Conditions: Severe Acute Respiratory Illness
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 260
Healthy volunteers: no

Brief summary:
Respiratory viruses are a significant cause of hospitalization for respiratory tract infections. This study will evaluate the safety, effectiveness, and tolerability of nitazoxanide (NTZ) in treating severe acute respiratory illness (SARI) in people who are hospitalized.

Detailed description:
Respiratory viral infections are one of the most common causes of illness in the world. These infections are major causes of SARI and can lead to severe outcomes, including hospitalization and death. NTZ is a medication that is approved in the United States and Mexico to treat gastrointestinal parasitic diseases. This study will evaluate the use of NTZ to treat SARI. The purpose of this study is to evaluate the safety, effectiveness, and tolerability of NTZ, in combination with standard care, in treating SARI in people who are hospitalized.

Participants will be hospitalized and study entry assessments will include medical assessments, blood collection, and a nasopharyngeal swab or wash. Participants will then be randomly assigned to receive NTZ or placebo for 5 days. Participants younger than 12 years will receive an oral suspension formulation of NTZ or placebo; participants 12 years and older will receive NTZ or placebo tablets. All participants will also receive standard of care treatment for acute severe viral respiratory infections, which may include antibiotics and/or treatment for influenza. They will be discharged from the hospital based on their doctors' recommendations. Participants will record their temperature and symptoms in a daily diary, which will be reviewed by study staff during study visits. Follow-up visits will occur on Days 3, 7, 14, and 28, and may occur as inpatient or outpatient visits. These visits may include the same assessments that occurred at baseline, as well as physical examinations, depending on the visit. Participants who are still hospitalized at Day 28 will be followed by study staff until they are discharged from the hospital.

Arms:
arm 1: Participants will receive NTZ for 5 days. Participants younger than 12 years will receive an oral suspension formulation of NTZ; participants 12 years and older will receive NTZ tablets. arm 2: Participants will receive placebo for 5 days. Participants younger than 12 years will receive an oral suspension formulation of placebo; participants 12 years and older will receive placebo tablets.

Interventions: intervention 1: Nitazoxanide intervention 2: Placebo
Intervention descriptions: intervention 1: Participants 1 to 3 years old: 5 mL oral suspension (100 mg NTZ) every 12 hours for 5 days.

Participants 4 to 11 years old: 10 mL oral suspension (200 mg NTZ) every 12 hours for 5 days.

Participants 12 years and older: two 300-mg NTZ tablets orally twice daily for 5 days. intervention 2: Participants 1 to 3 years old: 5 mL placebo oral suspension every 12 hours for 5 days.

Participants 4 to 11 years old: 10 mL placebo oral suspension every 12 hours for 5 days.

Participants 12 years and older: two placebo tablets orally twice daily for 5 days.

Protocol document:
Prot_001.pdf: 
 
 
 
 
 
 
TITLE 
A Randomized Double-Blind Phase 2 Study Comparing the Efficacy, Safety, 
and Tolerability of Nitazoxanide Versus Placebo in Addition to Standard 
Care for the Treatment of Hospitalized Subjects with Severe Acute 
Respiratory Illness  
 
 
 
 
 
 
Sponsored by: 
Office of Clinical Research Policy and Regulatory Operations (OCRPRO) 
Division of Clinical Research (DCR) 
National Institute of Allergy and Infectious Diseases (NIAID) 
5601 Fishers Lane 
Bethesda, MD 20892 
 
 
 
 
IND 119511 
 
 
 
 
 
Version: 5 
Date: September 12, 2016 
 
 
 
 
 


Protocol: NTZ-SARI 
 
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LIST OF ABBREVIATIONS 
AE 
Adverse event  
ARDS 
Acute Respiratory Distress Syndrome 
ARI 
Acute Respiratory Illnesses 
CAP 
College of American Pathologists 
CFR 
Code of Federal Regulations 
CLIA 
Clinical Laboratory Improvement Act 
CSO 
Clinical Safety Office 
DSMB 
Data and Safety Monitoring Board 
eCRF 
electronic Case Report Form 
FDA 
Food and Drug Administration  
GCP 
Guidelines for Good Clinical Practice 
GI 
Gastrointestinal 
h 
Hours 
H1N1  
Influenza A H1N1, swine flu 
IB 
Investigator’s Brochure 
ICH 
International Conference on Harmonisation  
ICU 
Intensive Care Unit 
IEC 
Independent Ethics Committee 
IND 
Investigational New Drug Application 
ILI 
Influenza Like Illness 
IQR 
Interquartile Range 
IRB 
Institutional Review Board 
ITT 
Intention to treat  
NIAID 
National Institute of Allergy and Infectious Diseases 
NP(S) 
Nasopharyngeal (swab) 
NTZ 
Nitazoxanide 
OCRPRO 
Office of Clinical Research Policy and Regulatory Operations 
OTC 
Over the counter 
PCR 
Polymerase chain reaction 
PCB 
Placebo 
RVI 
Respiratory Viral Infection 
SAE 
Serious Adverse Event 
SARI 
Severe Acute Respiratory Illness 
SOC 
Standard of Care 
SOFA 
Sequential Organ Failure Assessment 
ULN 
Upper limit of normal  
VRI 
Viral Respiratory Illness 
WHO 
World Health Organization 
 
 


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TABLE OF CONTENTS 
LIST OF ABBREVIATIONS .................................................................................................. 2 
TABLE OF CONTENTS ......................................................................................................... 3 
PROTOCOL SUMMARY ....................................................................................................... 7 
1 BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE ........................ 10 
1.1 
BACKGROUND.......................................................................................................................... 10 
1.1.1 
Burden of Influenza-Like Illness ........................................................................................ 10 
1.1.2 
Existing Treatments .......................................................................................................... 10 
1.1.3 
WHO’s Battle Against Respiratory Viruses (BRaVe) Initiative........................................... 10 
1.1.4 
Severe Acute Respiratory Illness ....................................................................................... 10 
1.2 
NITAZOXANIDE ........................................................................................................................ 11 
1.2.1 
History and Significance ................................................................................................... 11 
1.2.2 
Mechanism of Action and Pre-Clinical Findings ............................................................... 11 
1.2.3 
Pharmacokinetics of Nitazoxanide and Tizoxanide in Humans .......................................... 12 
1.2.4 
Phase 2 Clinical Trials of NTZ in Subjects with Viral Respiratory Infection ...................... 13 
1.2.5 
Phase 2b-3 Clinical Trial of NTZ in Acute Uncomplicated Influenza ................................. 14 
1.3 
ETIOLOGY AND BURDEN OF ILIS IN MEXICO ............................................................................ 14 
1.4 
RISKS AND BENEFITS ............................................................................................................... 15 
1.4.1 
Risks of NTZ ..................................................................................................................... 15 
1.4.2 
Risk of Phlebotomy ........................................................................................................... 16 
1.4.3 
Risk of Nasopharyngeal Swab ........................................................................................... 16 
1.4.4 
Risk of Nasopharyngeal Aspirate ...................................................................................... 16 
1.4.5 
Benefits ............................................................................................................................. 16 
1.4.6 
Alternatives....................................................................................................................... 17 
2 STUDY OBJECTIVES .................................................................................................... 17 
2.1 
PRIMARY OBJECTIVE ............................................................................................................... 17 
2.2 
SECONDARY OBJECTIVES ......................................................................................................... 17 
3 INVESTIGATIONAL PLAN ........................................................................................... 17 
3.1 
RESEARCH QUESTION ............................................................................................................... 17 
3.2 
HYPOTHESIS ............................................................................................................................ 17 
3.3 
JUSTIFICATION FOR THE RESEARCH .......................................................................................... 18 
3.4 
OVERVIEW OF STUDY DESIGN .................................................................................................. 18 
3.5 
DEFINITIONS FOR THE PURPOSE OF THIS STUDY ....................................................................... 18 
3.6 
STUDY ENDPOINTS ................................................................................................................... 19 
3.6.1 
Primary Endpoint ............................................................................................................. 19 
3.6.2 
Secondary Endpoints ........................................................................................................ 19 
4 STUDY POPULATION ................................................................................................... 20 
4.1 
RATIONALE FOR RESEARCH SUBJECT SELECTION ..................................................................... 20 
4.1.1 
Justification for the Inclusion of Children > 12 Months Old .............................................. 20 
4.1.2 
Justification for the Exclusion of Pregnant Women and Children <12 Months Old ............ 21 
4.2 
RECRUITMENT ......................................................................................................................... 21 
4.3 
INCLUSION CRITERIA FOR ENROLLMENT .................................................................................. 21 
4.4 
EXCLUSION CRITERIA .............................................................................................................. 22 
4.5 
SUBJECT WITHDRAWAL ........................................................................................................... 23 


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4.6 
DISCONTINUATION OF STUDY MEDICATION ............................................................................. 23 
4.7 
DISCONTINUATION OF SUBJECT BY INVESTIGATOR................................................................... 24 
4.8 
DISCONTINUATION OF STUDY .................................................................................................. 24 
4.9 
PARTICIPATION IN OTHER PROTOCOLS ..................................................................................... 24 
4.10 
EMERGENCY UNBLINDING ..................................................................................................... 24 
5 TREATMENT .................................................................................................................. 25 
5.1 
BLINDING, RANDOMIZATION, STRATIFICATION, AND TREATMENT ASSIGNMENT ...................... 25 
5.2 
STUDY REGIMENS AND ADMINISTRATION ................................................................................ 25 
5.3 
JUSTIFICATION OF DOSE ........................................................................................................... 26 
5.4 
STUDY DRUG ACQUISITION ...................................................................................................... 26 
5.5 
STUDY DRUG ACCOUNTABILITY .............................................................................................. 26 
5.6 
STANDARD OF CARE TREATMENT ............................................................................................ 27 
5.7 
CONCOMITANT MEDICATIONS.................................................................................................. 27 
5.8 
PROHIBITED MEDICATIONS ...................................................................................................... 27 
5.9 
TREATMENT COMPLIANCE ....................................................................................................... 27 
6 STUDY PROCEDURES .................................................................................................. 27 
6.1 
PERSONNEL AND LOCATION FOR STUDY PROCEDURES ............................................................. 28 
6.2 
DETAILED DESCRIPTION OF ASSESSMENTS ............................................................................... 28 
6.2.1 
Study Day 0: Screening ..................................................................................................... 28 
6.2.2 
Determination of Eligibility and Randomization ................................................................ 30 
6.2.3 
Study Day 0: Baseline Evaluation ..................................................................................... 30 
6.2.4 
Study Day 3 (+/- 1 day)..................................................................................................... 31 
6.2.5 
Study Day 7 (-1 Day /+2 Days) ......................................................................................... 32 
6.2.6 
Study Day 14 (+/- 2 Days) ................................................................................................ 32 
6.2.7 
Study Day 28 (+/- 3 Days) ................................................................................................ 33 
6.2.8 
Hospital Discharge Evaluation ......................................................................................... 33 
7 MEASURES OF SAFETY, EFFICACY,AND COMPLIANCE .................................... 34 
7.1 
SAFETY EVALUATIONS ............................................................................................................. 34 
7.1.1 
Laboratory Evaluations .................................................................................................... 34 
7.1.2 
Other Safety Examinations ................................................................................................ 34 
7.2 
VIRAL DIAGNOSTICS ................................................................................................................ 34 
7.3 
EFFICACY EVALUATIONS ......................................................................................................... 34 
7.3.1 
Diary Card for Fever, Symptoms, and Functional Assessment ........................................... 34 
7.3.2 
Assessment for Presence of Complications ........................................................................ 36 
7.3.3 
Vital Signs, Including SaO2 ............................................................................................... 36 
7.4 
COMPLIANCE MEASURES ......................................................................................................... 36 
7.5 
SEVERITY OF ILLNESS SCORES ................................................................................................. 37 
7.5.1 
SOFA Score ...................................................................................................................... 37 
7.5.2 
Tal Bronchiolitis Score ..................................................................................................... 38 
8 ASSESSMENT OF SAFETY ........................................................................................... 39 
8.1 
DEFINITIONS ............................................................................................................................ 39 
8.2 
INVESTIGATOR ASSESSMENT OF ADVERSE EVENTS .................................................................. 40 
8.2.1 
Determination of Adverse Event ........................................................................................ 40 
8.2.2 
Period of Assessment ........................................................................................................ 41 
8.2.3 
Assessment of Adverse Event ............................................................................................. 41 
8.2.4 
Investigator Documentation of Adverse Event ................................................................... 42 


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8.3 
INVESTIGATOR REPORTING RESPONSIBILITIES TO THE SPONSOR .............................................. 42 
8.3.1 
Serious Adverse Events ..................................................................................................... 42 
8.3.2 
Unanticipated Problems.................................................................................................... 43 
8.3.3 
Pregnancy ........................................................................................................................ 43 
8.4 
INVESTIGATOR REPORTING RESPONSIBILITIES TO THE SITE IRB/EC ......................................... 43 
8.4.1 
IND safety reports............................................................................................................. 43 
8.4.2 
Expedited Reporting to the Site IRB/EC ............................................................................ 43 
8.4.3 
Annual Reporting to the IRB/EC ....................................................................................... 43 
8.5 
FOLLOW-UP OF ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS ......................................... 44 
8.6 
SPONSOR’S REPORTING RESPONSIBILITIES ............................................................................... 44 
8.7 
SAFETY MONITORING .............................................................................................................. 44 
8.7.1 
Investigator Safety Monitoring .......................................................................................... 44 
8.7.2 
Protocol Team Monitoring ................................................................................................ 45 
8.7.3 
Sponsor Medical Monitor.................................................................................................. 45 
8.7.4 
Pausing Rules ................................................................................................................... 45 
8.7.5 
Reporting a Pause............................................................................................................. 45 
8.7.6 
Safety Review and Communications Plan (SRCP) ............................................................. 46 
8.7.7 
Data and Safety Monitoring Board ................................................................................... 46 
9 STATISTICAL CONSIDERATIONS ............................................................................. 47 
9.1 
GENERAL CONSIDERATIONS ..................................................................................................... 47 
9.2 
SAMPLE SIZE AND POWER CALCULATIONS ............................................................................... 47 
9.3 
SUBJECT POPULATIONS ............................................................................................................ 49 
9.4 
STATISTICAL ANALYSIS ........................................................................................................... 49 
10 DATA MANAGEMENT AND MONITORING ........................................................... 49 
10.1 
STUDY MONITORING .............................................................................................................. 49 
10.2 
SOURCE DOCUMENTS ............................................................................................................. 49 
10.3 
DATA MANAGEMENT PLAN .................................................................................................... 50 
10.4 
DATA CAPTURE METHODS ..................................................................................................... 50 
10.5 
STUDY RECORD RETENTION ................................................................................................... 50 
11 HUMAN SUBJECTS...................................................................................................... 51 
11.1 
IRB/IEC APPROVAL ............................................................................................................... 51 
11.2 
COMPLIANCE WITH GOOD CLINICAL PRACTICES (GCP).......................................................... 51 
11.3 
INFORMED CONSENT PROCESS ............................................................................................... 51 
11.4 
ANONYMITY AND CONFIDENTIALITY ..................................................................................... 51 
11.5 
COMPENSATION ..................................................................................................................... 52 
12 STORED SPECIMENS, AND DATA ............................................................................ 52 
12.1 
SAMPLES/SPECIMENS ............................................................................................................. 52 
12.2 
STORAGE OF DATA ................................................................................................................. 52 
12.3 
STORAGE OF GENETIC SAMPLE .............................................................................................. 52 
12.4 
REPORTING LOSS OR DESTRUCTION OF SAMPLES/SPECIMENS/DATA ...................................... 52 
13 REFERENCES ............................................................................................................... 53 
 
 
 


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List of Tables 
 
Table 1:  Summary of Tizoxanide Glucuronide Plasma Pharmacokinetic Parameters ...... 13 
Table 2: Pathogen distribution in hospitalized ILI cases in LaRed over 3 years, by age 
group ........................................................................................................................ 15 
Table 3: Pediatric Nitazoxanide Dosage Recommendations ................................................. 20 
Table 4: Treatment Allocation ............................................................................................... 25 
Table 5: Schedule of Assessments .......................................................................................... 28 
Table 6: Sofa Score ................................................................................................................. 37 
Table 7: Tal Bronchiolitis Score ............................................................................................ 38 
Table 8: The total sample size required to achieve different powers under different 
assumptions about the benefit of nitazoxanide (Delta) using a two-sided .05 level 
test ............................................................................................................................ 48 
 
List of Figures 
 
Figure 1: Average (+ SD) tizoxanide plasma concentration vs. time profiles by dose group
 .................................................................................................................................. 12 
 
 
 


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PROTOCOL SUMMARY 
 
Full Title: A Randomized Double-Blind Phase 2 Study Comparing the Efficacy, Safety, and 
Tolerability of Nitazoxanide Versus Placebo in Addition to Standard Care for the Treatment of 
Hospitalized Subjects with Severe Acute Respiratory Illness  
 
Short Title: NTZ-SARI 
 
Clinical Phase: 2 
 
IND Sponsor: Office of Clinical Research Policy and Regulatory Operations (OCRPRO) 
National Institute of Allergy and Infectious Diseases (NIAID) 
 
Conducted by: Mexican Emerging Infectious Diseases Clinical Research Network (LaRed) 
 
Sample Size: N= 290 subjects  
 
Accrual Ceiling: Up to 500 subjects will be screened to randomize 290 subjects 
 
Study Population: Subjects who are hospitalized in Mexico with Severe Acute Respiratory 
Illness [SARI] (using the World Health Organization [WHO] case definition) 
 
Accrual Period: 3 years 
 
Background: Respiratory viruses are a significant cause of hospitalization for respiratory tract 
infections. Etiologic agents include influenza, parainfluenza virus, rhinovirus, adenovirus, 
metapneumovirus, respiratory syncytial virus (RSV), bocavirus and coronavirus.  Of these, only 
influenza has a licensed treatment.  Nitazoxanide (NTZ) is a licensed anti-infective agent with 
activity against many of these respiratory viruses.  In a pediatric Phase 2 study of outpatient ILI, 
the NTZ cohort showed symptom resolution in 4 days versus 7 days in the placebo group.  In a 
624 person Phase 3 study of ILI, the NTZ cohort showed symptom resolution in 94 h compared 
to 108 h in the placebo group (p=0.0026). These benefits were observed in the entire cohort, not 
just those infected with influenza.  If similar efficacy can be seen in the inpatient ILI population, 
there could be reductions in duration of hospitalization, morbidity, and costs.   
 
LaRed is a collaboration between the Mexican Ministry of Health and the US NIAID.  In a 
period of 4 years, LaRed has enrolled over 5600 subjects (of which over 2000 were hospitalized) 
into an observational ILI study at 6 sites in Mexico.  Viral etiologies are found in approximately 
60% of subjects enrolled.  
 
Study Design: The study will be a multicenter, randomized, double-blind, placebo controlled 
trial to evaluate the efficacy of NTZ + standard of care (SOC) compared to placebo (PCB) + 
SOC in treating acute viral respiratory infections in adults and children ≥ 12 months old with 
SARI (hospitalized ILI). It is anticipated that SOC would likely include antibiotics and may 
include treatment for influenza.  The study is designed to enroll a total of 290 subjects who will 
be randomized in a 1:1 ratio. Subjects will be followed on Days 3, 7, 14, and 28. The subject will 


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be discharged from the hospital when clinically indicated as determined by the treating 
physician.  Follow-up visits may occur as inpatients or as outpatients.  Subjects still hospitalized 
on Day 28 will be followed until discharged from the hospital. 
Study Duration: 
Enrollment start date: February 2014 
Anticipated enrollment end date: March 2017 
Anticipated final analysis: December 2017 
 
Study Agent: Nitazoxanide 
 
Primary Objective: Evaluate the effect of NTZ in addition to SOC as compared to PCB + SOC 
in the treatment of SARI as measured by the time to hospital discharge 
 
Secondary Objectives: 
1.  Evaluate the clinical efficacy of NTZ + SOC vs. PCB + SOC with regards to: 
• Percent hospitalized at Study Day 3, 7, 14 and 28 
• Death by Study Day 28 
• Duration of clinical symptoms (defined in Section 7.3.1.2) 
• Duration of fever 
• Use of supplemental oxygen (or increase greater than baseline oxygen requirement) 
• Admission to ICU 
• Intubation/mechanical ventilation 
• Proportion of subjects who develop complications including pneumonia, respiratory 
failure requiring mechanical ventilation, acute respiratory distress syndrome (ARDS), 
sepsis, or bronchiolitis. 
• Time to resumption of normal activity  
• Antibiotic/antiviral use during hospitalization  
• Systemic corticosteroid use during hospitalization  
• Re-hospitalization within 28 days 
 
2.   Evaluate the virologic efficacy of NTZ + SOC vs. PCB + SOC with regards to: 
• Percent cessation of viral shedding at Study Day 3 
 
3.  Evaluate the safety and tolerability of NTZ assessed by: 
• Cumulative incidence and severity of adverse events (AEs) 
• Cumulative incidence of serious AEs (SAEs) 
• Cumulative incidence of laboratory abnormalities on Study Days 3, 7 and 28 
 
Endpoints: 
Clinical Endpoints: 
• Hospitalization on Study Days 3, 7, 14, and 28 
• Date and time of hospital discharge 
• Date of death, if applicable  


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• Clinical symptoms (measured daily through Study Day 14 and then again on Study Day 
28) 
• Temperature (measured daily through Study Day 14 and then again on Study Day 28) 
• Oxygen use 
• Date of admission to ICU and discharge from ICU, if applicable 
• Date of intubation/extubation, if applicable 
• Presence of complications during study (pneumonia, respiratory failure requiring 
mechanical ventilation, ARDS, sepsis, or bronchiolitis) 
• Global assessment (measured daily through Study Day 14 and then again on Study Day 
28) (defined in Section 7.3.1.3) 
• Antibiotic/antiviral use during hospitalization (number and duration) 
• Re-hospitalization within 28 days 
• Use of systemic corticosteroids 
  
Virologic Endpoints: 
• Presence of virus on nasopharyngeal (NP) swab (or aspirate) at Study Day 3 (same virus 
as Day 0) 
 
Safety Endpoints: 
• AEs 
• SAEs 
• Chemistry and hematologic laboratory assessments on Study Days 3, 7 and 28 
 


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1 
BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE 
1.1 
Background 
1.1.1 
Burden of Influenza-Like Illness 
Respiratory viral infections (RVI) are one of the most common health conditions in the world 
and have enormous but under-recognized impacts on public health. According to the World 
Health Organization (WHO) estimates, 450 million cases of pneumonia are recorded every  
year1. In addition to their high frequency, RVIs are major causes of severe acute respiratory tract 
infection (SARI) that can lead to severe outcomes including hospitalization and death.  Evidence 
of viral infection have been detected in 22% of cases in adults, 1-6 and 49% (range 43–67) of 
cases in children1,7-11. Etiologic agents of influenza-like illness (ILI) include several respiratory 
viruses, such as influenza virus, parainfluenza virus, rhinovirus, adenovirus, metapneumovirus, 
respiratory syncytial virus (RSV), bocavirus and coronavirus12. 
 
Acute respiratory illnesses (ARIs) impose an enormous burden on communities both directly in 
terms of medical care and indirectly on the whole of society. Besides causing severe 
complications for patients, ARIs have huge impacts on outpatient care and hospital services, 
resulting in high costs for patients, families and society in general. In addition to direct costs of 
care, ARIs are responsible each year for major losses in productivity in part due to absenteeism.  
 
1.1.2 
Existing Treatments 
Of the viruses causing ILI, only influenza has an effective treatment.  Four medications are 
licensed for the treatment of influenza:  oseltamivir (OST), zanamivir, amantadine, and 
rimantadine.  Parainfluenza virus, rhinovirus, adenovirus, metapneumovirus, respiratory 
syncytial virus (RSV), bocavirus and coronavirus have no effective therapy. 
 
1.1.3 
WHO’s Battle Against Respiratory Viruses (BRaVe) Initiative 
In July and November 2012 the World Health Organization (WHO) held 2 informal 
consultations to introduce a new initiative. “Battle against respiratory viruses” (BRaVe) is 
highlighting the need of effective treatment options for non-influenza respiratory viruses.  From 
these consultations, the WHO released a Call to Action, specifically stating “cost-effective 
antiviral agents and other therapies for other (non-influenza) VRIs are not currently available, 
and an urgent need exists to support research for new safe and effective therapeutics to target 
specific respiratory viruses but also, if possible, to develop antivirals with broad spectrum 
activity.” 
 
1.1.4 
Severe Acute Respiratory Illness 
The WHO has created a case definition for SARI.  This case definition was created for outbreaks 
such as severe acute respiratory syndrome (SARS) and pandemic influenza.   
 
 


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The WHO 2004 SARI case definition was: 
Meets ILI case definition (sudden onset of fever ≥38°C and cough or sore throat in the 
absence of other diagnosis) AND shortness of breath or difficulty breathing AND 
requiring hospital admission. 
 
The WHO22 SARI case definition was revised in 2014 to read: 
An acute respiratory infection with: 
• history of fever or measured fever of ≥ 38 C°; 
• and cough; 
• with onset within the last 10 days; 
• and requires hospitalization. 
 
This case definition is the basis for defining a severe respiratory illness in the selection of 
participants in this protocol. 
 
1.2 
Nitazoxanide 
1.2.1 
History and Significance 
Nitazoxanide (NTZ) is an investigational new drug for the treatment of acute influenza that has 
also demonstrated efficacy against other respiratory illnesses. NTZ is the approved generic name 
for 2-acetyloxy-N-(5-nitro-2-thiazolyl)-benzamide, also known as PH-5776, or Alinia®. The 
drug is already marketed in the United States as an oral suspension for children ≥1 year of age 
and as tablets for patients ≥12 years for treatment of Giardia lamblia or Cryptosporidium 
parvum.  In Mexico, NTZ is licensed for use in patients ≥2 years of age. 
1.2.2 
Mechanism of Action and Pre-Clinical Findings 
Anti-influenza activity of NTZ and its circulating metabolite, tizoxanide, has been demonstrated 
in several human and canine cell lines after infection with 4 different strains of influenza A virus 
(including 2 mammalian H1N1 strains, 1 H3N2 strain, and the H5N9 low pathogenicity avian 
strain) and 1 strain of influenza B virus with EC50s between 0.3 and 1 μg/mL.  
In cell culture, tizoxanide has antiviral activity against other RNA and DNA viruses.  It inhibits 
replication of parainfluenza (Sendai virus, IC50 = 1 μg/mL), coronavirus (canine strain S-378, 
IC50 = 1 μg/mL), adenovirus type 5, and respiratory syncytial virus A2 
 
. Rhinovirus is not thought to be inhibited by NTZ.   
The wide spectrum of antiviral activity suggests a cell-mediated effect rather than a specific viral 
target. Tizoxanide inhibits the replication of H1N1 and other strains of influenza A virus by a 
novel mechanism, acting at the post-translational level by selectively blocking the maturation of 
the viral hemagglutinin at a stage preceding resistance to endoglycosidase H digestion, thus 
impairing hemagglutinin intracellular trafficking and insertion into the host plasma membrane, a 
key step for correct assembly and exit of the virus from the host cell .13 
The antiviral activity of NTZ alone or in combination with the neuraminidase inhibitors, OST 
phosphate and zanamivir, was studied in MDCK cells infected with 2 different strains of 
influenza A virus. NTZ exhibited synergism when combined with OST or zanamivir during 






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1.2.5 
Phase 2b-3 Clinical Trial of NTZ in Acute Uncomplicated Influenza 
During the 2010-2011 flu season, a Phase 2b-3 trial in 74 outpatient centers enrolled 624 subjects 
between the ages of 12 and 65 years who presented with acute uncomplicated influenza 
(symptoms onset <48 h).23  At baseline, 41% of patients had confirmed (RT-PCR) influenza 
infection (50% AH1N1, 30% Influenza B, 20% AH3N2).  Rhinovirus was the second-most 
detected pathogen (14%) of enrolled patients, followed by coronavirus (3%).  Over one third of 
patients (37%) had no pathogen detected by RT-PCR.  
 
Randomized subjects were given the extended release formula of NTZ 600 mg BID for 5 days.  
In a population infected with influenza, NTZ reduced time from illness onset to alleviation of flu 
symptoms (95.5 h in 600 mg dose [IQR 71-126] and 116.7 h in PCB [IQR 91-144] respectively, 
p=0.0084). The median duration of symptoms for the 300 mg cohort (109.1 h in 300 mg dose 
[IQR 82-152]) was not statistically more significant than placebo (p=0.5208).  
 
Analysis of all patients treated (i.e., all ILI, not just those with influenza) also showed a 
statistically significant reduction of times from first dose to resolution of symptoms for the 600 
mg NTZ treatment group (median 94.9 h, IQR: 62-126) compared to the placebo group (median 
108.2 h, IQR: 82-152, p=0.0026).  
 
An analysis of the subset of 37% of subjects with no virus identified at baseline also showed a 
dose-dependent reduction in duration of symptoms with a statistically significant difference 
(p=0.0208) observed between the 600 mg NTZ treatment group (median 88.4 h, IQR: 60-120) 
and the placebo group (median 105.7 h, IQR: 76.5-160). The numbers of subjects with other 
laboratory-documented respiratory virus infections at baseline were too small to draw 
meaningful interpretations, although the data suggested that there was no apparent treatment 
effect in subjects infected with rhinovirus. 
 
There are no data on the use of NTZ in a hospitalized population with influenza or other causes 
of ILI. 
1.3 
Etiology and Burden of ILIs in Mexico 
During 2009-2010, a new influenza virus (A/California/07/2009 H1N1) spread worldwide 
causing the first flu pandemic in more than 40 years. Because of the significant fatality rates and 
the fact that Mexico City was the epicenter of the earliest reported cases, the Mexican Ministry 
of Health and NIAID collaborated to establish the LaRed network.  LaRed’s observational cohort 
study of ILIs in Mexican adults and children has over 5600 subjects over 4 years (data as of July 
2014). Analysis of the first years data found that, in addition to influenza which accounted for 
24% of viral isolates, rhinovirus, coronavirus, RSV, and adenovirus contributed significantly to 
the burden of disease, accounting for 25%, 14%, 10%, and 9% of all viral isolates respectively.12 
Similar results are seen in the 3 year data (unpublished).  For severe (hospitalized) disease, 
similar viruses caused disease (see Table 2).  While NTZ is not thought to treat rhinovirus, it is 
thought to be efficacious in treating adenovirus, coronavirus, influenza, parainfluenza, and RSV, 
and likely efficacious in treating mixed infections. Additionally, in the Phase 2b-3 data there was 
efficacy in the “negatives” (pointing to likely infectious agent).  Taken together, these categories 
make up 76% of hospitalized ILI (i.e., SARI) patients that LaRed has been able to enroll 
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Phase 2 and 3 clinical studies have been conducted in approximately 4,000 patients to evaluate 
the safety and efficacy of NTZ in treating parasitic, bacterial, and viral infections. During these 
studies, no drug-related SAEs were observed. The side effects have been usually of a mild 
transient nature, and less than 1% of patients have discontinued therapy because of an AE. The 
most common AEs reported in clinical trials include abdominal pain, diarrhea, headache, nausea, 
and vomiting and did not differ significantly from those of placebo. Clinical chemistry and 
hematology obtained before and after treatment have not revealed any abnormalities attributable 
to the test drug.  
 
Nitazoxanide is US FDA Pregnancy Category B:  No impaired fertility or harm to the fetus in 
animal studies was noted, but there are no adequate and well-controlled studies in pregnant 
women. 
 
1.4.2 
Risk of Phlebotomy 
The primary risks of phlebotomy include local discomfort, occasional bleeding or bruising of the 
skin at the site of needle puncture, and rarely hematoma, infection, or fainting. At the time of 
enrollment and during study visits, each subject will be asked about participation in other 
research studies to ensure that blood draws do not exceed each institution’s limits of blood 
drawn. 
 
In children, the volume of blood samples for this study required for each visit represents 0.4% of 
circulating blood volume in well-nourished children, up to 1% of the circulating volume in 
malnourished children. Therefore, on a month-long study, the total volume of blood required is 
1.2% to 3% of circulating blood volume, depending on the constitution of each child. 
 
1.4.3 
Risk of Nasopharyngeal Swab 
The primary risk of a nasopharyngeal swab is local discomfort. Rarely, there can be local 
bleeding from the nasal mucosa, which is controlled with local measures such as pressure or 
packing with gauze.  Additionally the swab can cause coughing, gagging or infrequently 
vomiting. 
 
1.4.4 
Risk of Nasopharyngeal Aspirate 
The primary risk of a nasopharyngeal aspirate is local discomfort.  Rarely, this procedure can 
cause bleeding.  Also, this procedure cause coughing, gagging, or vomiting. 
 
1.4.5 
Benefits 
There may be no benefits to individual subjects for participation in this study. There may be 
earlier resolution of symptoms or fewer complications from SARI. 
 


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1.4.6 
Alternatives 
The alternative to participation in this study is routine standard of care (SOC). For suspected or 
confirmed severe influenza this will generally include an antiviral (likely oseltamivir or 
zanamivir based largely on availability and susceptibility). 
2 
STUDY OBJECTIVES 
2.1 
Primary Objective 
The primary objective is to evaluate the effect of NTZ in addition to SOC as compared to PCB + 
SOC in the treatment of SARI as measured by the time to hospital discharge. 
2.2 
Secondary Objectives 
1.  Evaluate the clinical efficacy of NTZ + SOC vs. PCB + SOC with regards to: 
• Percent hospitalized at Study Day 3, 7, 14 and 28 
• Death by Study Day 28 
• Duration of clinical symptoms (defined in Section 7.3.1.2) 
• Duration of fever 
• Use of supplemental oxygen (or increase greater than baseline oxygen requirement) 
• Admission to ICU 
• Intubation/mechanical ventilation 
• Proportion of subjects who develop complications including pneumonia, respiratory 
failure requiring mechanical ventilation, acute respiratory distress syndrome (ARDS), 
sepsis, or bronchiolitis. 
• Time to resumption of normal activity 
• Antibiotic/antiviral use during hospitalization  
• Systemic corticosteroid use during hospitalization  
• Re-hospitalization within 28 days 
 
2.   Evaluate the virologic efficacy of NTZ + SOC vs. PCB + SOC with regards to: 
• Percent cessation of viral shedding at Study Day 3 
 
3.  Evaluate the safety and tolerability of NTZ assessed by: 
• Cumulative incidence and severity of AEs 
• Cumulative incidence of SAEs 
• Cumulative incidence of laboratory abnormalities on Study Days 3, 7 and 28 
3 
INVESTIGATIONAL PLAN 
3.1 
Research question 
Does treatment with NTZ improve the outcome of subjects with SARI caused by respiratory 
viruses? 
 
3.2 
Hypothesis 


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NTZ improves the outcome of subjects with SARI caused by respiratory viruses, as measured by 
(duration of hospitalization, duration of symptoms, ICU requirements, O2 requirements, use of 
antibiotics, etc). 
 
3.3 
Justification for the research 
As respiratory viruses are major causes of ILI and SARI that can lead to severe outcomes 
including hospitalization and death, and the majority of these viruses have no available 
treatment, potential treatments of respiratory viruses causing SARI are needed. 
 
3.4 
Overview of Study Design 
The study will be a multicenter, randomized, double-blind, placebo controlled trial to evaluate 
the efficacy of NTZ+ SOC compared to PCB + SOC in treating acute viral respiratory infections 
in adults and children ≥ 12 months old with SARI.  The study will be conducted in up to 8 sites 
within Mexico, at sites that are part of the LaRed network.  Subjects will be selected according to 
the inclusion and exclusion criteria listed below (Sections 4.3 and 4.4). The study is designed to 
enroll a total of 290 subjects who will be randomized in a 1:1 ratio. Enrollment will continue 
until 290 subjects are randomized, or March 2017, whichever comes first. 
Prior to screening for inclusion in the study, informed consent (and assent for pediatric subjects 
as applicable) will be obtained. After completion of informed consent, screening for the study 
will occur.  This involves review of the subjects’ symptoms, medical conditions, physical exam, 
and pregnancy test for females able to become pregnant. All patients will initially be 
hospitalized.  If the subject qualifies for the study, baseline assessments will occur including 
baseline vitals, safety labs, and nasopharyngeal swab or aspirate for PCR.  Subjects will be 
randomized to a treatment kit and will begin treatment immediately.  They will receive 
instruction on completion of their diaries, concomitant medications, and attending follow-up 
visits.  Subjects will be followed on Study Days 3, 7, 14, and 28. The subject will be discharged 
from the hospital when clinically indicated as determined by the treating physician – follow-up 
visits may occur as inpatients or as outpatients.   
On Study Days 3 (+/- 1) and 7 (+/- 1) a clinical assessment will be performed, diary cards 
collected, and safety labs will be obtained.  Subjects that are hospitalized on Day 14 will have an 
in person visit.  For subjects that are no longer hospitalized, the Day 14 visit may occur in person 
or by telephone. This visit is primarily for the collection of Day 7-14 diary card information. 
Study Day 28 will mark the end of study where subjects return for final clinical assessment, 
safety labs, and convalescent serologies.  
Subjects that are still hospitalized after Study Day 28 will continue to be followed through the 
date of discharge.   
3.5 
Definitions for the Purpose of this Study 
Enrolled 


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For the purpose of collecting data and samples and reporting AEs, a subject will be 
considered enrolled beginning from the time the informed consent form is signed until the 
subject is considered “screen failure”, “discontinued”, or “completed”. 
 
Randomized 
Subjects are considered randomized when they meet all of the following criteria: 
◦ 
Confirmation that the inclusion and exclusion criteria are met 
◦ 
Consent is given and signed by the subject for the study 
◦ 
Randomization number is assigned 
 
Screen Failures 
Subjects are considered screen failures when they meet 1 of the following criteria after 
signing consent: 
◦ 
Screening tests reveal that the subject is ineligible 
◦ 
Subject withdraws consent before being randomized 
 
Discontinued 
Subjects are considered discontinued when they meet 1 or more of the following criteria: 
◦ 
Subject withdraws consent after being randomized (see Section 4.5) 
◦ 
Subject is withdrawn after enrollment by investigator (see Section 4.7) including lost 
to follow-up 
 
Completed 
Subjects are considered completed when they are followed through Study Day 28 and 
complete the final study follow-up visit (Study Day 28) or die prior to this study visit. 
3.6 
Study Endpoints 
3.6.1 
Primary Endpoint 
Duration of hospitalization (days and hours) 
 
3.6.2 
Secondary Endpoints 
Clinical Endpoints: 
• Hospitalization on Study Days 3, 7, 14, and 28 
• Date and time of hospital discharge 
• Date of death, if applicable  
• Clinical symptoms (measured daily through Study Day 14 and then again on Study Day 
28) 
• Temperature (measured daily through Study Day 14 and then again on Study Day 28) 
• Oxygen use 
• Date of admission to ICU and discharge from ICU, if applicable 
• Date of intubation/extubation, if applicable 
• Presence of complications during study (pneumonia, respiratory failure requiring 
mechanical ventilation, ARDS, sepsis, or bronchiolitis) 




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were no significant adverse events, only two events (one case of mild otitis media and one case 
of mild bronchitis) both these subjects were in the placebo treatment group.20 
 
In another large study in Egypt nitazoxanide there were included 546 subjects. They took 
medication with food at 12-hour intervals over 3 days; those older than 12 years received 500 mg 
of nitazoxanide, children aged 4 to 11 years received 200 mg of drug, and children aged 1 to 3 
years received 5 mL of a 100 mg per 5 mL suspension. Their results indicate that nitazoxanide is 
safe and effective for treating intestinal protozoan and helminthic infections with eradication 
rates of 81% for intestinal amebiasis, 94% for giardiasis, and 77% for balantidiasis.21 
 
4.1.2 
Justification for the Exclusion of Pregnant Women and Children < 6 Months Old 
Given the lack of known efficacy of the combination and the potential toxicities including 
teratogenicity, pregnant women are excluded from this study.  
 
NTZ is licensed in the US and Mexico for adults and children (1 year of age and older in the US 
and 2 years and older in Mexico) for gastrointestinal parasitic diseases (Giardia lamblia or 
Cryptosporidium parvum).  Given the clinical impact of respiratory viruses and SARI in children 
(as previously described), children (greater than or equal to 12 months) are eligible for inclusion 
in this study.  The use in children under 2 years of age in Mexico, and the use for respiratory 
infections are investigational.   
 
As the safety of nitazoxanide in children < 12 months of age has not been established, these 
children will be excluded. 
4.2 
Recruitment 
Subjects will be recruited through the hospital sites in Mexico that comprise LaRed. Information 
about this study will be disseminated to health care providers in these settings. Subjects that have 
been recently hospitalized with ILI, or that are in the emergency department or clinic that are 
going to be hospitalized with ILI will be evaluated for potential participation in this study.  
Additionally, direct-to-subject recruitment (using posters and/or other informational items) may 
occur in these hospital settings.  
 
Any direct-to-subject recruitment documents/materials will be submitted to the reviewing 
Institutional Review Board (IRB)/Independent Ethics Committee (IEC) for approval. Any flyers 
and advertisements that will be viewed directly by potential study subjects will be submitted to 
the site IRB/IEC for approval. 
 
Informational items about the study distributed to the health care staff only, including but not 
limited to the manual of procedures are not required to be reviewed by the IRB/IEC. 
4.3 
Inclusion Criteria for Enrollment 
1. Signed informed consent prior to performance or initiation of any study procedures. 
2. Age ≥ 12 months of age (no upper age limit). 
3. One of the following constitutional signs or symptoms within 7 days of screening: 
• Temperature of ≥ 38° C 


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• Temperature ≤ or 36° C 
• Myalgia 
• Headache 
• Malaise  
• Irritability (children < 5 years of age only) 
• Decreased appetite (children < 5 years of age only) 
4. One of the following lower respiratory sign/symptom within 7 days of screening: 
• Cough 
• Hypoxia (SaO2 < 95%) 
• Tachypnea (age adjusted, see section 7.3.4) 
• Dyspnea 
• Nasal flaring (children <2 only) 
• Chest retractions (children <2 only) 
5. Hospitalization for ILI (decision for hospitalization will be up to the individual treating 
clinician), with anticipated hospitalization for more than 24 hours. 
6. One of the following to avoid pregnancy: 
– Females who are able to become pregnant (i.e., are not postmenopausal, have not 
undergone surgical sterilization, and are sexually active with men) must agree to 
use at least 1 effective form of contraception from the date of informed consent 
through Day 28 of study. For hospitalized subjects, this can begin after hospital 
discharge. 
– Males who have not undergone surgical sterilization and are sexually active with 
women must agree to use condoms or have a partner use at least 1 effective form 
of contraception through Day 28 of study. For hospitalized subjects, this can 
begin after hospital discharge. 
4.4 
Exclusion Criteria 
1. Women who are pregnant or breast-feeding. 
2. Clinical suspicion that etiology of illness is primarily bacterial in origin. 
3. Prior treatment with antivirals (e.g. oseltamivir) for the current illness for more than 24 
hours. 
4. Subjects unable to take enteral medications (adults must tolerate tablets by mouth as they 
cannot be crushed, children must be able to swallow pediatric suspension or receive drug 
by nasogastric tube). 
5. Prior treatment with any investigational drug therapy within 30 days prior to screening. 
6. Known sensitivity to NTZ or any of the excipients comprising the NTZ tablets.  
7. Prior NTZ use within 1 week. 
8. Self-reported history of impaired renal function (no blood or urine kidney function 
laboratory testing will be done prior to enrollment, but intent is to exclude disease severe 
enough to cause estimated CrCl <30 mL/min). 
9. Self-reported history of liver disease (no blood laboratory testing will be done prior to 
enrollment, but intent is to exclude disease severe enough to cause cirrhosis or total 
bilirubin > 1.5×ULN, AST/ALT > 3×ULN, based on labs obtained previously for clinical 
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10. Presence of any pre-existing medical condition not listed above that, in the opinion of the 
investigator, would place the subject at an unreasonably increased risk through 
participation in this study. 
11. Subjects who, in the judgment of the investigator, will be unlikely to comply with the 
requirements of this protocol. 
12. The onset of respiratory symptoms occurs after hospitalization (to exclude nosocomial 
infections). 
13. Hospitalized for any reason for greater than 60 hours prior to enrollment. 
14. Participants previously enrolled in this study. 
15. Known chronic respiratory infection (e.g., tuberculosis, atypical mycobacterial 
infections). 
4.5 
Subject Withdrawal 
Subjects (or their parents or legal surrogates if subjects become unable to make informed 
decisions) can terminate study participation at any time without prejudice. If a subject terminates 
participation before completing the study, the reason for this decision will be recorded in the case 
report form (CRF). 
 
Subjects who indicate interest in withdrawing from the study should also be asked permission to 
be contacted at Study Day 28 by telephone for vital status (any AEs that occurred during the 
study). This is not considered full withdrawal of consent, and the agreement for limited follow-
up should be noted in the medical record. 
 
Subjects who fully withdraw consent will not be contacted further. 
 
 
Subjects who withdraw from the study will not be replaced. 
4.6 
Discontinuation of Study Medication 
Subjects will discontinue study medication for any of the following reasons: 
• Laboratory results from baseline or subsequent visits that show any of the following: 
- 
Estimated CrCl <30 mL/min 
- 
Total bilirubin >2×ULN 
- 
AST/ALT >3×ULN 
• The subject becomes unable to take oral medications (study drug cannot be given by 
nasogastric tube without unblinding) 
• Clinically significant grade 3 or 4 AEs (including safety laboratory results) that in the 
judgment of the site investigator are causally related to study medication 
• Any other AE or clinically significant laboratory result for which the investigator believes 
that continuation of the study medication would be detrimental to the subject 
• Positive pregnancy test 
 
Subjects who discontinue study drug should still be treated with standard care treatments 
(Section 5.6). 
 
The reason for discontinuation of the study drug is to be recorded on the CRF. All subjects who 
discontinue study drug will be encouraged to comply with the study visit schedule including 


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clinical and virologic assessment through Day 28. 
4.7 
Discontinuation of Subject by Investigator 
The investigator has the right to withdraw subjects from the study. Subjects may be withdrawn 
from the study for any of the following reasons: 
◦ 
The subject is lost to follow-up 
◦ 
The subject experiences an AE and the investigator believes that continuation in the 
study would be detrimental to the subject (in contrast to discontinuing the study 
medication and continuing follow-up as discussed in Section 4.6) 
 
The reason for withdrawal from the study is to be recorded on the CRF. If a non-serious AE is 
unresolved at the time of discontinuation, efforts should be made to follow-up until the event 
resolves or stabilizes, the subject is lost to follow-up, or there is some other resolution of the 
event. The investigator is to make every attempt to follow all SAEs to resolution. 
 
Subjects who miss a study visit should be contacted to reschedule. If subjects cannot be 
contacted immediately, periodic attempts should continue until study completion (Study 
Day 28). Lost to follow-up is defined as unsuccessful contact after at least 2 documented 
telephone calls. 
 
Any subject withdrawn from the study will not be replaced. 
4.8 
Discontinuation of Study 
NIAID as the study sponsor, the reviewing IRB/IEC, the US Food and Drug Administration 
(FDA), and the Mexico Federal Commission for the Protection against Sanitary Risk 
(COFEPRIS) have the right to terminate the study at the sites they are responsible for at any 
time. 
4.9 
Participation in Other Protocols 
Subjects in this protocol may participate in other research protocols, as long as the other research 
does not require more than 30 mL of blood to be given in any 4-week period of time and does 
not administer any unlicensed drug, unlicensed vaccine, or any treatment (licensed or unlicensed) 
for influenza or influenza like illness within the 30 days or 5 half-lives (whichever is longer) 
prior to enrollment or during the duration of this study. 
 
LaRed has an ongoing ILI/SARI surveillance study and it is anticipated many subjects may be 
co-enrolled in this study. 
4.10 
Emergency Unblinding 
Any pregnancy occurring on study will be immediately unblinded (regardless of known AE or 
known fetal toxicities). As nitazoxanide is US FDA pregnancy category B, this unblinding only 
applies to subjects and not partners. The participant will be told if they were receiving 
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The sponsor will supply each site with study agent near the time of site activation.  Each 
randomized subject will receive a study drug kit consisting of 5 days of treatment. The site 
pharmacy will distribute the study kits.  The method of supplying study agent to hospitalized 
subjects will be customized at each site. 
 
 
Subjects take the medication twice daily, with food, and each dose will consist of the following: 
 
Adults and Children 12 years and older: 
The active formulation for this study is a yellow, film-coated tablet that contains 300 mg NTZ 
plus standard excipients. This is an extended release formulation of licensed NTZ. This formula 
provides a mean AUCt 29 µg*hr/mL and mean Cmin (12 h) 0.8 µg/mL. 
 
The placebo tablet will have the same appearance and inactive ingredients as the active tablet. 
 
Group 1 (NTZ): 2 NT-300 mg tablets orally BID x 5 days. 
Group 2 (Placebo): 2 placebo tablets orally BID x 5 days.  
 
Children younger than 12 years: 
The formulation for children younger than 12 years is the currently licensed suspension of 
nitazoxanide (Alinia®), or matching placebo. 
 
Group 1 (NTZ): 
4-11 years: 10 mL oral suspension (200 mg NTZ) every 12 hours x 5 days 
1-3 years: 5 mL oral suspension (100 mg NTZ) every 12 hours x 5 days 
 
Group 2 (Placebo): 
4-11 years: 10 mL oral suspension (placebo) every 12 hours x 5 days 
1-3 years: 5 mL oral suspension (placebo) every 12 hours x 5 days  
 
5.3 
Justification of Dose 
The pediatric dose of NTZ for subjects 1-11 years or age is the same as the licensed dose.  
 
The adult dose (600 mg) is slightly higher than the licensed adult dose (500 mg) but is equivalent 
to the dose used in previous influenza treatment studies where efficacy was demonstrated (as 
discussed in the background section).  This higher dose is needed to provide favorable 
pharmacokinetics thought to be needed for the treatment of ILI. 
5.4 
Study Drug Acquisition 
Study drug will be stored in a central repository. Sites will be given an initial supply of study 
drug after the local IRB/IEC has approved the study, the US FDA and Mexico COFEPRIS have 
granted the study safe to proceed, the sponsor has approved shipment of study agent, and after all 
import licenses have been obtained, as applicable. 
5.5 
Study Drug Accountability 


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The investigator or his/her designee is required to maintain accurate drug accountability records. 
A binder containing instructions and the required accountability documentation will be provided 
to the investigator or his/her designee. When the study is completed, copies of the study drug 
accountability records will be maintained at the study site and all originals returned to the 
sponsor. Copies of the drug accountability records must be maintained with the rest of the 
documentation for the study. All unused study drug must be disposed of upon authorization by 
NIAID or its designee. All standard operating procedures and records regarding the disposition 
of study drug must be available for inspection by the study monitors and regulatory authorities. 
5.6 
Standard of Care Treatment 
It is anticipated that subjects will receive concomitant medications for likely treatable pathogens 
that may cause SARI.  These would likely include antibiotics and may include other treatments 
for influenza such as oseltamivir.  As treatments will be different due to age, medical conditions, 
exposures, clinical presentation, etc., the treating physician will make all decisions about 
standard of care treatments, and no specific treatment regimen is mandated by this protocol. 
 
5.7 
Concomitant Medications 
Subjects will be monitored throughout the study for use of concomitant medications. Any 
prescription medications, and/or over-the-counter preparations (OTC) taken during the study 
period must be recorded on the source documents and in the designated CRF. 
5.8 
Prohibited Medications 
Subjects may not receive investigational medications (other than the study drug provided) at any 
time during the study. Their use would not be considered SOC and therefore withholding these 
compounds would still be consistent with best medical practice.  
5.9 
Treatment Compliance 
Treatment compliance during hospitalization will be documented by the hospital record.  
Compliance after discharge will be assessed by examination of subject’s remaining study product 
on each study visit. 
6 
STUDY PROCEDURES 
The following table (Table 5) outlines all of the assessments to be conducted during the study. A 
detailed presentation of assessments immediately follows the table. The day when the subject is 
randomized is denoted as Study Day 0, the first day after enrollment is Study Day 1, etc. 
 
 




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Subjects will be identified from subjects that are in the emergency room or have been recently 
hospitalized, or may be referred from other health care workers within the institution.  As early 
treatment is likely to provide the best treatment effect (as seen in influenza), subjects should be 
identified, and if appropriate, approached, enrolled, and if enrolled, administered baseline 
evaluation and given first does as soon as possible, but no longer than 24 hours. 
6.2.1.1 Informed Consent 
The site investigator will review the informed consent document with the subject or legal 
representative. Informed consent should be obtained from the subject, or if a subject is judged by 
the investigator to be unable to provide informed consent, consent should be obtained from 
his/her legally authorized representative. The use of a surrogate for consent may only be 
permitted if allowed by local regulation and must be in accordance with local requirements. 
 
Children should be presented the study assent (in addition to consent being obtained from his/her 
legally authorized representative). The age cutoff for assent will follow institutional or site IRB 
policies/stipulations. 
 
A single informed consent form will be used for both screening and enrollment into this protocol. 
6.2.1.2 Demographics 
The following information should be recorded: 
• Age 
• Sex 
• Ethnicity  
• Race 
 
6.2.1.3 Medical History 
The Investigator (or designee) will take a medical history at the time of consent and conduct a 
complete physical examination. Information about the ILI symptoms, tolerating oral diet, 
medical history, and other research protocols must be obtained from the subject if possible, other 
information can be abstracted from the chart if needed.  The following information should be 
recorded:  
• Day of onset of ILI symptoms 
• Ability to tolerate oral medications and food/fluids 
• Date and hour of hospital admission 
• Influenza vaccination history  
• History of chronic medical conditions (including, but not limited to, kidney and liver 
disease).  This includes calculation of Charlson comorbidity index. 
• Current use of prescription and OTC medications within the last 7 days  
• Chronic oxygen use 
• History of allergies 
• History of exposure to NTZ products 
• Participation in any recent research protocols (within the last 3 months) 
• Smoking history 
 


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6.2.1.4 Physical Exam 
A brief physical exam including vital signs and SaO2 should be performed and will be used to 
ensure there are no medical conditions (either chronic or acute) that would increase a subject’s 
risk for participation in this study. 
 
6.2.1.5 Laboratory 
Female subjects of child bearing potential will have a urine pregnancy test performed at 
screening (serum pregnancy test may be substituted as needed). 
 
6.2.2 
Determination of Eligibility and Randomization 
6.2.2.1 Determination of Eligibility 
After the previously mentioned evaluations have been completed (i.e., medical history), the 
investigator is to review the inclusion/exclusion criteria and determine the subject’s eligibility for 
study participation. Any laboratory obtained as part of the subject routine care should be 
reviewed for clinically significant findings and taken into account to determine study eligibility. 
 
6.2.2.2 Randomization 
The study team will assign the subject the next study kit in sequence that is available at the site.  
This study drug kit number will be conveyed to the pharmacy and the kit will be distributed from 
the pharmacy. 
 
6.2.2.3 Screening Failures 
The following information will be collected on screening failures (as subjects have already 
signed consent): demographics (age, screen number, sex, birth date, ethnicity, and race) and 
reason for ineligibility. Subjects who are found to be ineligible will be told the reason for 
ineligibility and may not be re-screened for the study. 
 
6.2.3 
Study Day 0: Baseline Evaluation 
Baseline evaluation must be completed prior to the first dose of study medication. 
 
6.2.3.1 Clinical Data on Day 0 
• Assessment for presence of complications (see Section 7.3.2) 
• Vital signs, including SaO2 (see Section 7.3.3) 
• Assessment for AEs occurring after consent and prior to administration of study drug 
• Severity of illness score (Sequential Organ Failure Assessment (SOFA) score or if < 
24 months of age use Tal bronchiolitis score) 
 
6.2.3.2 Laboratory Data 
The following laboratory test will be performed: 


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◦ 
CBC with differential white cell count (to include neutrophil, lymphocyte, and 
eosinophil percentages), hemoglobin, hematocrit, and platelets 
◦ 
Blood chemistries (creatinine, ALT/GPT, AST/GOT, total bilirubin, LDH, CRP) 
If these labs were performed for clinical care on the day of enrollment (or within 24 hours prior 
to enrollment), these labs do not need to be repeated and can be obtained from the clinical 
record. These tests are performed as a baseline for safety monitoring, and results do not need to 
be obtained before starting study drug. 
 
If laboratory tests are drawn after enrollment, within 24 hours of enrollment these labs should be 
reviewed.  If laboratory results that show estimated CrCl < 30 mL/min, total bilirubin >2×ULN, 
or AST/ALT >3×ULN, the study drug should will be stopped (per section 4.6)). 
 
6.2.3.3 Research Procedures on Day 0 
At baseline, a NP swab will be sent for multiplex PCR.  If a NP swab cannot be obtained for 
medical reasons, an NP aspirate can be substituted.  See Section 7.2 
 
If this testing is performed for clinical care or other protocols on Day 0, and the results can be 
used for this study, the testing does not need to be repeated. 
 
6.2.3.4 Study Day 0: Study Drug Distribution 
While the patient is hospitalized, the study drug will be distributed from the pharmacy per local 
standards.  
 
6.2.3.5 Distribution of Diary Cards 
A subject diary card booklet assessing fever, symptoms and functional assessment, will be 
distributed to subjects.  Collection of baseline assessments and subject recalled pre-illness 
condition(s) (See Section 7.3.1) will be completed by the study team and instructions will be 
given to the subject on the completion of the diary card. 
 
6.2.4 
Study Day 3 (+/- 1 day) 
6.2.4.1 Clinical Data on Day 3 
• Review and collection of diary cards since last visit (i.e. Days 1-3).  The diary card 
documents fever, symptoms and functional assessment (See Section 7.3.1) 
• Assessment for presence of complications (See Section 7.3.2) 
• If discharged – complete discharge assessment and reinforcement of study procedures 
post discharge will be performed.  
• Vital signs, including SaO2 (See section 7.3.3) 
• Review of study drug and assessment of compliance (see Section 7.4) 
• Review of concomitant medications  
• Symptom targeted physical exam (for safety assessment, see Section 7.1.2) 
• Assessment for AEs 


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• Severity of illness score (SOFA score or if < 24 months of age use Tal bronchiolitis 
score) (see Section 7.5.1) 
 
6.2.4.2 Clinical Laboratory Tests on Day 3(+/- 1 day) 
The following laboratory test will be performed: 
◦ 
CBC with differential white cell count (to include neutrophil, lymphocyte, and 
eosinophil percentages), hemoglobin, hematocrit, and platelets 
◦ 
Blood chemistries (creatinine, ALT/GPT, AST/GOT, total bilirubin, LDH, CRP)  
If these labs were performed for clinical care on this study day (or within the window), these labs 
do not need to be repeated and can be obtained from the clinical record. 
6.2.4.3 Research Procedures on Day 3 (+/- 1 day) 
A follow-up NP swab will be sent for multiplex PCR.  If a NP swab cannot be obtained for 
medical reasons, an NP aspirate can be substituted.  The method of specimen collection on Day 0 
should be the same method used on Day 3.  See Section 7.2  
 
6.2.5 
Study Day 7 (-1 Day /+2 Days) 
For subjects that are hospitalized and subjects no longer hospitalized, this visit will occur in 
person.  
6.2.5.1 Clinical Data on Day 7 
• Review and collection of diary cards since last visit (i.e. Days 3-7).  The diary card 
documents fever, symptoms and functional assessment (See Section 7.3.1) 
• Assessment for presence of complications (See Section 7.3.2) 
• If discharged – complete discharge assessment.  If still hospitalized – assess if 
medically able to be discharged from hospital. 
• Vital signs, including SaO2 (See Section 7.3.3) 
• Review of concomitant medications  
• Symptom targeted physical exam (for safety assessment, see Section 7.1.2) 
• Assessment for AEs 
6.2.5.2 Clinical Laboratory Tests on Day 7 (+/- 1 day) 
The following laboratory test will be performed: 
◦ 
CBC with differential white cell count (to include neutrophil, lymphocyte, and 
eosinophil percentages), hemoglobin, hematocrit, and platelets 
◦ 
Blood chemistries (creatinine, ALT/GPT, AST/GOT, total bilirubin, LDH, CRP)  
If these labs were performed for clinical care on this study day (or within the window), these labs 
do not need to be repeated and can be obtained from the clinical record. 
 
6.2.6 
Study Day 14 (+/- 2 Days) 
For subjects that are hospitalized, this visit will occur in person.  For subjects that are no longer 
hospitalized, this visit may occur in person or by telephone.  However, if telephone visits are 
used, all study endpoint information must still be collected.   


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6.2.6.1 Clinical Data on Day 14 
• Review and collection of diary cards since last visit (i.e. Days 8-14).  The diary card 
documents fever, symptoms and functional assessment (See Section 7.3.1).  If this 
visit occurs by telephone, all diary card data is collected by phone, and subjects are 
instructed to bring the diary card at Day 28 visit. 
• Assessment for presence of complications (See Section 7.3.2) 
• If discharged – complete discharge assessment.  If still hospitalized – assess if 
medically able to be discharged from hospital. 
• Review of concomitant medications  
• Assessment for AEs 
6.2.7 
Study Day 28 (+/- 3 Days) 
6.2.7.1 Clinical Data on Day 28 
• Review symptoms and functional assessment (See Section 7.3.1) 
• If Day 14 was a telephone visit contact – the diary cards for Day 7 – 14 are collected, 
and verified against the data obtained by telephone by the study staff. 
• Assessment for presence of complications (See Section 7.3.2) 
• If discharged – complete discharge assessment.  If still hospitalized – assess if 
medically able to be discharged from hospital. 
• Vital signs, including SaO2 (See section 7.3.3) 
• Review of concomitant medications  
• Symptom targeted physical exam (for safety assessment, see Section 7.1.2) 
• Assessment for AEs 
6.2.7.2 Clinical Laboratory Tests on Day 28 
The following laboratory test will be performed: 
◦ 
CBC with differential white cell count (to include neutrophil, lymphocyte, and 
eosinophil percentages), hemoglobin, hematocrit, and platelets 
◦ 
Blood chemistries (creatinine, ALT/GPT, AST/GOT, total bilirubin, LDH, CRP) 
If these labs were performed for clinical care on this study day (or within the window), these labs 
do not need to be repeated and can be obtained from the clinical record.  
 
6.2.8 
Hospital Discharge Evaluation 
Near the time of hospital discharge, data pertaining to the hospitalization will be collected.  If 
subjects are still hospitalized after Day 28, they will be followed through hospital discharge.  
 
A discharge source document and CRF should be completed by reviewing the medical chart 
within 4 days of discharge (if subjects are hospitalized for over 28 days, this evaluation should 
be done within 10 days of the day of discharge).  This will document: 
• Date and hour of discharge 
• Date of death (if applicable) 
• Oxygen use during hospitalization 
• Dates of admission to ICU and discharge from ICU (if applicable) 
• Dates of intubation/extubation (if applicable) 


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• Antibiotic/antiviral use during hospitalization (number and duration) 
 
7 
MEASURES OF SAFETY, EFFICACY,AND COMPLIANCE 
7.1 
Safety Evaluations 
7.1.1 
Laboratory Evaluations 
All laboratory evaluations (except reference endpoint assays) will be performed at the local 
certified (e.g., Clinical Laboratory Improvement Amendments [CLIA], College of American 
Pathologists [CAP], or comparable certification) clinical laboratory. The same laboratory should 
be used throughout the study for any given patient. Blood samples will be collected from 
subjects at baseline (Day 0) and on Study Days 3, 7, and 28 for evaluation of routine laboratory 
safety (chemistry, complete blood count with differential).  
 
Abnormal labs, if thought to be erroneous, should be repeated.  Not all abnormal labs need to be 
repeated.  Abnormal labs, if thought to be erroneous, which will cause cessation of study 
medication, should be confirmed by repeating the lab test as soon as possible. 
 
On the designated days, the following laboratory test will be performed: 
◦ 
CBC with differential white cell count (to include neutrophil, lymphocyte, and 
eosinophil percentages), hemoglobin, hematocrit, and platelets 
◦ 
Blood chemistries (creatinine, ALT/GPT, AST/GOT, total bilirubin, LDH, CRP)  
 
7.1.2 
Other Safety Examinations 
A brief physical examination will be conducted at screening to ensure there are not medical 
conditions (either chronic or acute) that would increase a subject’s risk for participation in this 
study. Symptom-targeted physical examinations will be conducted at all other visits as needed to 
evaluate new complaints and possible AEs. Due to the variability and the difficulty of 
standardization, the physical exam will not be used as efficacy data. 
 
7.2 
Viral Diagnostics 
The NP swab on Days 0 and 3 will be tested by a central lab using a multiplex PCR for 22 
respiratory pathogens and influenza types. The platform, Respifinder®, will be used according to 
manufacturer instructions.  This multiplex PCR test can detect and differentiate 18 viruses 
(Coronavirus NL63, OC43, 229E, HKU1, Human metapneumovirus, Influenza A, Influenza A 
H1N1v, Influenza B, Parainfluenza 1 to 4, Respiratory syncytial virus (RSV) A and B, 
Rhinovirus/Enterovirus, Adenovirus, Bocavirus) as well as 4 bacteria (Bordetella pertussis, 
Chlamydophila pneumoniae, Legionella pneumophila, Mycoplasma pneumoniae). 
 
7.3 
Efficacy Evaluations 
7.3.1 
Diary Card for Fever, Symptoms, and Functional Assessment 
Subjects will maintain a diary card, and will be asked to make a daily entry in the evening.  On 
Day 0, subjects will be instructed on the diary card and the initial (baseline) assessment will be 


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completed by the subject and collected.  The subject will make daily entries through Day 14.   
The subject completes the final diary card at the time of the final visit on Day 28 to represent end 
of study functional assessment and symptoms. 
 
Completion of subsequent diary cards should be done by the subject if possible.  For children 
unable to complete the card, it may be completed by a parent or close relative (and documented 
accordingly).  For those subjects too ill to complete the diary card, it may be completed by the 
study team or treating team (physicians or nurses) and this will be documented accordingly. 
 
At each subsequent study visit, the diary card for the day(s) since the last visit will be collected. 
This diary will contain the information listed below (Section 7.3.1.1 – 7.3.1.3). 
7.3.1.1 Fever 
Subjects will be asked to measure temperature orally at the time of completing the diary card and 
at any time they exhibit symptoms of feverishness, and will be asked to record the maximal 
temperature since the prior diary card). 
7.3.1.2 Symptoms 
Using a 4-point scale (0 = absent, 1 = mild, 2 = moderate, 3 = severe), each symptom will be 
assessed for severity.  
 
The symptoms assessed are: 
- 
Cough  
- 
Sore throat 
- 
Fatigue 
- 
Headache 
- 
Myalgia 
- 
Rhinorrhea 
- 
Nausea 
- 
Vomiting 
- 
Diarrhea 
- 
Difficulty breathing/shortness of breath 
 
7.3.1.3 Global Assessment 
Subjects will be asked 2 global assessment questions: 
• “Are you feeling as good as you did before you had the respiratory illness?” with a yes/no 
response, referring to the status immediately prior to onset of ILI symptoms. 
• “Are you functioning as well as you were before you had the respiratory illness?” with a 
yes/no response, referring to the status immediately prior to onset of ILI symptoms. 
 
Pediatric subjects that are not capable of answering the above questions will be assessed by a 
parent or close relative regarding: 
• “Is your child as active as they were before they had the respiratory illness?” with a 
yes/no response, referring to the status immediately prior to onset of ILI symptoms. 
• “Is your child eating as much as they were before they had the respiratory illness?” with a 
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8 
ASSESSMENT OF SAFETY 
8.1 
Definitions 
Adverse Event (AE) 
An AE is any untoward or unfavorable medical occurrence in a human subject, including any 
abnormal sign (e.g., abnormal physical exam or laboratory finding), symptom, or disease, 
temporally associated with the subject’s participation in the research, whether or not it is 
considered related to the research. 
 
Adverse Reaction (AR) 
An AE that is caused by an investigational agent (drug or biologic) 
 
Suspected Adverse Reaction (SAR) 
An AE for which there is a reasonable possibility that the investigational agent caused the AE. 
‘Reasonable possibility’ means that there is evidence to suggest a causal relationship between the 
drug and the AE. A suspected adverse reaction implies a lesser degree of certainty about 
causality than an adverse reaction which implies a high degree of certainty. 
 
Serious Adverse Event (SAE) 
A SAE is an AE that results in 1 or more of the following outcomes: 
 
• death 
• a life threatening (i.e., an immediate threat to life) event 
• an inpatient hospitalization or prolongation of an existing hospitalization 
• a persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions 
• a congenital anomaly/birth defect 
• a medically important event* 
 
* Medical and scientific judgment should be exercised in deciding whether expedited 
reporting is appropriate in other situations, such as important medical events that may not 
be immediately life threatening or result in death or hospitalization but that may jeopardize 
the subject or may require intervention to prevent 1 of the other outcomes listed above.  
 
Unexpected Adverse Event 
An AE is unexpected if it is not listed in the IB or Package Insert (for marketed products) or is 
not listed at the specificity or severity that has been observed.  It is the responsibility of the IND 
Sponsor to make this determination. 
 
Serious and Unexpected Suspected Adverse Reaction (SUSAR) 
A SUSAR is a Suspected Adverse Reaction that is both Serious and Unexpected.   
 
Unanticipated Problem (UP) 
An Unanticipated Problem is any event, incident, experience, or outcome that is 
 
1. unexpected in terms of nature, severity, or frequency in relation to 


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a. the research risks that are described in the IRB-approved research protocol and informed 
consent document; Investigator’s Brochure or other study documents; and 
b. the characteristics of the subject population being studied; and 
2. possibly, probably, or definitely related to participation in the research; and 
3. places subjects or others at a greater risk of harm (including physical, psychological, 
economic, or social harm) than was previously known or recognized. (Per the IND Sponsor, 
an AE with a serious outcome will be considered increased risk.) 
 
Unanticipated Problem that is not an Adverse Event (UPnonAE) 
An incident, experience or outcome that is not associated with an AE which meets the 3 criteria 
of a UP.  Examples include occurrences of breaches of confidentiality, accidental destruction of 
study records, and unaccounted-for study drug. 
 
Protocol Violation 
A Protocol Violation is any change, divergence, or departure from the study design or procedures 
in an IRB-approved research protocol that has a major impact on the subject’s rights, safety, or 
well-being and/or the completeness, accuracy or reliability of the study data. 
 
Protocol Deviation 
A Protocol Deviation is any change, divergence, or departure from the study design or 
procedures of an IRB-approved research protocol that does not have a major impact on the 
subject’s rights, safety or well-being, and/or the completeness, accuracy and reliability of the 
study data. 
 
8.2 
Investigator Assessment of Adverse Events 
8.2.1 
Determination of Adverse Event 
All worsening symptoms should be evaluated as potential adverse events: 
• If a diagnosis is clinically evident (or subsequently determined), the diagnosis, rather than 
the individual signs and symptoms or lab abnormalities, will be recorded as the AE.  
• Gastrointestinal tract SARI symptoms such as nausea, vomiting, or diarrhea, can be either 
related to SARI or the study drug.  For this reason, if these gastrointestinal symptoms are 
new from baseline or worsen, they should be graded per the DAIDS toxicity table, and if 
they are new or represent a worsening grade then they should be reported as adverse 
events. 
• Upper respiratory tract SARI symptoms (such as cough, sore throat, fatigue, headache, 
myalgia, rhinorrhea) can worsen due to the underlying disease.  As these are unlikely to 
be related to the study drug, these do not need to be reported as Adverse Events. 
• Any other new symptoms should be recorded as AEs. 
• Symptoms present at baseline that resolve should have an end date (unless likely flu 
related).  If they recur, the recurrence should be reported as an adverse event.  
Intermittent symptoms (such as cough, headache, rhinorrhea) would not be AEs if likely 
influenza related. 
 
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• If an abnormal laboratory finding is captured as a component of a diagnosis AE term that 
has already been recorded as a pre-study condition, the individual abnormal laboratory 
finding is NOT recorded as a separate AE. 
• A laboratory abnormality should be reported as an AE only if it requires an intervention. 
Interventions include, but are not limited to, discontinuation of treatment, dose 
reduction/delay, additional assessments (including additional lab assessments), or 
concomitant treatment.  
• In addition, any medically important laboratory abnormality may be reported as an AE at 
the discretion of the investigator who considers the test result clinically significant. This 
could include a laboratory result for which there is no intervention but the abnormal value 
is of clinical concern or suggests disease or organ toxicity. Grading should be based on 
the toxicity table where applicable. 
 
8.2.2 
Period of Assessment 
All AEs that occur from the time the informed consent is signed through Day 28 will be 
documented, recorded, and reported. After the end of the protocol-defined AE reporting period, 
sites must report to the safety office serious, unexpected, clinically suspected adverse drug 
reactions if the study site staff becomes aware of the event on a passive basis. 
 
8.2.3 
Assessment of Adverse Event 
The Investigator will evaluate all AEs with respect to Seriousness (criteria listed above), 
Severity (grading), and Causality (relationship to study agent and relationship to research) 
according to the following guidelines. 
 
8.2.3.1 Severity 
The Investigator will grade the severity of each AE according to the “DAIDS (Division of AIDS) 
Table for Grading the Severity of Adult and Pediatric Adverse Events” Version 1.0, December, 
2004: (Clarification August 2009) which can be found at:  http://rsc.tech-
res.com/Document/safetyandpharmacovigilance/Table_for_Grading_Severity_of_Adult_Pediatri
c_Adverse_Events.pdf 
 
8.2.3.2 Causality of Adverse Event to the Intervention 
Causality (likelihood that the event is related to the study agent) will be assessed considering the 
factors listed under the following categories:  
 
Definitely Related 
 
• reasonable temporal relationship 
• follows a known response pattern 
• clear evidence to suggest a causal relationship 
• there is no alternative etiology 
 
Probably Related 
 
• reasonable temporal relationship 


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• follows a suspected response pattern (based on similar agents) 
• no evidence of a more likely alternative etiology 
 
Possibly Related 
 
• reasonable temporal relationship 
• little evidence for a more likely alternative etiology 
 
Unlikely Related 
 
• does not have a reasonable temporal relationship  
• OR 
• good evidence for a more likely alternative etiology 
 
Not Related  
• does not have a temporal relationship 
• OR 
• definitely due to an alternative etiology 
 
Other factors (e.g., dechallenge, rechallenge) should also be considered for each causality 
category when appropriate. Causality assessment is based on available information at the time of 
the assessment of the AE. The investigator may revise the causality assessment as additional 
information becomes available. 
 
8.2.4 
Investigator Documentation of Adverse Event 
The severity of the AE will be recorded in an appropriate source document. AEs (per the 
definition above) and SAEs will be recorded in the appropriate section of the AE electronic case 
report forms (eCRF) and entered into a database for IRB/IEC review and FDA/COFEPRIS 
reporting requirements.  
 
8.3 
Investigator Reporting Responsibilities to the Sponsor 
8.3.1 
Serious Adverse Events 
SAEs (whether or not they are also UPs) must be reported on the SAE/UP Report Form and sent to 
the Sponsor Clinical Safety Office (CSO) by fax or e-mail attachment. Deaths and immediately 
life threatening SAEs must be reported within 1 business day after the site becomes aware of the 
event. All other SAEs must be reported within 3 business days of site awareness.  
 
SPONSOR CLINICAL SAFETY OFFICE CONTACT INFORMATION:  
 
OCRPRO Clinical Safety Office 
5705 Industry Lane 
Frederick, MD 21704 
 
Phone 301-846-5301 
Fax 301-846-6224 


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E-mail: rchspsafety@mail.nih.gov 
 
8.3.2 
Unanticipated Problems 
Non-Serious AEs that are UPs must also be reported on the SAE/UP Report Form and sent to the 
CSO by fax or e-mail attachment no later than 7 calendar days of site awareness of the event. 
The UPs that are not AEs are not reported to the Sponsor CSO.  
 
8.3.3 
Pregnancy 
Pregnancy itself is not an AE. However, complications of pregnancies are AEs and may be 
SAEs.  Pertinent obstetrical information for all pregnancies will be reported to the CSO via fax 
or email within 3 business days from site awareness of the pregnancy.   
 
Pregnancy outcome data (e.g., delivery outcome, spontaneous or elective termination of the 
pregnancy) will be reported to the CSO within 3 business days of the site’s awareness on a 
protocol-specified form. 
 
The procedures that should be followed in the event of a pregnancy include: 
• Discontinuation of the study agent 
• Unblind per the unblinding section of the protocol 
• Pregnancies that do not result in SAEs will be reported to the IRB/IEC in summary format 
with the continuing review or according to the local IRB/IEC requirements 
• Advise research subject to notify the obstetrician of study agent exposure 
 
Additionally the protocol team will report the pregnancy to the DSMB. 
 
8.4 
Investigator Reporting Responsibilities to the Site IRB/EC 
8.4.1 
IND safety reports 
Investigators are responsible for submitting IND Safety Reports and UP summaries that are 
received from the IND Sponsor to their local IRB/Ethics Committee.  Investigators must also 
comply with all local IRB/Ethics Committee reporting requirements.   
 
8.4.2 
Expedited Reporting to the Site IRB/EC  
Unanticipated problems that are either AEs or non-AEs, (as defined above) and protocol 
violations which do not meet the definition of a UP will be reported within 7 calendar days of 
investigator awareness (or as required by the site IRB/EC).  
 
8.4.3 
Annual Reporting to the IRB/EC  
In addition to each IRB/EC yearly reporting requirements, the following items will be reported to 
the IRB/EC in summary at the time of Continuing Review (or more frequently as required by the 
site IRB/ECs): 
• All unanticipated problems 


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• All protocol deviations which in the opinion of the investigator should be reported 
according to the site’s IRB/EC reporting guidelines 
• Summaries of all AEs 
 
8.5 
Follow-up of Adverse Events and Serious Adverse Events 
AEs that occur following enrollment of the subject (by signing the informed consent) are 
followed until the final outcome is known or until the end of the study follow-up period (Study 
Day 28). 
 
SAEs that have not resolved by the end of the follow-up period are followed until final outcome 
is known. If it is not possible to obtain a final outcome for an SAE (e.g., the subject is lost to 
follow-up), the reason a final outcome could not be obtained will be recorded by the investigator 
on the AE CRF (if the CRF is still open) and the SAE/UP Report Form. 
 
SAEs that occur after the study follow-up period that are reported to and are assessed by the 
Investigator to be possibly, probably, or definitely related must be reported to the CSO, as 
described above. 
 
8.6 
Sponsor’s Reporting Responsibilities 
Serious and unexpected suspected adverse reactions (SUSARs) as defined in 21 CFR 312.32 and 
determined by the IND Sponsor will be reported to US FDA and all participating Investigators as 
IND Safety Reports.  
 
The IND Sponsor will submit an Annual Report of the progress of the investigation to the US 
FDA and Mexico COFEPRIS as required. 
 
AEs that are also UPs will be summarized by the IND Sponsor and distributed to Investigators. 
 
8.7 
Safety Monitoring 
8.7.1 
Investigator Safety Monitoring 
Investigators participating in this clinical trial are responsible for: 
◦ 
Protecting the safety and welfare of subjects 
◦ 
Evaluating subject safety, including physician assessment of AEs for seriousness, 
severity, and causality 
◦ 
Notifying the sponsor of SAEs and immediately-reportable events (per 8.3) 
◦ 
Providing detailed written reports, including confirmatory tests promptly following 
immediate initial reports 
◦ 
Informing the IRB/IEC of SAEs as required by applicable regulatory requirements 
 


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8.7.2 
Protocol Team Monitoring 
The protocol team will review the enrollment and study-related safety data (AEs and SAEs) from 
all sites periodically during the study. These reviews will occur at a minimum twice monthly 
during active enrollment and follow-up.  
 
8.7.3 
Sponsor Medical Monitor 
A Medical Monitor, representing the IND Sponsor, has been appointed for oversight of safety in 
this clinical study. The Sponsor Medical Monitor will be responsible for performing safety 
assessments as outlined in a Safety Review and Communications Plan (SRCP) (see Section 
8.7.6).  
 
8.7.4 
Pausing Rules 
The following automatic pausing rules to suspend study drug administration are in place for this 
study: 
o 2 (or more) subjects experience the same Grade 4 AE and/or SAE that is unexpected 
and possibly, probably, or definitely related to the study drugs OR 
o 4 (or more) subjects experience the same Grade 3 or higher AE that is unexpected and 
possibly, probably, or definitely related to the study drugs 
• If any of pausing rules are triggered, the following will occur: 
o The Sponsor’s Medical Monitor will undertake a review of cumulative AE data 
within 72 hours of being made aware of the events specified above, AND 
o The DSMB will be notified of the above Medical Monitor review, and of the Medical 
Monitor’s findings.   
• If the Medical Monitor is unable to complete the review of the safety data within 72 hours of 
awareness by the Clinical Safety Office, study enrollment will be halted until the review can 
take place. The DSMB will again be notified of any such review, and of the findings of the 
Sponsor’s Medical Monitor.  In the event of a study pause, after the above appropriate 
review, the sponsor in consultation with the Sponsor’s Medical Monitor may allow 
enrollment or ask the DSMB for a review of the safety data. 
• The IND Sponsor, in collaboration with the PI, may also pause for an individual subject or 
entire group if a safety concern is identified during routine aggregate data analysis. 
 
8.7.5 Reporting a Pause 
If a pausing requirement is met, a description of the adverse event(s) or safety issue must be 
reported by the Site Investigator by fax or email within one business day to the Sponsor CSO, PI, 
the IRB, and the DSMB. 
 
The IND Sponsor will notify all sites that the study has been paused. 
 
8.7.5.1 Review of Pauses and Resuming Rules 
The site IRB/IECs will be notified by the site PI of any study pause, and the DSMB will be 
notified by the study chair of any study pause. The IND Sponsor, in consultation with the 
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resume or close the study for events that meet the criteria for stopping the study. As part of the 
review, the reviewers will also advise on whether the study needs to be paused again for any 
subsequent event of the same type. The IND Sponsor will notify the Site Investigators of this 
decision. The Site Investigators will notify their local IRB(s) of the decision to resume 
administration of the study agent prior to resumption. 
 
The reviewing IRB/IEC has the right to pause enrollment at the sites it is responsible for at any 
time. 
 
8.7.6 
Safety Review and Communications Plan (SRCP) 
A Safety Review and Communication Plan (SRCP) has been developed for the protocol. The 
SRCP is an internal communications document which delineates the safety oversight 
responsibilities of the Protocol chairs, the CSO, and other stakeholders. The SRCP also includes 
the overall plan for conducting periodic safety surveillance assessments.  
 
8.7.7 
Data and Safety Monitoring Board 
 
The DSMB will review and approve a detailed DSMB monitoring plan before the study 
commences. The Board will review the study per the monitoring plan, but as long as subjects are 
enrolled into the study, the Board will review the study at least annually, and may convene 
additional reviews as necessary.  The Board will review the study data to evaluate the safety, 
efficacy, study progress, and conduct of the study. All SAEs, all unanticipated problems, and all 
IND Safety Reports will be reported by the PI to the DSMB at the same time they are submitted 
to the IRB or IND Sponsor. The PI will notify the DSMB of any cases of intentional or 
unintentional unblinding as soon as possible. The PI will notify the Board at the time pausing or 
halting criteria are met and obtain a recommendation concerning continuation, modification, or 
termination of the study. The PI will submit the written DSMB summary reports with 
recommendations to the IRB(s).  
 
The DSMB will review study-related data at the following intervals: 
◦ 
Before enrollment 
◦ 
Periodic safety review during the study, at least twice a year 
 
These reviews may contain data that have not been monitored and therefore not verified against 
the source documents. Details of the review will be provided in the DSMB monitoring plan. A 
copy of the randomization codes will be provided to the DSMB executive secretary in a sealed 
envelope in case the DSMB requires this information to make its recommendation. 
 
8.7.7.1 Interim Analysis 
The study will undertake a formal interim efficacy examination.  An unblinded statistician that is 
not associated with a site, not part of the protocol team and not part of the operational support for 
this study will perform this analysis. 
 


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After half of the total sample size has completed 28 days of follow-up, primary analysis using 
the Fay-Shaw statistic (13) will be conducted.  The study will be stopped for benefit if the one-
sided p-value for benefit is less than .001.  The study will be stopped for futility if the one-sided 
p-value for harm is less than .025. 
9 
STATISTICAL CONSIDERATIONS 
This section briefly describes the statistical analyses to be used for the study. A Statistical 
Analysis Plan will provide further details. 
9.1 
General Considerations 
This is a double-blind, randomized, placebo, controlled trial in patients with hospitalized 
influenza-like-illness to evaluate the efficacy of NTZ compared to placebo on the time to 
hospital discharge.  The primary analysis will use the Shaw-Fay formulation of the 2 sample 
Mann-Whitney-Wilcoxon rank-sum statistic.  The primary endpoint will be time to hospital 
discharge, censored at 28 days.  Patients who withdraw consent will be counted as being 
censored at the time of withdrawal.  Patients who die by Day 28 will receive the worst ranks, 
(i.e., worse than any patients who remain hospitalized).  Furthermore, patients who die earlier 
will receive worse ranks than those who die later.  Patients who withdraw consent prior to day 28 
are thus censored for death and discharge at the time of withdrawal.  Such censoring is addressed 
by the method of Shaw and Fay (2013).  A permutation method will be used to determine 
statistical significance.  The primary analysis will follow the intent-to-treat principle where all 
randomized patients will be used in the analysis.  The primary analysis will use a two-sided 
alpha level of .05.     
9.2 
Sample Size and Power Calculations 
Sample size calculations are based on the primary endpoint only (i.e. Duration of 
hospitalization). Secondary endpoints may or may not be adequately powered with the chosen 
sample size. 
 
When there is no censoring or deaths, power for the two-sample Mann-Whitney-Wilcoxon rank-
sum test can be approximated assuming that days of hospitalization follows a log normal 
distribution. The parameters used in the calculation were from the observed distribution of days 
to hospital discharge for hospitalized subjects who enrolled in the ILI002 observational study. 
We obtained data on patients who survived with hospitalization less than 28 days. The data were 
truncated at 28 days to avoid the influence of aberrant values on the estimates.  This eliminated 
about 4% of the data.  The mean and variance of the days in the hospital were 7.7 and 33.2.  We 
assumed that the effect of treatment would be to reduce the number of days in the hospital by 
Delta but that there would be no effect of treatment on the variance of the number of days in the 
hospital.  Thus for the treatment group the mean and variance are given by 7.7-Delta and 33.2, 
where Delta is varied.  We next assume that the distribution of days to hospital discharge 
followed a log-normal distribution in each group, which is equivalent to assuming that the 
log(Days) follows a normal distribution, where Days is the number of days until hospital 
discharge.  A log-normal distribution is specified by its moments E{log(Days)} = m and 
var(log(Days)=v.  These moments are related to the mean, E(D), and variance, V(D), of the 
number of days (D) in the hospital by the formulas.     
 




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Important additional analyses will be to repeat the primary analysis for those who are influenza 
positive.  Other subgroups include age (<12 years of age, ≥12 years of age) and pathogen type. 
9.3 
Subject Populations 
Intention to Treat (ITT) Population: The ITT population will consist of all participants who are 
randomized and received at least 1 dose of the study drug. For interim reviews, this will be 
limited to data entered into the electronic database up to the cut-off date. 
9.4 
Statistical Analysis  
The Statistical Analysis Plan will provide the procedure for accounting for missing, unused, and 
spurious data. 
 
10 
DATA MANAGEMENT AND MONITORING 
10.1 
Study Monitoring 
The trial will be conducted in compliance with this protocol, International Conference on 
Harmonization (ICH) Guidelines for Good Clinical Practice (GCP), the Food and Drug 
Administration’s (FDA) Code of Federal Regulations (CFR) and any applicable regulatory 
requirement(s). This study monitoring will be conducted according to the “NIAID Intramural 
Clinical Monitoring Guidelines.” Monitors under contract to the NIAID will visit the clinical 
research site to monitor all aspects of the study in accordance with the appropriate regulations. 
The objectives of a monitoring visit will be:  
1. To verify the prompt reporting of all data points, including reporting SAEs, and also to 
check the availability of signed informed consent. 
2. To compare individual subjects records and the source documents (supporting data, 
laboratory specimen records and medical records to include physician progress notes, 
nurse’ notes, subjects’ hospital charts). 
3. To ensure compliance with the protocol, and accuracy and completeness of records. 
 
The monitors also will inspect the clinical site regulatory files to ensure that regulatory 
requirements (Mexican and US) are being followed. During the monitoring visits, the 
Investigator (and/or designee) and other study personnel will be available to discuss the study 
progress and monitoring visit.  The Sponsor will retain original copies of the Form FDA 1572 
and copies of other study documents as deemed necessary.   
 
The Investigator (and/or designee) will make study documents (e.g., consent forms and eCRFs) 
and pertinent hospital or clinical records readily available for inspection by the local IRB/IEC, 
the local and national regulatory authorities, the US FDA, the site monitors, and the NIAID staff 
for confirmation of the study data.  
 
10.2 
Source Documents 
The primary source document for this study will be the subject’s medical record. If the 
Investigators maintain separate research records, both the medical record and the research 
records will be considered the source documents for the purposes of auditing the study. The 


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investigator will retain the source documents. The Investigator will permit monitoring and 
auditing of this data, and will allow NIAID, IRB/IEC, and regulatory authorities access to the 
original source documents, regardless of media. 
 
The Investigator is responsible for assuring that the data collected is complete, accurate, and 
recorded in a timely manner. Source documentation (the point of initial recording of information) 
should support the data collected on the eCRF. All eCRFs should be reviewed by the Investigator 
and signed as required with written or electronic signature, as appropriate. Data for eCRFs will 
be collected directly from subjects, clinical assessments, and tests during study visits or will be 
abstracted from subjects’ medical records. The subject’s medical record must record his/her 
participation in the clinical trial, including obtaining informed consent, concomitant medications 
(with doses and frequency), medical interventions or treatments that were administered, and 
adverse reactions experienced during the trial. 
10.3 
Data Management Plan 
Study data will be collected at the study site(s) and maintained on eCRFs. These forms are to be 
completed on an ongoing basis during the study. Corrections on any study related source record 
must be made by striking through the incorrect entry with a single line (taking care not to 
obliterate or render the original entry illegible) and entering the correct information adjacent to 
the incorrect entry. Corrections to paper sources must be initialed and dated by the person 
making the correction. 
10.4 
Data Capture Methods 
Clinical data will be entered into an Internet Data Entry System (IDES) (US 21 CFR 11-
compliant). The data system includes password protection and internal quality checks, to identify 
data that appear inconsistent, incomplete, or inaccurate.  
10.5 
Study Record Retention 
The Investigator is responsible for retaining all essential documents listed in the ICH Good 
Clinical Practice Guideline. The US FDA requires study records to be retained for up to 2 years 
after marketing approval or disapproval (21 CFR 312.62), or until at least 2 years have elapsed 
since the formal discontinuation of clinical development of the investigational agent for a 
specific indication. These records are also to be maintained in compliance with IRB/EC, state, 
and federal medical records retention requirements, whichever is longest.  
 
All stored records are to be kept confidential to the extent provided by federal, state, and local 
law. It is the Investigator’s responsibility to retain copies of source documents until receipt of 
written notification to the contrary from OCRPRO/NIAID. No study document should be 
destroyed without prior written agreement between OCRPRO /NIAID and the Principal 
Investigator. Should the Investigator wish to assign the study records to another party and/or 
move them to another location, the Investigator must provide written notification of such intent 
to OCRPRO /NIAID with the name of the person who will accept responsibility for the 
transferred records and/or their new location.  
 
NIAID must be notified in writing and written NIAID permission must be received by the site 
prior to destruction or relocation of research records. 


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11 
HUMAN SUBJECTS 
11.1 
IRB/IEC Approval 
This protocol, informed consent document, diary card, relevant supporting information, and all 
types of patient recruitment or advertisement information must be submitted to the IRB/IEC for 
review and must be approved before the study is initiated. 
 
Any amendments must also be approved by the IRB/IEC prior to implementing changes in the 
study. 
 
The Investigator is responsible for keeping the IRB/IEC appraised of the progress of the study as 
deemed appropriate, but in any case at least once a year. The Investigator must also keep the 
IRB/IEC informed of any significant AEs. 
11.2 
Compliance with Good Clinical Practices (GCP) 
This study will be conducted in compliance with the conditions stipulated by NIAID and local 
IRB/IEC, informed consent regulations, US FDA and local regulatory agencies, and supported 
by ICH/GCP guidelines. In addition, all local regulatory requirements will be adhered to, in 
particular those which afford greater protection to the safety of the trial subjects. 
11.3 
Informed Consent Process 
Informed consent is a process where information is presented to enable persons to voluntarily 
decide whether or not to participate as a research subject. It is an on-going conversation between 
the human research subject and the researchers about the essential information about the study, 
which begins before consent is given and continues until the end of the subject's involvement in 
the research. Discussions of essential information about the research will include the study's 
purpose, duration, experimental procedures, alternatives, risks, and benefits, and subjects will 
have the opportunity to ask questions and have them answered. 
 
The participants will sign the informed consent document prior to any procedures being done 
specifically for the study. The participants may withdraw consent at any time throughout the 
course of the trial. A copy of the informed consent document will be given to the participants for 
their records. The researcher will document the signing of the consent form in the subject’s 
medical record. The rights and welfare of the participants will be protected by emphasizing to 
them that the quality of their medical care will not be adversely affected if they decline to 
participate in this study. 
 
Children will receive an assent according to their institutional and or IRB/EC requirements. 
 
11.4 
Anonymity and Confidentiality 
The information obtained during the conduct of this clinical study is confidential. The results of 
the research study may be published, but patient names or identities will not be revealed. 
Records will remain confidential. To maintain confidentiality, the investigators at each site will 
keep records in locked cabinets and the results of tests will be coded to prevent association with 
the subject’s names. 


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11.5 
Compensation 
 
Each site is responsible for generating a compensation scheme as applicable (accounting for 
travel cost and time lost from work for outpatient visits), and that fits the local legal and 
regulatory requirements as well as the cultural norm. Any compensation must be reviewed by the 
local IRB/IEC.   
12 
STORED SPECIMENS, AND DATA 
12.1 
Samples/Specimens 
The samples collected during this study are for clinical laboratory and virologic (respifinder) 
testing only.  No samples are stored as part of this protocol.   
12.2 
Storage of Data 
Data will be stored using codes assigned by the sponsor. Data will be kept in password-protected 
computers, which are located in locked rooms.  
 
12.3 
Storage of Genetic Sample 
No samples are being stored for genetic testing on the subjects.   
12.4 
Reporting Loss or Destruction of Samples/Specimens/Data 
Any loss or unanticipated destruction of data (for example, misplacing a printout of data with 
identifiers) will be reported to the corresponding IRB/IECs. 
 
Any inadvertent release or unanticipated destruction of centrally maintained data will be reported 
to all IRB/IECs. 
 
 


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13 
REFERENCES 
1. 
Ruuskanen O, Lahti E, Jennings LC, Murdoch DR. Viral pneumonia. Lancet 
2011;377(9773):1264–75.  
2. 
Jennings LC, Anderson TP, Beynon KA, et al. Incidence and characteristics of viral 
community-acquired pneumonia in adults. Thorax 2008;63(1):42–8.  
3. 
Johansson N, Kalin M, Tiveljung-Lindell A, Giske CG, Hedlund J. Etiology of 
community-acquired pneumonia: increased microbiological yield with new diagnostic 
methods. CLIN INFECT DIS 2010;50(2):202–9.  
4. 
Templeton KE, Scheltinga SA, van den Eeden WCJFM, Graffelman AW, van den Broek 
PJ, Claas ECJ. Improved diagnosis of the etiology of community-acquired pneumonia 
with real-time polymerase chain reaction. CLIN INFECT DIS 2005;41(3):345–51.  
5. 
Huijskens EGW, van Erkel AJM, Palmen FMH, Buiting AGM, Kluytmans JAJW, Rossen 
JWA. Viral and bacterial aetiology of community-acquired pneumonia in adults. Influenza 
Resp Viruses 2013;7(4):567–73.  
6. 
Saito A, Kohno S, Matsushima T, et al. Prospective multicenter study of the causative 
organisms of community-acquired pneumonia in adults in Japan. J Infect Chemother 
2006;12(2):63–9.  
7. 
Lahti E, Peltola V, Waris M, et al. Induced sputum in the diagnosis of childhood 
community-acquired pneumonia. Thorax 2009;64(3):252–7.  
8. 
Honkinen M, Lahti E, Österback R, Ruuskanen O, Waris M. Viruses and bacteria in 
sputum samples of children with community-acquired pneumonia. Clin Microbiol Infect 
2012;18(3):300–7.  
9. 
Juvén T, Mertsola J, Waris M, et al. Etiology of community-acquired pneumonia in 254 
hospitalized children. Pediatr Infect Dis J 2000;19(4):293–8.  
10. 
Tsolia MN, Psarras S, Bossios A, et al. Etiology of community-acquired pneumonia in 
hospitalized school-age children: evidence for high prevalence of viral infections. CLIN 
INFECT DIS 2004;39(5):681–6.  
11. 
Cilla G, Oñate E, Perez-Yarza EG, Montes M, Vicente D, Perez-Trallero E. Viruses in 
community-acquired pneumonia in children aged less than 3 years old: High rate of viral 
coinfection. J Med Virol 2008;80(10):1843–9.  
12. 
Galindo-Fraga A, Ortiz-Hernández AA, Ramirez-Venegas A, et al. Clinical characteristics 
and outcomes of influenza and other influenza-like illnesses in Mexico City. Int J Infect 
Dis 2013; 
13. 
Rossignol J-F, La Frazia S, Chiappa L, Ciucci A, Santoro MG. Thiazolides, a new class of 
anti-influenza molecules targeting viral hemagglutinin at the post-translational level. J 


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Biol Chem 2009;284(43):29798–808.  
14. 
Shaw, PA, and Fay, MP.  Rank tests for time-to-event data that incorporate information on 
both a true and surrogate event. (unpublished) 
15.  
Vincent JL, de Mendonca A, Cantraine F, Moreno R, Takala J, Suter PM, Sprung CL, 
Colardyn F, Blecher S: Use of the SOFA score to assess the incidence of organ 
dysfunction/failure in intensive care units: results of a multicenter, prospective study. 
Working group on "sepsis-related problems" of the European Society of Intensive Care 
Medicine. Crit Care Med 1998, 26(11):1793-1800. 
16. 
Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, Reinhart CK, 
Suter PM, Thijs LG: The SOFA (Sepsis-related Organ Failure Assessment) score to 
describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related 
Problems of the European Society of Intensive Care Medicine. Intensive Care Med 1996, 
22(7):707-710. 
17. 
Pandharipande PP, Shintani AK, Hagerman HE, St Jacques PJ, Rice TW, Sanders NW, 
Ware LB, Bernard GR, Ely EW: Derivation and validation of Spo2/Fio2 ratio to impute 
for Pao2/Fio2 ratio in the respiratory component of the Sequential Organ Failure 
Assessment score. Crit Care Med 2009, 37(4):1317-1321. 
18. 
Martinez R, Maggiolo J, Girardi G, Mora F, Carreno V, Mascaro J. Frecuencia 
respiratoria en lactantes y preescolares sanos y con infeccion respiratoria aguda. Enf 
Respir Cir Torac 1990;6:134–140. 
19.  
Based on Product Information: AliniaR, nitazoxanide tablets and oral suspension. Romark 
Pharmaceuticals, Tampa, Fl, USA, 2005. Available  in: MICROMEDEX® 2.0 and 
MICROMEDEX® 1.0 (Healthcare Series). 
 
20. 
Rossignol JF, Abu-Zekry M, Husssein A and Santoro G. Effect of nitazoxanide for 
treatment of severe rotavirus dairrhoea: randomised double-blind placebo-controlled trial. 
Lancet 2006; 368 (8): 124-129. 
 
21.   Abaza H, El-Zayadi AR, Kabil SM, et al. Nitazoxanide in the treatment of Subjects with 
intestinal protozoan and helminthic infections: A report on 546 Subjects in Egypt. Current 
Therapeutic Res 1998; 59(2):116-121. 
22. 
World Health Organization’s (WHO) case definition for SARI (and as amended). 
http://who.int/influenza/surveillance_monitoring/ili_sari_surveillance_case_definition/en/) 
23. 
Haffizulla J, Hartman A, Hoppers M, Resnick H, Samudrala S, Ginocchio C, Bardin M, 
Rossignol JF; US Nitazoxanide Influenza Clinical Study Group. Effect of nitazoxanide in 
adults and adolescents with acute uncomplicated influenza: a double-blind, randomised, 
placebo-controlled, phase 2b/3 trial. Lancet Infect Dis. 2014 Jul;14(7):609-18. 

SAP_000.pdf: 
Statistical Analysis Plan: NTZ-SARI 
 
Page 1 of 13  
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Statistical Analysis Plan 
 
A Randomized Double-Blind Phase 2 Study Comparing the Efficacy, Safety, and 
Tolerability of Nitazoxanide Versus Placebo in Addition to Standard Care for the 
Treatment of Hospitalized Subjects with Severe Acute Respiratory Illness  
 (NTZ-SARI) 
 (Based on Protocol Version 5 dated 16 September 2016) 
 
Introduction 
This document describes the content proposed for the primary statistical analysis of NTZ-SARI.  The 
focus is on analyses that address the major randomized comparisons for key safety, tolerability and 
efficacy outcome measures, including those needed to address the study’s primary objective as well as 
secondary objectives. 
 
Table of Contents 
Table of Contents ................................................................................................................................... 1 
Study Background and Objectives .......................................................................................................... 2 
Study Objectives .................................................................................................................................... 2 
Study Endpoints: .................................................................................................................................... 3 
Analysis Plan ......................................................................................................................................... 4 
Subject Populations ............................................................................................................................ 4 
1. 
Accrual, eligibility violations and exclusions from analyses  ....................................................... 5 
2. 
Accrual, eligibility violations and exclusions from analyses  ....................................................... 5 
3. 
Selected characteristics of participants at baseline (Day 0) .......................................................... 5 
4. 
Study status of participants and loss to follow-up ........................................................................ 6 
5. 
Study drug receipt  ...................................................................................................................... 6 
6. 
Concomitant medications  ........................................................................................................... 7 
7. 
Mortality..................................................................................................................................... 7 
8. 
Serious Adverse Events .............................................................................................................. 7 
9. 
Adverse Events ........................................................................................................................... 8 
10. 
Laboratory Values................................................................................................................... 8 
11. 
Primary Endpoint .................................................................................................................... 8 
12. 
Secondary Endpoints .............................................................................................................. 9 
Appendix 1........................................................................................................................................... 12 


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Study Background and Objectives 
 
Respiratory viruses are a significant cause of hospitalization for respiratory tract infections. Etiologic 
agents include influenza, parainfluenza virus, rhinovirus, adenovirus, metapneumovirus, respiratory 
syncytial virus (RSV), bocavirus and coronavirus.  Of these, only influenza has a licensed treatment.  
Nitazoxanide (NTZ) is a licensed anti-infective agent with activity against many of these respiratory 
viruses.  In a pediatric Phase 2 study of outpatient ILI, the NTZ cohort showed symptom resolution in 4 
days versus 7 days in the placebo group.  In a 624 person Phase 3 study of ILI, the NTZ cohort showed 
symptom resolution in 94 h compared to 108 h in the placebo group (p=0.0026). These benefits were 
observed in the entire cohort, not just those infected with influenza.  If similar efficacy can be seen in 
the inpatient ILI population, there could be reductions in duration of hospitalization, morbidity, and 
costs.   
 
The study is a multicenter, randomized, double-blind, placebo controlled trial to evaluate the efficacy of 
NTZ + standard of care (SOC) compared to placebo (PCB) + SOC in treating acute severe viral 
respiratory infections in adults and children ≥12 months old with SARI. It is anticipated that SOC would 
likely include antibiotics and may include treatment for influenza.  The study is designed to enroll a total 
of 290 subjects who will be randomized in a 1:1 ratio. Subjects will be followed on Days 3, 7, 14, and 
28. The subject will be discharged from the hospital when clinically indicated as determined by the 
treating physician – follow-up visits may occur as inpatients or as outpatients.  Subjects still hospitalized 
on Day 28 will be followed until discharged from the hospital. 
 
Study Objectives 
Primary Objective: Evaluate the effect of NTZ in addition to SOC as compared to PCB + SOC in the 
treatment of SARI as measured by the time to hospital discharge 
 
Secondary Objectives:  
1.  Evaluate the clinical efficacy of NTZ + SOC vs. PCB + SOC with regards to: 
• Percent hospitalized at Study Day 3, 7, 14 and 28 
• Death by Study Day 28 
• Duration of clinical symptoms (defined in Section 7.3.1.2) 
• Duration of fever 
• Use of supplemental oxygen (or increase greater than baseline oxygen requirement) 
• Admission to ICU 
• Intubation/mechanical ventilation 
• Proportion of subjects who develop complications including pneumonia, respiratory failure 
requiring mechanical ventilation, acute respiratory distress syndrome (ARDS), sepsis, or 
bronchiolitis. 
• Time to resumption of normal activity  
• Antibiotic/antiviral use during hospitalization  
• Systemic corticosteroid use during hospitalization  
• Re-hospitalization within 28 days 
 
2.   Evaluate the virologic efficacy of NTZ + SOC vs. PCB + SOC with regards to: 
• Percent cessation of viral shedding at Study Day 3 


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3.  Evaluate the safety and tolerability of NTZ assessed by: 
• Cumulative incidence and severity of adverse events (AEs) 
• Cumulative incidence of serious AEs (SAEs) 
• Cumulative incidence of laboratory abnormalities on Study Days 3, 7 and 28 
 
Study Endpoints: 
Primary Endpoint: 
• Duration of hospitalization (days and hours) 
 
Secondary Endpoints:  
Clinical Endpoints: 
• Hospitalization on Study Days 3, 7, 14, and 28 
• Date and time of hospital discharge 
• Date of death, if applicable  
• Clinical symptoms (measured daily through Study Day 14 and then again on Study Day 28) 
• Temperature (measured daily through Study Day 14 and then again on Study Day 28) 
• Oxygen use 
• Date of admission to ICU and discharge from ICU, if applicable 
• Date of intubation/extubation, if applicable 
• Presence of complications during study (pneumonia, respiratory failure requiring mechanical 
ventilation, ARDS, sepsis, or bronchiolitis) 
• Global assessment (measured daily through Study Day 14 and then again on Study Day 28) 
(defined in Section 7.3.1.3) 
• Antibiotic/antiviral use during hospitalization (number and duration) 
• Re-hospitalization within 28 days 
• Use of systemic corticosteroids 
  
Virologic Endpoints: 
• Presence of virus on nasopharyngeal (NP) swab (or aspirate) at Study Day 3 (same virus as Day 
0) 
 
Safety Endpoints: 
• AEs 
• SAEs 
• Chemistry and hematologic laboratory assessments on Study Days 3, 7 and 28 
 


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Analysis Plan 
Subject Populations 
Here we give the definitions for the populations that will be referred to for different analyses. 
• Enrolled: all subjects that signed consent 
• Intention to Treat (ITT) population: per protocol defined as all participants who are randomized 
and received at least 1 dose of the study drug, and for analysis the treatment group will be 
assigned as randomized.  
• ITT age subgroups (only on specified analyses): 
o Adults ≥ 18 years 
o Children aged <18 years 
• ITT pediatric formulation subgroups (only on specified analyses; may be omitted depending on 
the number of subjects enrolled in each pediatric subgroup): 
o Children ≥ 13 years and <18 years (children that take the adult tablet formulation)  
o Children aged <13 years (as this is the age for pediatric formulation) 
• ITT virology subgroups (only on specified analyses): 
o Influenza A or B 
§ Influenza A  
§ Influenza B  
o RSV  
o Human Metapneumovirus  
o Rhinovirus/Enterovirus  
o Adenovirus  
o Mycoplasma pneumoniae  
o Chlamydophila pneumoniae  
o Legionella pneumophila  
o Bordetella pertussis  
o Parainfluenza  
o Bocavirus  
o Coronavirus  
 
 
 


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Table and Figure presentation 
Results in figures and tables will be presented  
• all subjects (total) 
• by randomized arm 
Number in brackets [] represents corresponding table number 
 
1. Accrual, eligibility violations and exclusions from analyses (Enrolled)  
• Table: Number enrolled: overall and by month/year and by institution.  Dates of first and last 
subjects screened. [14.1.1.1] 
• Figure: Number enrolled, by month/year 
• Table: Screen failures, and number of subjects for each inclusion and exclusion criteria. 
[14.1.1.2] 
• List: description of subjects screened and excluded from the ITT: Randomized arm, study drug 
received (yes or no), site, age, subject ID, subject’s study status (completed study, died, 
discontinued early from study), reason for exclusion. 
 
2. Accrual, eligibility violations and exclusions from analyses (ITT and ITT age subgroup) 
• Table: Number randomized: overall and by month/year and by institution.  Dates of first and last 
randomizations.  [14.1.1.3] 
• Figure: Number randomized, by month/year.  Note the date of data lock for interim efficacy 
analysis.  
• List: Description of violations of eligibility criteria among subjects randomized: Randomized 
arm, study drug received (yes or no), site, age, subject ID, subject’s study status (completed 
study, died, discontinued early from study), reason for violation as noted by site. 
 
3. Selected characteristics of participants at baseline (Day 0) (ITT) 
Baseline is defined as the last observation prior to study drug administration. P-values using the test of 
means for continuous variables, test of proportions for binary endpoints or chi-square tests for 
categorical endpoints  
• Demographics [14.1.3] 
o Table: Age (median, 25th and 75th percentile, mean, min, max) 
o Table: number randomized by age group (<2 years, ≥2 years to <8 years, ≥8 years to <13 
years, ≥13 years to <18 year, ≥18 years to <65 years, ≥65 years). 
o Sex (%) 
o Self-reported NIH race/ethnicity (%) 
o Medical History (occurring in 5% or more of the study population) 
o BMI for adults age ≥18 years 
o Z score for age <18 years 
o Smoking History 
• Baseline Disease Characteristics [14.1.4.1, 14.1.4.2, 14.1.4.3, 14.1.4.4] 
o Influenza vaccination history (categorical - vaccinated the season of enrollment) 
o Confirmed pathogen by multiplex PCR (i.e. RespifinderÒ).  Include totals for pathogen 
type (e.g. all influenzas), and for each strain (e.g., H1N1 influenza) 
o Days since onset of symptoms (onset of symptoms to randomization).  
o Days since onset of symptoms to first dose.  
o SaO2  


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o Severity of illness score  
§ Sequential Organ Failure Assessment (SOFA) score for subjects ≥ 24 months of 
age 
§ Tal bronchiolitis score for subjects < 24 months of age 
o Charlson comorbidity index.  
o Chronic oxygen use 
o Oxygen requirement (yes/no) 
o ICU requirement (yes/no) 
• Presence of Complications 
o Pneumonia (clinical diagnosis supported by radiographic data) 
o Respiratory failure requiring mechanical ventilation (documentation of mechanical 
ventilation) 
o ARDS (clinical diagnosis supported by radiographic data) 
o Sepsis (clinical diagnosis)  
o Bronchiolitis (clinical diagnosis) 
• Presence of symptoms for each of the following (defined as 2 or 3 = symptoms present): 
o Cough 
o Sore throat 
o Fatigue 
o Headache 
o Myalgia 
o Rhinorrhea 
o Nausea 
o Vomiting 
o Diarrhea  
• CBC with differential white cell count (to include neutrophil, lymphocyte, and eosinophil 
percentages), hemoglobin, hematocrit, and platelets 
• Blood chemistries (creatinine, ALT/GPT, AST/GOT, total bilirubin, LDH, CRP) 
• Global Assessment 
o Adult 
§ Overall question 
§ Function question 
o Pediatric 
§ Activity 
§ Diet 
 
4. Study status of participants and loss to follow-up (ITT) 
• Table: Number (%) for the following categories: [14.1.2] 
o Off study: completed study (completed day 28 visit or died prior to 28 days of follow-up) 
o Off study: died 
o Off study: lost to follow-up before completing 28 days of follow-up 
§ subcategories for each of the reasons for early discontinuation 
• List: subjects lost of follow-up and last date 
 
5. Study drug receipt (ITT) [14.2.1] 
• Table showing number (%) in following categories 


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o Full planned treatment 
o Partial treatment (by doses received – 9,8,7…etc.) 
• Listing of subjects that did not receive full planned treatment: subject ID, site, age, at request of 
study team, reason for not receiving full planned treatment.   
 
6. Concomitant medications (ITT)  
• Anti-influenza antivirals during first 5 days [14.3.4.1] 
o Table of influenza antivirals taken (y/N) 
o If yes: number (%) for each specific drug  
• Antibiotic during first 5 days [14.3.4.2] 
o Table of if antibiotics taken (Y/N) 
o If yes: number (%) for each specific drug  
§ Grouping by family 
§ Grouping by pathogens targeted (gram positive, gram negative, atypical, 
anaerobic) 
(note – groupings will be decided after study is closed to new enrollment by 
looking at pooled data but before study unblinding) 
• Systemic steroids during first 5 days [14.3.4.3] 
o Table of systemic steroids taken (y/N) 
o If yes: number (%) for each specific drug  
 
7. Mortality (ITT and ITT age subgroups)  
• Table: [14.3.3] 
o number (%) total deaths 
o deaths in first 5 days 
• List of deaths: Randomized arm, days from randomization to death, subject ID, site, age, primary 
cause of death, relatedness to study intervention. Sort by randomized arm, days from 
randomization to death and subject ID.   
• Figure and Analysis: Kaplan-Meier plot of time from randomization to death (censoring at 28 
days if completed follow-up, or at date of last contact if lost to follow-up prior to 28 days), with 
associated table showing: number censored and number (%) dying, median time to death and 
associated 95% confidence interval; p-value from log-rank test.  The estimated hazard ratio and 
associated 95% confidence interval comparing randomized arms will be obtained using a 
proportional hazards model applied to the times of death with censoring as above.   
 
8. Serious Adverse Events (ITT)  
• Table: [14.3.2.1]  Number (%) of subjects with an SAE by MedDRA System Organ Class (SOC) 
and Preferred Term (PT); number (%) of subjects with any SAE. In these tables, subjects with 
SAEs will be counted (e.g. counting a subject with multiple SAEs with the same PT only once 
for that PT). 
 
• Table: [14.3.2.2]Number of SAEs by MedDRA System Organ Class (SOC) and Preferred Term 
(PT); number (%) of SAEs. In these tables, SAEs will be counted (e.g. counting multiple SAEs 
with the same PT within the same subject). 
 


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• List of SAEs: Randomized arm, days from randomization to first SAE experienced by a subject, 
subject ID, site, age, days from start of study drug to SAE, SAE (MedDRA SOC and PT, and 
verbatim description), severity grade, relatedness to study intervention, outcome (sort by 
randomized arm, subject ID, MedDRA SOC and PT and, if a subject has multiple SAEs, days 
from randomization to SAE). This listing will include any SAE that occur after day 28 and are 
reported. 
• Listing of SAE after enrollment (informed consent) and not included in the ITT 
 
9. Adverse Events (ITT) 
• Table: [14.3.1.1] Number (%) of subjects with an AE by MedDRA System Organ Class (SOC) 
and Preferred Term (PT) and severity grade; number (%) of subjects with any AE. In this table, 
subjects with AEs will be counted (e.g. counting a subject with multiple AEs with the same PT 
only once for that PT). 
 
• Table: [14.3.1.2]  Number of AEs by MedDRA System Organ Class (SOC) and Preferred Term 
(PT) and severity grade; number (%) of AEs.  In this table, AEs will be counted (e.g. counting 
multiple AEs with the same PT within the same subject). 
 
• List of AEs: Randomized arm, days from randomization to first AE experienced by a subject, 
subject ID, site, age, days from start of study drug to AE, AE (MedDRA SOC and PT, and 
verbatim description), severity grade, relatedness to study intervention, outcome (sort by 
randomized arm, subject ID, MedDRA SOC and PT and, if a subject has multiple AEs, days 
from randomization to AE). This listing will include any AE that occur after day 28 and are 
reported. 
• Listing of AE after enrollment (informed consent) and not included in the ITT 
 
10. Laboratory Values (ITT and ITT age subgroups)  
The following should be performed for the protocol specified collection days of 0, 3, 7, and 28.  Figure  
and table  that includes  the  min, 25%tile , 50%tile, 75%tile, max, change from baseline and % change 
from baseline at each day for each of the following lab values. 
• CBC with differential white cell count (to include neutrophil, lymphocyte, and eosinophil 
percentages), hemoglobin, hematocrit, and platelets [14.3.5.1.x] 
• Blood chemistries (creatinine, ALT/GPT, AST/GOT, total bilirubin, LDH, CRP) [14.3.5.2.x] 
 
11. Primary Endpoint (ITT, ITT age subgroups, ITT pediatric formulation subgroups, ITT 
virology subgroups)  
Table to show the completeness of the primary endpoint should include number (%) with [14.2.2]: 
• Complete data (Day of hospitalization and discharge or death) 
• Incomplete data (missing day of hospitalization or discharge/death 
 
The following table and figure provide descriptive statistics of the primary endpoint. The table and 
figures should impute values of 28 days for patients who died and should censor patients with missing 
discharge date at the time of last follow up. 
• Figure: Kaplan-Meier plot of time to hospital discharge/death (only ITT and ITT age subgroups) 
• Table: with the following estimates from the Kaplan-Meier curves- 25th , 50th and  75th percentile 
along with  min and max values in hours [14.2.3.1.x] 


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o The between group difference in median time to discharge will be used to estimate the 
treatment effect and will be reported along with a 95% two-sided confidence interval. 
o Additionally, data from median, min, max converted to “days, hours” 
• The p-value for the 2 group comparison of the primary endpoint analysis will be performed using 
the Shaw-Fay method as described in appendix 1.  
• Sensitivity analyzes to exam effect of missing death or discharge data. (only ITT and ITT age 
subgroups) 
o Figure with Kaplan-Meier curves and Shaw-Fay p-values on the ITT only where missing 
death or discharge dates are imputed in the placebo group as censored at the time of last 
follow up and in the experimental group are imputed as events at day 28. 
o Figure with Kaplan-Meier curves and Shaw-Fay p-values on the ITT only where missing 
death or discharge dates are imputed in both groups as events at day 28. 
o For any imbalance seen in baseline characteristics (p<.05) perform a cox proportional 
hazards model with deaths receiving event times of 28 days. Missing discharge dates will 
be censored at last follow up time.  
 
12. Secondary Endpoint (ITT and ITT age subgroups) 
For secondary endpoints that test proportion: 
• Deaths are always counted as worst case (i.e. deaths are counted as being hospitalized through 
Day 28).   
• Missing data is analyzed in two ways: 
o Missing data is excluded after date of last follow-up. i.e. any analysis after the date of last 
follow up will exclude the missing subject from the denominator. This represents the 
“best case” for the missing data.  
o Missing data is assigned the worst case. i.e. for hospitalization, this missing data would 
be assumed to be hospitalized through Day 28. This represents the “worst case” scenario 
for the missing data.  
For secondary endpoints that are time to events, the Fay-Shaw method accounts for deaths and missing 
data.  In cases where the Fay-Shaw method is not appropriate, the Log-Rank p-value will be reported. 
  
 
• Percent hospitalized at Study Day 3, 7, 14 and 28 [14.2.3.2.x] 
o Table N (%) hospitalized at Study Day 3, 7, 14 and 28 and test of proportions 
o Figure of proportions at each time point 
• Duration of clinical symptoms [14.2.4.1.x] 
Subjects with 0-1 on all symptoms on Day 0 are considered to have a time of 0 hours.  
o Table: time (in hours) from symptom onset to symptom free (symptom free is 0-1 on all 
symptoms that last at least 2 days), noting min, 25%tile, 50%tile, 75%tile 
§ P-value obtained using Shaw-Fay method (here only treat deaths as worst rank 
and missing as censored) 
o Figure using Kaplan-Meier plot. 
 
• Duration of fever- defined as temperature ≥ 38.0 C [14.2.4.2.x] 
o Table: v with min, 25%tile, 50%tile, 75%tile, max.   
§ P-value obtained using Shaw-Fay method (here only treat deaths as worst rank 
and missing as censored) 


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o Figure using Kaplan-Meier plot. 
 
• Use of supplemental oxygen (or increase greater than baseline oxygen requirement) [14.2.5.1.x] 
o Resolution is defined as off oxygen   Subjects without stop date will be censored at 28 
days.  A time of 00:00 will be imputed for subjects with a stop date but missing stop time. 
o Table N (%) of use of oxygen (Y/N) at any point during the study, and at each time point 
§ P-value obtained using test of proportions 
o Figure of proportions at each time point 
o Table duration of oxygenation: defined as time of oxygen first administered, to time off 
oxygen (in hours) noting min, 25%tile, 50%tile, 75%tile, max [14.2.5.2.x] 
§ Table includes all subjects – where subjects not requiring oxygen have 0 hours. 
§ P-value obtained using Shaw-Fay method (here only treat deaths as worst rank 
and missing as censored) 
o Table duration of oxygenation: defined as time of oxygen first administered, to time off 
oxygen (in hours) noting min, 25%tile, 50%tile, 75%tile, max  [14.2.5.3.x] 
§ Table is restricted to those requiring oxygen at any point during the study.  
§ P-value obtained using Shaw-Fay method (here only treat deaths as worst rank 
and missing as censored) 
o Figure using Kaplan-Meier plot 
§ Figure includes all subjects – where subjects not requiring oxygen have 0 hours. 
§ Figure is repeated, but restricted to those requiring oxygen at any point during the 
study.  
 
• Admission to ICU  
o Table N (%) of requiring ICU (Y/N) at any point during the study, and at each time point 
[14.2.6.1.x] 
§ P-value obtained using test of proportions 
o Figure of proportions at each time point 
o Table duration of ICU: defined as time subject admitted to ICU, to time discharged from 
ICU (in hours) noting min, 25%tile, 50%tile, 75%tile, max [14.2.6.2.x] 
§ Table includes all subjects – where subjects not requiring ICU have 0 hours. 
§ P-value obtained using Shaw-Fay method (here only treat deaths as worst rank 
and missing as censored) 
o Table duration of ICU: defined as time subject admitted to ICU, to time discharged from 
ICU (in hours) noting min, 25%tile, 50%tile, 75%tile, max [14.2.6.3.x] 
§ Table is restricted to those requiring ICU at any point during the study.  
§ P-value obtained using Shaw-Fay method (here only treat deaths as worst rank 
and missing as censored) 
o Figure using Kaplan-Meier plot 
§ Figure includes all subjects – where subjects not requiring ICU have 0 hours. 
§ Figure is repeated, but restricted to those requiring ICU at any point during the 
study 
 
• Intubation/mechanical ventilation 
o Table N (%) of requiring mechanical ventilation (Y/N) at any point during the study, and 
at each time point [14.2.7.1] 


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§ P-value obtained using test of proportions 
o Figure of proportions at each time point 
o Table duration of mechanical ventilation: defined as time subject placed on mechanical 
ventilation, to time extubated (removed from mechanical ventilation) noting min, 
25%tile, 50%tile, 75%tile, max [14.2.7.2.x] 
§ Table includes all subjects – where subjects not requiring mechanical ventilation 
have 0 hours. 
§ P-value obtained using Shaw-Fay method (here only treat deaths as worst rank 
and missing as censored) 
o Table duration of mechanical ventilation: defined as time subject placed on mechanical 
ventilation, to time extubated (removed from mechanical ventilation) noting min, 
25%tile, 50%tile, 75%tile, max [14.2.7.3.x] 
§ Table is restricted to those requiring mechanical ventilation at any point during 
the study.  
§ P-value obtained using Shaw-Fay method (here only treat deaths as worst rank 
and missing as censored) 
o Figure using Kaplan-Meier plot 
§ Figure includes all subjects – where subjects not requiring mechanical ventilation 
have 0 hours. 
§ Figure is repeated, but restricted to those requiring mechanical ventilation at any 
point during the study 
 
• Proportion of subjects who develop complications including pneumonia, acute respiratory 
distress syndrome (ARDS), sepsis, or bronchiolitis at Day 3, 7, 14 and 28 
o Table for any complication: restricted to those subjects without any at baseline 
[14.2.8.1.x] 
o Figure of proportions at each time point 
o Table for each complication: restricted to those subjects without that complication at 
baseline [14.2.8.2.x] 
§ Pneumonia 
§ Respiratory failure requiring mechanical ventilation  
§ ARDS  
§ Sepsis  
§ Bronchiolitis  
o Figure of proportions at each time point 
 
• Global assessment [14.2.9.x] 
o Table duration (days) from enrollment until stating the first affirmative to global 
assessment questions  
§ P-value obtained using Shaw-Fay method (here only treat deaths as worst rank 
and missing as censored) 
o Figure using Kaplan-Meier plot (time until stating the first affirmative). 
o There are two global assessment questions for adults and two global assessment questions 
for children.  Each of these four questions will be analyzed separately.  
 
• Antibiotic/antiviral use during hospitalization [14.2.10] 


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o Table N (%) of subjects with an antibiotic starting on or after Day 3 
§ P-value obtained using test of proportions 
 
• Systemic steroids use during hospitalization [14.2.10] 
o Table N (%) of subjects with systemic steroids starting after Day 3 
§ P-value obtained using test of proportions 
 
• Re-hospitalization within 28 days [14.2.10] 
o Table N (%) of subjects with rehospitalization within 28 days 
§ P-value obtained using test of proportions 
o Listing of rehospitalizations:  Randomized arm, days from randomization to re-
hospitalization, subject ID, site, age, (sort by randomized arm, day from randomization) 
 
• Evaluate the virologic efficacy of NTZ + SOC vs. PCB + SOC with regards to: 
Restricted to those with virus detectable on Day 0 
o Table N (%) of subjects that had any virus detectable on Day 0, and no longer had any 
virus detectable on Day 3 [14.2.11] 
§ If more than one virus was present on Day 0, both viruses must be cleared to be 
considered as no detectable virus.  If Day 3 has a virus that was not detected on 
Day 0 (day 0 had virus A and Day 3 virus B), this is not considered as having no 
detectable virus.   
§ P-value obtained using test of proportions 
o Table N (%) of subjects that had virus detectable on Day 0, and had a different virus 
detectable on Day 3. 
 
Appendix 1 
 
The primary endpoint is time to hospital discharge or death within 28 days. The primary analysis will 
follow the intent to treat principal where all patients randomized will be used in the analysis and 
analyzed according to treatment assignment. Observations will be censored at 28 days if discharge or 
death does not occur before 28 days.  
The Shaw-Fay methodology uses ranks to form the test statistic. The following ranking system 
will be followed if no loss to follow up occurs. Patients who die will be given worse ranks than those 
who are alive. Among those who die, early deaths receive worse ranks than those who are alive and 
among those alive the order of ranking from worst to best is no discharge, late, than early discharge. 
Table 1 gives an example of rankings for an invented data set. 
 
Table 1. Example of rankings for invented data set. C indicates censored at day 28 or censored 
due to death. Larger ranks are worse than smaller ranks. 
Person 
Day of discharge  
Day of Death 
Rank 
1 
C 
5 
8 
2 
C 
10 
7 
3 
3 
15 
6 
4 
C 
C 
5 
5 
15 
C 
4 
6 
5 
C 
3 


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7 
2 
C 
1.5 
8 
2 
C 
1.5 
 
 
The test statistics is the sum of the ranks for patients in the Nitazoxanide group. Treatment labels 
will be permuted to calculate the probability of obtaining a test statistic as extreme as the observed sum 
of the ranks of the experimental group. 
If patients are lost to follow up (i.e. withdraw consent) prior to day 28 the Shaw-Fay formulation 
of the 2 sample Mann-Whitney Wilcoxon rank-sum statistic will be formed. Ranks for observed data 
will be as described above and ranks for those with missing data will be as described in Shaw-Fay. R 
code will be provided that calculates the ranks for those patients who are lost to follow up. The rank 
based permutation test as described above will be used to calculate the test statistics. 
 
Reference: Shaw, Pamela A., and Michael P. Fay. "A rank test for bivariate time-to-event outcomes 
when one event is a surrogate." Statistics in Medicine 2016; 35(19): 3413-3423.