Protocol Iranian Registry of Clinical Trials

06 Oct 2021

Phase II, Safety and Immunogenicity of RAZI SARS-CoV-2 recombinant Spike protein (RAZI Cov Pars) in adults aged 18-70 years; a Randomised, double blind, parallel 2 arms clinical trial

Protocol summary vaccine dose: SAEs, SUSARs, MAAEs, up to 6 months after last vaccine dose; Neutralizing antibody activity Study aim VNT; and Cell-mediated immunity by exposing extracted Phase two of safety and immunogenicity of recombinant PBMC to viral antigen up to 1 year after start of protein sub-unit Covid vaccine developed by RAZI . institute (Razi Cov Pars) Design General information Phase II, two parallel groups, randomized, double blind, placebo controlled trial will be conducted on 500 Reason for update volunteers. Acronym Settings and conduct IRCT registration information Tehran Rasoul Akram Hospital IRCT registration number: IRCT20201214049709N2 Participants/Inclusion and exclusion criteria Registration date: 2021-04-13, 1400/01/24 Important inclusion criteria: Iranian nationals; Able to Registration timing: prospective read and write; 18 - 70 years old; Negative RT-PCR tests for COVID, Negative S antibody titer; Signed informed Last update: 2021-04-13, 1400/01/24 consent, Non pregnant or lactating (women); Important Update count: 0 exclusion criteria: Any ongoing, symptomatic, Registration date uncontrolled, acute or chronic illness requiring 2021-04-13, 1400/01/24 medication or surgery (including respiratory/cardiac diseases, uncontrolled hypertension, uncontrolled Registrant information diabetes, neurological diseases, serious psychiatric Name disorder & blood disorders that diagnosed by a Ali Eshaghi physician); Breastfeeding; History of allergic diseases or Name of organization / entity reaction to the drug/vaccine. Razi Vaccine and Serum Research Institute Intervention groups Country The two study groups consists of one vaccine group Iran (Islamic Republic of) receiving a selected vaccine dose from phase I, and a Phone placebo group receiving adjuvant only. They will receive +98 26 3457 0038 an injection of IMP on day 0 and 21 followed by Email address intranasal spray on day 51. [email protected] Main outcome variables Primary outcomes: Immediate abnormal vital signs & Recruitment status anaphylactic reactions after vaccination: Local & Recruitment complete Systemic adverse events within the first week post Funding source vaccination; Serum ELISA IgG level for SARS CoV- 2 antigens S، S1, N, S2, NTC، RBD. Secondary outcomes: Expected recruitment start date Abnormal lab findings within one week of vaccination, 2021-04-21, 1400/02/01 Occurrence of COVID-19 disease 2 weeks after 2nd Expected recruitment end date

1 2021-06-15, 1400/03/25 the past 4 months, except topical steroids; History of Actual recruitment start date allergic diseases such as angioedema or anaphylactic empty reactions; History of any allergy to the drug or vaccine Actual recruitment end date (defined as any clinical signs or symptom of itching at empty the injection site, urticaria in the body after injection, Trial completion date excessive redness at the injection site); History of empty autoimmune diseases (other than controlled autoimmune thyroid disease, stable celiac disease, mild Scientific title psoriasis, vitiligo that does not require corticosteroid or Phase II, Safety and Immunogenicity of RAZI SARS-CoV-2 immunosuppressive therapy); History of chemotherapy recombinant Spike protein vaccine (RAZI Cov Pars) in in the last 5 years; History of cancer in the last 5 years; adults aged 18-70 years; a Randomised, double blind, History of serious psychiatric illnesses; History of blood parallel 2 arms clinical trial disorders (dyscrasia, coagulopathy, platelet deficiency or Public title disorder, deficiency of blood factors); Suffering from Phase II, Safety and Immunogenicity of recombinant chronic obstructive pulmonary disease such as asthma vaccine for COVID-19 and COPD that diagnosed by a specialist and is/was Purpose under medication; Suffering from ischemic heart disease Prevention that is/was under medication by a specialist , history of Inclusion/Exclusion criteria cardiac interventions; Suffering from uncontrolled Inclusion criteria: hypertension (systolic blood pressure > 140 and diastolic Having Iranian citizenship; Able to read and write blood pressure > 90); Suffering from uncontrolled preferably having Diploma; Adults aged 18 - 70 years; diabetes (HbA1c >7) or requiring insulin treatment; Body mass index 17 to 35kg/m2; Having sublingual History of chronic neurological diseases (including temperature less than or equal to 37.2 ° C in the seizures and epilepsy); Any history of substance or morning based on electronic thermometer; Negative IgG alcohol abuse within the last 2 years; Any abnormality in and IgM antibody titers for COVID-19 N antigen; Negative the hematology or biochemical laboratory tests based on RT-PCR test forCOVID-19; Negative IgG ELISA for HIV; FDA toxicity score (grade >1) on the screening day; Having heart rate between 60 and 100; Signed the History of confirmed COVID-19; Acute febrile illness at informed consent form; The participant agrees to reduce the time of vaccination; History of acetaminophen the risk of developing ofCOVID-19; For females of allergy; Acute or chronic hepatitis B and C; Receiving childbearing age 18 to 49years: not being pregnant prophylactic drug against tuberculosis; History of based on the first day of the last menstrual period; For syncope with blood transfusion or blood observation; females of childbearing age 18to 49 years: negative Splenectomy for any reason; Any close contact with a pregnancy test based on bHCG on the day of screening confirmed COVID-19 case within two weeks before the and the day of vaccination if deemed necessary by first dose of vaccine; History of SARS or MERS; principle investigator; For females of childbearing age 18 Participate in any clinical trials (research) study other to 49 years: use at least one effective method of than this study. contraception (condoms, oral contraceptive pills, Age intrauterine device, Norplant capsule) and willing to From 18 years old to 70 years old continue using it up to three month after last vaccine Gender dose; Unwillingness to have children and use effective Both methods of contraception up to three months after Phase completion of vaccination (all participants). Confirmation 2 by a psychiatrist that the participant's mental health and capacity allows him/her to make a decision regarding Groups that have been masked his/her participation in the trial. Participant Exclusion criteria: Care provider Any ongoing, symptomatic acute or chronic illness Investigator requiring continuous medical or surgical care on the day Outcome assessor of vaccination; Working in an occupation with a high risk Data analyser of exposure to COVID-19 including medical staff, Data and Safety Monitoring Board occupations with close contact with the client; Breastfeeding; Receipt any vaccine during the 30 days Sample size before the screening day; Received blood and/or any Target sample size: 500 blood products and/or immunoglobulins within three Randomization (investigator's opinion) months preceding the screening day; Any confirmed or Randomized suspected immunodeficient state; History of long-term Randomization description use of immunosuppressive medication (defined as more In this study, we will use Block Randomization method than 14 continuous days) in the last 4 months leading up with various block sizes. The sequence within each block to screening day; Long-term use (defined as more than will be randomized using Excel software and rand() 14 continuous days) of systemic corticosteroids function. A unique four-digit code will be assigned to (equivalent to 10 mg or more daily prednisolone) within each participant for the purpose of concealment and s/he

2 will be identified with this number until the end of the signs within two hours of receiving the vaccine at each study (randomization code). doses will be recorded. Abnormal vital signs include Blinding (investigator's opinion) temperature, respiratory rate, heart rate, systolic and Double blinded diastolic blood pressure. Anaphylaxis is defined as an Blinding description immediate systemic hypersensitivity simultaneously In this study, placebo will be used. The adjuvant used in involving two systems. Anaphylactic reactions include: the vaccine will be used as placebo. All study staff will be erythema, pruritus, urticaria and angioedema, blinded to the type of intervention received by the bronchospasm, laryngeal edema, dizziness, hypotension, participant. Randomization codes will be kept by the nausea, shortness of breath, wheezing, arrhythmia, study epidemiologist and will be used for unblinding if cyanosis, vomiting, diarrhea, abdominal pain and will be necessary. checked up to two hours after each vaccination. Placebo Timepoint Used Before vaccination and every 40 minutes up to two hours Assignment after vaccination at each dose Parallel Method of measurement Other design features Clinical examination

Secondary Ids 2 empty Description The number and percentage of local adverse reactions Ethics committees within the first week post-vaccination (including pain, tenderness, erythema/redness, swelling and stiffness, 1 itching) that will be assessed based on the severity score, duration and peak intensity. Ethics committee Timepoint Name of ethics committee Seven days after 1st and 2nd vaccination (Days 0-7 National Research Ethics Committee and21-27) daily assessment Street address Method of measurement Floor 13, Block A, Ministry of Health & Medical They will be assessed through daily telephone calls. Education Headquarters, Between Zarafashan & Furthermore symptom registration cards will be given to South Falamak, Qods Town, Tehran, Iran each patient at the time of vaccination and they will be City asked to bring them back on the next visit. Tehran Province Tehran 3 Postal code Description The number and percentage of systemic adverse event ۸۱۴۵۵۶۱۸ Approval date within the first week post-vaccination (including nausea 2021-01-16, 1399/10/27 and vomiting, diarrhea, headache, fatigue, muscle pain) Ethics committee reference number that will be assessed based on the severity score, IR.NREC.1399.005 duration and intensity. Timepoint Health conditions studied Seven days after each vaccination step (Days 0-7 and 21-27 and 51-57) daily assessment 1 Method of measurement They will be assessed through daily telephone calls. Description of health condition studied Furthermore symptom registration cards will be given to SARS-CoV-2 each patient at the time of vaccination and they will be ICD-10 code asked to bring them back on the next visit. U07.1 ICD-10 code description U07.1 4 Description Primary outcomes Serum levels of specific IgG antibodies against S, S1, S2,NTC, RBD components of SARS-CoV-2 spike protein antigen(s). Changes in these factors as well as showing 1 no response against N antigen will be explored. Description Timepoint Abnormal vital signs and anaphylactic reactions before Days zero, 21, 35, 51, and months 3, 6, 9, and 12 and immediately after vaccination: number and Method of measurement percentages of participants who develop abnormal vital Will be measured using ELISA method.

3 Secondary outcomes Number and percentage of Covid-19 disease occurrence two weeks after second vaccine dose Timepoint Aَny time between the 14 days after second vaccine dose 1 Description and the end of study The number and percentage of people who shows Method of measurement abnormal laboratory findings, including biochemistry, Diagnosis of Covid-19 disease will be based on Iran's hematology, and urine tests. These tests include: Ministry of Health's guideline and a positive positive PCR Hemoglobin, WBC, Lymphocytes cell, Neutrophils, test Eosinophils, Platelets, ESR, CRP, Sodium, Potassium, BUN, Creatinine, Alkaline phosphatase, ALT, AST, 6 Bilirubin (total), Uric Acid, U/A, Urine protein, Urine glucose, Urine RBC Description Timepoint Neutralizing antibody activity: Neutralizing antibody 7 Days after each vaccine dose (Days 7, 28, 58) titers will be measured on day zero and day 35 (2 weeks Method of measurement after the second dose) in all participants. Measurements Each test will be performed using the appropriate kit. in other times will only be performed on 10% of participants. The following tasks will be performed during 2 the conduct of this test. 1- In vitro assessment of inhibitory effect of antibody on the binding of Spike Description antigen with human ACE2 receptor and 2- Assessing VNT Number and percentage of Severe Adverse event (SAEs) titer Timepoint Timepoint Monthly until sixth month after last vaccine dose Humoral immunity will be assessed based on the Method of measurement neutralizing antibody titers on days 0, 35, 65, and These events will be collected monthly through face to months 5, 8, and 12, and comparisons will be done with face or telephone contacts. In case of Severe Adverse day 0. event identification in the participants, more information Method of measurement about the event will be collected and discussed at the Virus Nutralization Test (VNT) DSMB meeting

7 3 Description Description The cell-mediated immunity will be evaluated by Number and percentage of Suspected Unexpected counting the number of CD3, CD4 and CD8 cells and joint Serious Adverse Reaction(SUSAR ) Timepoint calculation of CD3 and CD4 and CD3 and CD8 . IFN- Monthly until sixth month after last vaccine dose γ,TNF-α, and interleukins 2, 4, 6, and 17 will also be Method of measurement measured. Evaluation of cell mediated immunity will be These events will be collected monthly from the performed only in 10% of participants in each group. Cell participants through face to face or telephone contacts. mediated immunity will be measured in all participants In case of Suspected Unexpected Serious Adverse on day 35 (2 weeks after the second dose). Summary of Reaction identification in the participants, more the measures performed in this section are as follows: 1- information about the event will be collected and Assessment of CD4 to CD8 cell proportions after discussed at the DSMB meeting. stimulation of PBMC (Peripheral Blood Mononuclear Cells) by inactivated virus and recombinant spike protein using flow cytometry 2- Assessment of specific proliferation of 4 PBMC cells stimulated by inactivated virus and Description recombinant spike protein using flow cytometry 3 - Number and percentage of Medically Attended Adverse Assessment of TH1 and TH2 specific cellular immunity Events (MAAEs) after PBMC stimulation in vaccinated individuals with Timepoint recombinant spike protein to determine the levels of Monthly until sixth month after last vaccine dose interferon-gamma, interleukin-4, tumor necrosis factor- Method of measurement alpha and interleukin 6 using Eli spot and ELISA kit. These events will be collected monthly from the Timepoint participants through face to face or telephone contacts. Cell mediated immunity will be assessed on days 0, 35 In case of medically attended events identification in the and 65 and months 3, 6, 9 and 12 and comparison will be participants, more information about the event will be made between day 0 and other time points. collected and discussed at the DSMB meeting. Method of measurement Immunologic lab tests 5 Description Intervention groups

4 1 Email [email protected] Description Grant name Intervention group: Participants in this group will receive Grant code / Reference number two doses (IM) of RAZI recombinant spike protein vaccine Is the source of funding the same sponsor 21 days apart followed by a nasal spray 51 days after the organization/entity? first dose (day 0). Yes Category Title of funding source Prevention Razi Vaccine and Serum Research Institute Proportion provided by this source 2 100 Public or private sector Description Public Control group: Participants in this group will receive two Domestic or foreign origin doses (IM) of placebo (Adjuvant only) by 50% v/v Domestic concentration produced in RAZI institute 21 days apart Category of foreign source of funding followed by another dose in the form of nasal spray at empty day 51 (counted from day 0) Country of origin Category Type of organization providing the funding Placebo Industry

Recruitment centers Person responsible for general inquiries

1 Contact Name of organization / entity Recruitment center Razi Vaccine and Serum Research Institute Name of recruitment center Full name of responsible person Rasoul Akram Hospital Mohammad Hossein Fallah Mehrabadi Full name of responsible person Position Arash Mohazzab Faculty member Street address Latest degree Corner of Mansouri, Niayesh, Satarkhan Av, Tehran Ph.D. City Other areas of specialty/work Tehran Province Street address Tehran Hesarak - Shahid Beheshti street- Karaj Postal code City Karaj ۱۴۴۵۶۱۳۱۳۱ Phone Province +98 21 6653 8539 Alborz Email Postal code [email protected] 3197619751 Phone Sponsors / Funding sources +98 26 3457 0038 Fax Email 1 [email protected] Sponsor Name of organization / entity Person responsible for scientific Razi Vaccine and Serum Research Institute inquiries Full name of responsible person Ali Eshaghi Contact Street address Name of organization / entity Beheshti Ave, Hesarak, Karaj, Alborz Province Iran University of Medical Sciences City Full name of responsible person Karaj Saeid Kalantari Province Position Alborz Associate Professor Postal code Latest degree 3197619751 Specialist Phone Other areas of specialty/work +98 26 3457 0038 Infectious diseases

5 Street address Sharing plan Corner of Mansouri, Niayesh, Satarkhan Av, Tehran City Deidentified Individual Participant Data Set (IPD) Tehran Yes - There is a plan to make this available Province Study Protocol Tehran Yes - There is a plan to make this available Postal code Statistical Analysis Plan Yes - There is a plan to make this available ۱۴۴۵۶۱۳۱۳۱ Phone Informed Consent Form Yes - There is a plan to make this available +98 21 6435 1000 Clinical Study Report Email Yes - There is a plan to make this available [email protected] Analytic Code Yes - There is a plan to make this available Person responsible for updating data Data Dictionary Yes - There is a plan to make this available Contact Title and more details about the data/document Name of organization / entity Deidentified IPD related to outcome will be shared. Razi Vaccine and Serum Research Institute When the data will become available and for how Full name of responsible person long Ladan Mokhberossaf The access period will begin once the study is complete Position and the main results have been published in peer Assistant Professor reviewed journals. Latest degree To whom data/document is available Specialist The data that have been published in peer reviewed Other areas of specialty/work journals, will be available just for academic researchers. Under which criteria data/document could be used Public Health/Community Medicine The proposed study protocol should be submitted to RAZI Street address vaccine and serum research institute and approved by its Beheshti Ave, Hesarak, Karaj, Alborz Province scientific and technical committee City From where data/document is obtainable Karaj After publishing the article researchers can submit their Province request to Dr. Mohammad Hossein Fallah at the following Alborz email address ([email protected] ) Postal code What processes are involved for a request to access 3197619751 data/document Phone Data will be made availabe after consideration and 00982634570038-46 approval by the relevant authorities from Razi Vaccine Email and Serum Research Institute. [email protected] Comments

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