Advisory Committee on Immunization Practices (ACIP) does not make specific 
recommendations about simultaneous or sequential administration of Tdap and IIV for 
pregnant women.  However, based on the ACIP Best Practice Guidelines for 
Immunization, Tdap and IIV (both inactivated vaccines) may be administered to pregnant 
women either simultaneously or sequentially (ACIP Best Practice Guidelines for 
Immunization accessed at https://www.cdc.gov/vaccines/hcp/acip-recs/general-
recs/index.html)  
 
1. Simultaneous administration of vaccines is defined as administering more than 
one vaccine on the same clinic day, at different anatomic sites, and not combined 
in the same syringe. Experimental evidence and extensive clinical experience 
provide the scientific basis for administering vaccines simultaneously. 
Simultaneously administering all vaccines for which a person is eligible at the 
time of a visit increases the probability that a child, adolescent, or adult will be 
vaccinated fully by the appropriate age.    
Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) and 
quadrivalent inactivated influenza vaccine can be administered simultaneously.   

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There is the potential risk of loss of confidentiality about information obtained as part of 
this study. 
 
8.4 Adequacy of Protection Against Risks 
 
8.4.1 Protections against Risk 
Subjects will be counseled on possible side effects following vaccination and followed 
closely during the 7 days post-vaccinations for assessment of moderate to severe local 
or systemic reactogenicity. Subjects will be evaluated and cared for as described in the 
Unscheduled Visit section above. All subjects will be monitored in a sitting or lying 
position for 20 minutes following vaccinations to help prevent fainting, and injuries 
caused by a fall. Subjects with a prior history of any reaction following either IIV or Tdap 
will be excluded from study enrollment.  
Every effort possible will be made to keep information about participants confidential. 
Computerized participant information will be kept in password protected files on secured 
servers.   Paper case report forms will be kept in locked files belonging to the study 
personnel.   Any publications resulting from this work will not contain any identifiable 
participant information. 
 
8.4.2 ClinicalTrials.gov Requirements 
The project is registered on ClinicalTrials.gov. (NCT02783170).  
 
8.5 Human Subjects 
In obtaining and documenting informed consent, the Investigator and study team will 
comply with the applicable regulatory requirements, Good Clinical Practices, and ethical 
principles. The written informed consent form must be signed and dated by the study 
participant prior to initiation of any study activities.   
 
8.5.1 Vulnerable Subjects Research 
 
Vulnerable subjects 
This study proposes to include pregnant women and neonates. 
 
Pregnant women 
Tdap and IIV are FDA licensed vaccines and are recommended by the CDC and ACOG 
during pregnancy, however the risks for both vaccines are listed in section 8.3.   
 
The specific procedures to be performed as part of this study are limited to minimal 
blood draw (<50mL over an 8-week period and not more than twice in a 7-day period), 
and other non-invasive procedures that are commonly performed during routine physical 
exams and are considered safe for pregnant women.  These procedures do not pose 
greater than minimal risk to the fetus. Collection of the placenta for research purposes 
following delivery of the fetus will be conducted in accordance with 45 CFR 46.206. 
 
This study will involve only those women who have given their free and informed 
consent in accordance with 45 CFR 46.116 and has the prospect of direct benefit to both 
the mother and infant. Randomization of vaccine administration provides minimal risk to 
the subject and fetus as these vaccines are routinely given either sequentially or 
simultaneously during pregnancy and do not go beyond the scope of standard of care.  

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The small amount of blood that will be drawn during the duration of pregnancy (up to 45 
ml) are considered safe and are not expected to cause any harm to the baby.  No 
inducement, monetary or otherwise, will be offered to terminate a pregnancy.  Individuals 
engaged in the research will have no part in any decisions as to the timing, method or 
procedures used to terminate a pregnancy, or in determining the viability of a neonate.   
 
Infants 
Identifiable private information will be collected about the infants at the time of delivery.  
Significant infant complications identified during the delivery visit will be followed up to 
60 days of life.    
 
Mothers will be informed about the infant data collection at the time they consent for the 
study, and thus, the consent form for pregnant women will also serve as the parental 
permission for including the infant as a subject after delivery.  A separate consent form 
will be used to obtain informed consent from pregnant or postpartum mothers or fathers 
for collection of an infant blood sample and documentation of any history of pertussis 
illness at 2-months of age. These procedures do not pose greater than minimal risk to 
the infant.  
 

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REFERENCES 
1. 
ACOG Committee Opinion No. 566: Update on immunization and pregnancy: 
tetanus, diphtheria, and pertussis vaccination. Obstet Gynecol 2013;121:1411-4. 
2. 
Centers for Disease C, Prevention. Updated recommendations for use of tetanus 
toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in adults aged 
65 years and older - Advisory Committee on Immunization Practices (ACIP), 2012. 
MMWR Morb Mortal Wkly Rep 2012;61:468-70. 
3. 
Committee on Obstetric P, Immunization Expert Work G, Centers for Disease C, 
Prevention's Advisory Committee on Immunization US, American College of O, 
Gynecologists. Committee opinion no. 608: influenza vaccination during pregnancy. 
Obstet Gynecol 2014;124:648-51. 
4. 
Grohskopf LA, Olsen SJ, Sokolow LZ, et al. Prevention and control of seasonal 
influenza with vaccines: recommendations of the Advisory Committee on Immunization 
Practices (ACIP) -- United States, 2014-15 influenza season. MMWR Morb Mortal Wkly 
Rep 2014;63:691-7. 
5. 
Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and Control of Seasonal 
Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization 
Practices - United States, 2017-18 Influenza Season. MMWR Recomm Rep 2017;66:1-
20. 
6. 
Neuzil KM, Reed GW, Mitchel EF, Simonsen L, Griffin MR. Impact of influenza 
on acute cardiopulmonary hospitalizations in pregnant women. American journal of 
epidemiology 1998;148:1094-102. 
7. 
Jamieson DJ, Honein MA, Rasmussen SA, et al. H1N1 2009 influenza virus 
infection during pregnancy in the USA. Lancet 2009;374:451-8. 
8. 
Mak TK, Mangtani P, Leese J, Watson JM, Pfeifer D. Influenza vaccination in 
pregnancy: current evidence and selected national policies. Lancet Infect Dis 2008;8:44-
52. 
9. 
Neuzil KM, Reed GW, Mitchel EF, Jr., Griffin MR. Influenza-associated morbidity 
and mortality in young and middle-aged women. JAMA 1999;281:901-7. 
10. 
Rasmussen SA, Jamieson DJ. Influenza and pregnancy in the United States: 
before, during, and after 2009 H1N1. Clin Obstet Gynecol 2012;55:487-97. 
11. 
Siston AM, Rasmussen SA, Honein MA, et al. Pandemic 2009 influenza A(H1N1) 
virus illness among pregnant women in the United States. JAMA 2010;303:1517-25. 
12. 
Haberg SE, Trogstad L, Gunnes N, et al. Risk of fetal death after pandemic 
influenza virus infection or vaccination. The New England journal of medicine 
2013;368:333-40. 
13. 
Pierce M, Kurinczuk JJ, Spark P, Brocklehurst P, Knight M, Ukoss. Perinatal 
outcomes after maternal 2009/H1N1 infection: national cohort study. Bmj 
2011;342:d3214. 
14. 
Madhi SA, Cutland CL, Kuwanda L, et al. Influenza vaccination of pregnant 
women and protection of their infants. The New England journal of medicine 
2014;371:918-31. 
15. 
Kharbanda EO, Vazquez-Benitez G, Lipkind H, et al. Inactivated influenza 
vaccine during pregnancy and risks for adverse obstetric events. Obstet Gynecol 
2013;122:659-67. 
16. 
Moro PL, Tepper NK, Grohskopf LA, Vellozzi C, Broder K. Safety of seasonal 
influenza and influenza A (H1N1) 2009 monovalent vaccines in pregnancy. Expert Rev 
Vaccines 2012;11:911-21. 
17. 
Munoz FM. Safety of influenza vaccines in pregnant women. Am J Obstet 
Gynecol 2012;207:S33-7. 

Tdap-IIV Simultaneous vs. Sequential 
 
Version 6.0 
December 5, 2017 
 
36 
18. 
Guris D, Strebel PM, Bardenheier B, et al. Changing epidemiology of pertussis in 
the United States: increasing reported incidence among adolescents and adults, 1990-
1996. Clin Infect Dis 1999;28:1230-7. 
19. 
Farizo KM, Cochi SL, Zell ER, Brink EW, Wassilak SG, Patriarca PA. 
Epidemiological features of pertussis in the United States, 1980-1989. Clin Infect Dis 
1992;14:708-19. 
20. 
Cherry JD. The epidemiology of pertussis: a comparison of the epidemiology of 
the disease pertussis with the epidemiology of Bordetella pertussis infection. Pediatrics 
2005;115:1422-7. 
21. 
Cortese MM, Baughman AL, Zhang R, Srivastava PU, Wallace GS. Pertussis 
hospitalizations among infants in the United States, 1993 to 2004. Pediatrics 
2008;121:484-92. 
22. 
Tanaka M, Vitek CR, Pascual FB, Bisgard KM, Tate JE, Murphy TV. Trends in 
pertussis among infants in the United States, 1980-1999. JAMA 2003;290:2968-75. 
23. 
Vitek CR, Pascual FB, Baughman AL, Murphy TV. Increase in deaths from 
pertussis among young infants in the United States in the 1990s. Pediatr Infect Dis J 
2003;22:628-34. 
24. 
Edwards KM. Overview of pertussis: focus on epidemiology, sources of infection, 
and long term protection after infant vaccination. The Pediatric infectious disease journal 
2005;24:S104-8. 
25. 
Castagnini LA, Healy CM, Rench MA, Wootton SH, Munoz FM, Baker CJ. Impact 
of maternal postpartum tetanus and diphtheria toxoids and acellular pertussis 
immunization on infant pertussis infection. Clin Infect Dis 2012;54:78-84. 
26. 
Lessin HR, Edwards KM, Committee On P, Ambulatory M, Committee On 
Infectious D. Immunizing parents and other close family contacts in the pediatric office 
setting. Pediatrics 2012;129:e247-53. 
27. 
Skowronski DM, De Serres G. Is routine influenza immunization warranted in 
early pregnancy? Vaccine 2009;27:4754-70. 
28. 
Coalition IA. Adults Only Vaccination: A Step-by-Step Guide 2004. 
29. 
Sukumaran L, McCarthy NL, Kharbanda EO, et al. Safety of Tetanus Toxoid, 
Reduced Diphtheria Toxoid, and Acellular Pertussis and Influenza Vaccinations in 
Pregnancy. Obstet Gynecol 2015;126:1069-74. 
30. 
Munoz FM, Bond NH, Maccato M, et al. Safety and immunogenicity of tetanus 
diphtheria and acellular pertussis (Tdap) immunization during pregnancy in mothers and 
infants: a randomized clinical trial. JAMA 2014;311:1760-9. 
31. 
McNeil SA, Noya F, Dionne M, et al. Comparison of the safety and 
immunogenicity of concomitant and sequential administration of an adult formulation 
tetanus and diphtheria toxoids adsorbed combined with acellular pertussis (Tdap) 
vaccine and trivalent inactivated influenza vaccine in adults. Vaccine 2007;25:3464-74. 
32. 
Weston WM, Chandrashekar V, Friedland LR, Howe B. Safety and 
immunogenicity of a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis 
vaccine when co-administered with influenza vaccine in adults. Hum Vaccin 2009;5:858-
66. 
33. 
Schlaudecker EP, McNeal MM, Dodd CN, Ranz JB, Steinhoff MC. Pregnancy 
modifies the antibody response to trivalent influenza immunization. J Infect Dis 
2012;206:1670-3. 
34. 
Kharbanda EO, Vazquez-Benitez G, Lipkind HS, et al. Evaluation of the 
association of maternal pertussis vaccination with obstetric events and birth outcomes. 
JAMA 2014;312:1897-904. 
35. 
Edwards RK. Chorioamnionitis and labor. Obstet Gynecol Clin North Am 
2005;32:287-96, x. 

Tdap-IIV Simultaneous vs. Sequential 
 
Version 6.0 
December 5, 2017 
 
37 
36. 
Malloy MH. Chorioamnionitis: epidemiology of newborn management and 
outcome United States 2008. J Perinatol 2014;34:611-5. 
37. 
Bland PB. Influenza in its relation to pregnancy and labor. Am J Obstet 
1919;79:184-97. 
38. 
Immune Response Induced by a Vaccine Against Group B Streptococcus and 
Safety in Pregnant Women and Their Offsprings. 2015. (Accessed May 2, 2015, at 
https://clinicaltrials.gov/show/NCT01446289.) 
39. 
Safety and Immunogenicity of a Trivalent Group B Streptococcus Vaccine in 
Healthy Pregnant Women. 2015. (Accessed May 2, 2015, at 
https://clinicaltrials.gov/ct2/show/NCT02046148.) 
40. 
Surveillance for Viral Hepatitis - United States, 2013. 2015. (Accessed May 10, 
2015, at http://www.cdc.gov/hepatitis/Statistics/2013Surveillance/index.htm.) 
41. 
National Center for I, Respiratory D. General recommendations on immunization 
--- recommendations of the Advisory Committee on Immunization Practices (ACIP). 
MMWR Recomm Rep 2011;60:1-64. 
42. 
Turnbull FM, Heath TC, Jalaludin BB, Burgess MA, Ramalho AC. A randomized 
trial of two acellular pertussis vaccines (dTpa and pa) and a licensed diphtheria-tetanus 
vaccine (Td) in adults. Vaccine 2000;19:628-36. 
43. 
Booy R, Van der Meeren O, Ng SP, Celzo F, Ramakrishnan G, Jacquet JM. A 
decennial booster dose of reduced antigen content diphtheria, tetanus, acellular 
pertussis vaccine (Boostrix) is immunogenic and well tolerated in adults. Vaccine 
2010;29:45-50. 
44. 
Influenza activity--United States and worldwide, 2007-08 season. MMWR Morb 
Mortal Wkly Rep 2008;57:692-7. 
45. 
Madhi SA, Nunes MC, Cutland CL. Influenza vaccination of pregnant women and 
protection of their infants. N Engl J Med 2014;371:2340. 
46. 
Zaman K, Roy E, Arifeen SE, et al. Effectiveness of maternal influenza 
immunization in mothers and infants. N Engl J Med 2008;359:1555-64. 
47. 
Amirthalingam G, Andrews N, Campbell H, et al. Effectiveness of maternal 
pertussis vaccination in England: an observational study. Lancet 2014;384:1521-8. 
48. 
Donegan K, King B, Bryan P. Safety of pertussis vaccination in pregnant women 
in UK: observational study. BMJ 2014;349:g4219. 
 
 
 

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Appendix A: Memory Aid Instructions 
 
 
 

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Appendix B: Memory Aid for Simultaneous Group – Visit 1 
 
 
 

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Appendix C: Memory Aid for Sequential Group  – Visit 1 
 
 
 

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Appendix D: Memory Aid for Simultaneous Group  – Visit 4 
 
 
 

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Appendix E: Memory Aid for Sequential Group – Visit 4 
 
 
 

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Appendix F: Phone Script 
 
 
 

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Appendix G: Recruitment Letter 
 
 
 

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Appendix H: Recruitment Email 
 
 
 

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Appendix I: Informed Consent Form