A Phase III Clinical Trial of the 5-Dose Poliomyelitis Vaccine (Vero Cell), Inactivated, Sabin Strain

Project Title:A Phase III Clinical Trial of the 5-Dose Poliomyelitis Vaccine (Vero Cell), Inactivated, Sabin Strain

Protocol Title: A clinical trial with an open-label phase to evaluate the safety of Sabin Inactivated Poliovirus Vaccine (Vero cell) (2.5 ml/dose)(hereinafter referred to as “msIPV”) in adults, children and infants, and a blinded, randomized and controlled phase to evaluate the lot consistency immunogenicity, and safety of the msIPV in 2 months old infants

Name of the Investigational Product: 5-Dose Poliomyelitis Vaccine (Vero Cell), Inactivated, Sabin Strain

Sponsor: Sinovac Biotech Co., Ltd.

Investigator: Henan Province Center for Disease Control and Prevention

Statistics Party: Beijing Key Tech Statistical Technology Co., Ltd.

Protocol No.: PRO-msIPV-3001

Protocol Version Date: October 12, 2020

Version No.: 1.2

Protocol Approver: Yin Weidong 

Signature of the Approver:

Approved Date:  year 　  month 　 day

Signature of the Principal Investigator

I agree to:

·    Take the responsibility to correctly guide the conduct of the clinical study in the region.

·    Ensure that this study can be conducted according to the trial protocol and standard operating procedures for clinical studies. 

·    Ensure that the personnel who participate in the project have fully understood the information of the investigational product and other responsibilities and obligations related to the study specified in the project.

·    Ensure that any modification of the trial protocol will not be conducted without the review and written form approval of the sponsor and the independent ethics committee (IEC), unless the immediate hazard for the subjects should be eliminated or follow the requirements of the registration regulatory authorities (e.g., administrative management aspect of the project).

·    I am completely familiar with the method to correctly use the vaccine described in the trial protocol, have fully understood other information provided by the sponsor, include but not limited to the following contents: current investigator's brochure (IB) or equivalent documents and supplements of the investigator’s brochure (if any).

·    I am familiar with and will abide by Good Clinical Practice (GCP), Guidelines for Quality Management of Clinical Trials of Vaccines (Trial) and all the current regulations.

Name of the Principal Investigator: Wang Yanxia 

Signature:

Date:  year 　  month 　 day

Study Team

Sponsor

Name: Sinovac Biotech Co., Ltd.

Address: Peking University Biology City, No.39, Shangdi Xi Road, Haidian District, Beijing

Name of the Contact Person: Zeng Gang

Tel: 13581724748      Fax: 010-82890408   Post Code: 100085

E-mail: zengg@sinovac.com

Responsible Institution of the Clinical Trial: Henan Province Center for Disease Control and Prevention

Address: Nongye East Road, Zhengdong New District, Zhengzhou City, Henan Province

Professional Department: Vaccine Clinical Study Center

Name of the Person in Charge: Xia Shengli

Tel: 13592610137        Fax: 0371-68089219     Post Code: 450016

Principal Investigator

Name: Wang Yanxia

Institution: Henan Province Center for Disease Control and Prevention

Tel: 13613816598       Fax: 0371-68089219     Post Code: 450016

E-mail: wangyanxia99@163.com

Clinical Trial Site 1

Institution Name: Xiangcheng County Center for Disease Control and Prevention

Address: Center Road, Xiangcheng County, Xuchang City, Henan Province

Name of the Contact Person: Yan Yongqiang

Tel: 13849897071       Fax: 0374-7359116      Post Code: 461700

E-mail: xcxfyz@163.com

Clinical Trial Site 2

Institution Name: Kaifeng City Xiangfu District Center for Disease Control and Prevention

Address: No.32, Weisheng Street, North Section of Qingnian Road, Xiangfu Ditrict, Kaifeng City

Name of the Contact Person: Ma Shi

Tel: 13938600398       Fax: 0371-22700066      Post Code: 475100

E-mail: kfxyang@163.com

Person in Charge of Supervision

Name: Hu Yuansheng

Institution: Sinovac Biotech Co., Ltd.

Address: Peking University Biology City, No.39, Shangdi Xi Road, Haidian District, Beijing

Tel: 13436950182, 010-82799318  Fax: 010-82890408      Post Code: 100085

E-mail: huys@sinovac.com

Serum Antibody Detection Institution

Institution: National Institutes for Food and Drug Control

Address: No.31, Huatuo Road, Daxing District, Beijing City

Tel: 010-53851770       Post Code: 102629

Data Management Institution

Institution Name: Shijiazhuang Horizon Medical Technology Co., Ltd.

Address: 508/509, Zhong’an Shengye Mansion, No.168, Beiyuan Road, Chaoyang District, Beijing City

Name of the Contact Person: Huo Yuliang

Tel: 18600127970   Post Code: 100101      E-mail: huoyuliang@blueballon.cn

Statistical Analysis Institution

Institution: Beijing Key Tech Statistical Technology Co., Ltd.

Address: 1018-1119w, Sihui Mansion, Huihe South Street, Chaoyang District, Beijing City

Contact Person: Jiang Zhiwei

Tel: 18618483152   Post Code: 100025      E-mail: zhi.wei.jiang@ktstat.com

Protocol Amendment Record

Clinical Trial of the 5-Dose Poliomyelitis Vaccine (Vero Cell), Inactivated, Sabin Strain

Protocol Synopsis

Glossary

Clinical Protocol Synopsis

The 5-dose Poliomyelitis Vaccine (Vero Cell), Inactivated, Sabin Strain (hereinafter referred to as “5-dose sIPV”) developed by Sinovac Biotech Co., Ltd. can induce the body to produce the active immunity and prevent the poliomyelitis caused by poliovirus type I, type II and type III.

For the market demand, Sinovac Biotech has developed two kinds of sIPV, i.e., single dose strength free of preservative and 5-dose strength containing preservative. The former China Food and Drug Administration (CFDA) drug clinical trial approval (approval no.: 2015L04056) was obtained for the single dose sIPV in 2015 and the phase I/phase II, phase III (booster immunization has been finished) and sequential clinical trials have been finished in Jiangsu province at present. The results of the clinical trials showed that the investigational vaccine had relatively good safety and immunogenicity. The risk of contamination is increased due to many times of drawing in the process of use of the multi-dose vaccine, and addition of preservative is the most effective solution. Preservations have been added for the marketed multi-dose vaccines at present. Therefore, the difference between the 5-dose sIPV and single dose sIPV of Sinovac Biotech is that the preservative 2-phenoxyethanol has been added in the preparation of final bulk. In addition, the preservative 2-phenoxyethanol has been maturely used in poliomyelitis vaccines, and 2-phenoxyethanol has also been used as the preservative in the single dose IPV of Sanofi Pasteur (hereinafter referred to as Pasteur) and the single dose sIPVs manufactured by other manufacturers in China.

The preclinical animal tests revealed that the 5-dose sIPV had good safety in guinea pigs, mice and rats, and had good immunogenicity in rats. The preclinical studies have been finished according to the requirements of the Provisions for Drug Registration issued by the former CFDA, and the National Medical Products Administration (NMPA) clinical trial notification (no.: CXSL1800065) has been obtained. Hereby the phase III clinical trial is conducted.

The clinical study protocol is made according to the related requirements of Provisions for Drug Registration, Good Clinical Practice (GCP), Technical Guidelines for Clinical Trials of Vaccines and Guidelines for Quality Management of Clinical Trials of Vaccines (Trial) issued by the former CFDA.

The project is divided into two phases: phase I has open-label design and phase II has randomized, blinded and controlled design. The objective of the project is to evaluate the safety of the 5-dose sIPV in different populations and the lot consistency, immunogenicity and safety of 3 consecutive lots of the 5-dose sIPV manufactured with commercial scale in 2 months old infants (aged 60 - 89 days) and validate that the 5-dose sIPV was non-inferior to the Inactivated Poliovirus Vaccine (trade name IMOVAX POLIO, hereinafter referred to as IPV) manufactured by Pasteur and single dose sIPV manufactured by Sinovac Biotech.

Phase I: Carry out the clinical trial with adults aged 18 to 49 years, children aged 4 years and infants aged 2 months (60 to 89 days old) as the subjects. Inoculate 1 dose or 4 doses of the trial vaccine under the premise that informed consent has been obtained from the subjects or their guardians with the objective to evaluate the safety of the investigational vaccine in different populations. Seventy-two healthy subjects were selected, including 24 adults, 24 children and 24 infants. Carry out the study for adults, children and infants in turn. Firstly, 24 adults are selected to receive the one dose of the investigational vaccine. Under the circumstances that the 7-day safety observation has been assessed, and it has been preliminarily confirmed to be safe, choose 24 children to receive the inoculation of one dose of the investigation vaccine. Under the circumstances that the 7-day safety observation has been assessed, and it has been preliminarily confirmed to be safe, choose 24 infants to inoculate 4 doses of the trial vaccine according to the immunization schedule of month 0, month 1 and month 2 for primary immunization and booster immunization when the subjects are 18 months old.

Phase II: The enrollment of the subjects of phase II should be started under the premise that the 7-day safety observation has been finished for the subjects in the infant group in phase I after inoculation of the first dose, and safety has been preliminary confirmed through assessment and the results comply with the protocol. Under the premise that the informed consent has been obtained from the guardians of the subjects, recruit 1,500 2 months old infants and randomly divide the subjects into 5 groups according to the ratio of 1:1:1:1:1:1: trial group 1, trial group 2, trial group 3, IPV control group and single dose sIPV control group in which the subjects in the 3 trial groups should receive inoculation of 3 consecutive lots of the 5-dose sIPV manufactured at the commercial scale, the IPV control group will receive the IPV manufactured by Pasteur and the single dose sIPV control group will receive inoculation of the single dose sIPV manufactured by Sinovac Biotech. All the subjects will receive the inoculation of 4 doses of the investigational vaccine or control vaccine according to the immunization schedule of month 0, month 1 and month 2 for primary immunization and booster immunization when the subjects are 18 months old.

Observe the 30 min immediate reaction, systemic and local solicited adverse reactions from day 0 to day 7 and unsolicited adverse events from day 0 to day 30 after inoculation of each dose after inoculation of each dose of all the subjects in phase I and phase II and finish the SAE monitoring during the safety observation period.

Blood will not be collected for subjects in phase I. About 2.5 ml of venous blood should be collected from all the subjects in phase II before primary immunization, 30 days after primary immunization, before booster immunization and 30 days after booster immunization. The serum is used for the detection of the neutralizing antibodies against poliovirus type I, type II and type III so as to evaluate the primary immunization effects, immune persistence and booster immunization effects.

This clinical protocol will be independently undertaken by the investigator after approval has been obtained from the ethics committee. The clinical research associates designated by the sponsor have inspected the whole process of the study so as to ensure that the trial can be conducted in a safety and standardized manner.

Table of Contents

1.Introduction--------------------------------------------------------------------------------------------------------------------------------------------------------------------------14

2.Participating Institutions and Responsibilities-------------------------------------------------------------------------------------------------------------------------------15

2.1 Responsible Institution of the Clinical Trial--------------------------------------------------------------------------------------------------------------------------------15

2.2 Clinical Study Site Institution--------------------------------------------------------------------------------------------------------------------------------------------------17

2.3 Clinical Trial Sponsor-----------------------------------------------------------------------------------------------------------------------------------------------------------22

2.4 Test Institution of the Test Samples-----------------------------------------------------------------------------------------------------------------------------------------24

2.5 Supervision Institution----------------------------------------------------------------------------------------------------------------------------------------------------------24

2.6 Data Management Institution25

2.7 Statistical Analysis Responsible Institution--------------------------------------------------------------------------------------------------------------------------------26

3.Background and Principle--------------------------------------------------------------------------------------------------------------------------------------------------------27

3.1 Summary---------------------------------------------------------------------------------------------------------------------------------------------------------------------------27

3.2 Virology-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------28

3.3 Epidemiology----------------------------------------------------------------------------------------------------------------------------------------------------------------------29

3.4 Production and Application of sIPV------------------------------------------------------------------------------------------------------------------------------------------30

3.5 Considerations on the Inoculation Population and Immunization Schedule--------------------------------------------------------------------------------------32

4.Preclinical Studies and Laboratory Evaluation of Vaccines-------------------------------------------------------------------------------------------------------------33

4.1 Safety-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------33

4.2 Immunogenicity-------------------------------------------------------------------------------------------------------------------------------------------------------------------34

4.3 Antigen Stability and Safety Study of Reuse------------------------------------------------------------------------------------------------------------------------------36

5.Preliminary Clinical Study of the Single Dose sIPV------------------------------------------------------------------------------------------------------------------------37

5.1 Phase Ⅰ/Ⅱ Clinical Trial------------------------------------------------------------------------------------------------------------------------------------------------------38

5.2 Phase III Clinical Trial-----------------------------------------------------------------------------------------------------------------------------------------------------------39

5.3 Sequential Clinical Trial--------------------------------------------------------------------------------------------------------------------------------------------------------41

6.Brief Introduction of the Product Characteristics---------------------------------------------------------------------------------------------------------------------------42

6.1 Preparation Process and Formulation of the Vaccine------------------------------------------------------------------------------------------------------------------42

6.2 Vaccine Stability------------------------------------------------------------------------------------------------------------------------------------------------------------------43

6.3 Control Vaccine-------------------------------------------------------------------------------------------------------------------------------------------------------------------43

6.4 Storage and Transportation of the Vaccine-------------------------------------------------------------------------------------------------------------------------------44

6.5 Inoculation Route and Schedule of the Vaccine-------------------------------------------------------------------------------------------------------------------------44

6.6 Information of the Trial Products---------------------------------------------------------------------------------------------------------------------------------------------44

6.7 Vaccine Packaging--------------------------------------------------------------------------------------------------------------------------------------------------------------45

7.Trial Objective-----------------------------------------------------------------------------------------------------------------------------------------------------------------------45

8.Test Design--------------------------------------------------------------------------------------------------------------------------------------------------------------------------46

8.1 Design------------------------------------------------------------------------------------------------------------------------------------------------------------------------------46

8.2 Trial Endpoints-------------------------------------------------------------------------------------------------------------------------------------------------------------------48

8.3 Study Hypothesis and Evaluation Criteria---------------------------------------------------------------------------------------------------------------------------------49

8.4 Study Plan-------------------------------------------------------------------------------------------------------------------------------------------------------------------------49

8.5 Randomization and Blind Method-------------------------------------------------------------------------------------------------------------------------------------------52

8.6 Flow Chart of the Clinical Trial------------------------------------------------------------------------------------------------------------------------------------------------56

8.7 Study Time-------------------------------------------------------------------------------------------------------------------------------------------------------------------------58

8.8 Trial Discontinuation and Early Termination-------------------------------------------------------------------------------------------------------------------------------58

8.9 Protocol Violations and Deviations------------------------------------------------------------------------------------------------------------------------------------------59

9.Subject Population-----------------------------------------------------------------------------------------------------------------------------------------------------------------59

9.1 Subject Inclusion Criteria------------------------------------------------------------------------------------------------------------------------------------------------------59

9.2 Subject Exclusion Criteria-----------------------------------------------------------------------------------------------------------------------------------------------------60

9.3 Exclusion Criteria for Inoculation of the Second Dose, Third Dose and Fourth Dose for Infant Subjects------------------------------------------------64

9.4 Subject Discontinuation and Termination Criteria-----------------------------------------------------------------------------------------------------------------------64

10.Methods and Procedure--------------------------------------------------------------------------------------------------------------------------------------------------------65

10.1 Recruitment and Informed Consent---------------------------------------------------------------------------------------------------------------------------------------65

10.2 Screening and Randomization----------------------------------------------------------------------------------------------------------------------------------------------65

10.3 Blood Sample Collection before and after Immunization------------------------------------------------------------------------------------------------------------66

10.4 Vaccine Inoculation------------------------------------------------------------------------------------------------------------------------------------------------------------66

10.5 Medical Observation----------------------------------------------------------------------------------------------------------------------------------------------------------67

10.6 Safety Observation and Follow-up----------------------------------------------------------------------------------------------------------------------------------------67

10.7 Safety Evaluation69

10.8 Concomitant Medication and Vaccines-----------------------------------------------------------------------------------------------------------------------------------81

10.9 Immunogenicity Evaluation--------------------------------------------------------------------------------------------------------------------------------------------------82

10.10 Data Management-----------------------------------------------------------------------------------------------------------------------------------------------------------83

10.11 Statistical Analysis------------------------------------------------------------------------------------------------------------------------------------------------------------85

11.Monitoring of the Clinical Trial-------------------------------------------------------------------------------------------------------------------------------------------------94

11.1 Responsibilities of the Sponsor---------------------------------------------------------------------------------------------------------------------------------------------94

11.2 Responsibilities of the Investigator-----------------------------------------------------------------------------------------------------------------------------------------94

11.3 Personnel Training-------------------------------------------------------------------------------------------------------------------------------------------------------------94

11.4 Subject Compliance Guarantee--------------------------------------------------------------------------------------------------------------------------------------------94

11.5 Management of the Clinical Trial Vaccines------------------------------------------------------------------------------------------------------------------------------95

11.6 Management of the Clinical Trial Samples------------------------------------------------------------------------------------------------------------------------------96

11.7 Storage of the Clinical Trial Data-------------------------------------------------------------------------------------------------------------------------------------------96

11.8 Completion Criteria of the Clinical Trial-----------------------------------------------------------------------------------------------------------------------------------97

12.Schedule----------------------------------------------------------------------------------------------------------------------------------------------------------------------------97

13.Ethics Approval------------------------------------------------------------------------------------------------------------------------------------------------------------------100

13.1 Review and Approval--------------------------------------------------------------------------------------------------------------------------------------------------------100

13.2 Implementation of the On-site Supervision----------------------------------------------------------------------------------------------------------------------------100

13.3 Confidentiality-----------------------------------------------------------------------------------------------------------------------------------------------------------------101

14.Clinical Trial Protocol Amendment------------------------------------------------------------------------------------------------------------------------------------------101

15.Disclosure and Publication of the Data------------------------------------------------------------------------------------------------------------------------------------101

16.References-----------------------------------------------------------------------------------------------------------------------------------------------------------------------101

1. Introduction

sIPV developed by Sinovac Biotech is indicated for the immunoprophylaxis of poliomyelitis caused by poliovirus type I, type II and type III. For different market demands, Sinovac Biotech has developed two kinds of sIPV, i.e., single dose strength free of preservative and 5-dose strength containing preservative.

The former China Food and Drug Administration (CFDA) drug clinical trial approval (approval no.: 2015L04056) was obtained for the single dose sIPV in 2015 and the phase I/phase II, phase III (booster immunization has been finished) and sequential clinical trials have been finished in Jiangsu province at present. The results of the clinical trials showed that the investigational vaccine had relatively good safety and immunogenicity. The risk of contamination is increased due to many times of drawing in the process of use of the multi-dose vaccine, and addition of preservative is the most effective solution. Preservations have been added for the marketed multi-dose vaccines at present. Therefore, the difference between the 5-dose sIPV and single dose sIPV of Sinovac Biotech is that the preservative 2-phenoxyethanol has been added in the preparation of final bulk. In addition, the preservative 2-phenoxyethanol has been maturely used in poliomyelitis vaccines, and 2-phenoxyethanol has also been used as the preservative in the single dose IPV of Pasteur and the single dose sIPVs manufactured by other manufacturers in China.

The preclinical animal tests revealed that the 5-dose sIPV had good safety in guinea pigs, mice and rats, and had good immunogenicity in rats. The preclinical studies have been finished according to the requirements of the Provisions for Drug Registration issued by the former CFDA, and the National Medical Products Administration (NMPA) clinical trial notification (no.: CXSL1800065) has been obtained. Hereby clinical study is conducted.

The clinical study protocol of the preservative-containing 5-dose sIPV is formulated according to the related requirements of Provisions for Drug Registration, Good Clinical Practice (GCP), Technical Guidelines for Clinical Trials of Vaccines and Guidelines for Quality Management of Clinical Trials of Vaccines (Trial) issued by the former CFDA by referring to the relevant regulations and guidelines such as World Health Organization (WHO) Position paper (March 2016), and it is proposed to carry out the lot consistency evaluation of the investigational vaccine of three commercial scale lots and the non-inferiority evaluation to the marketed control vaccine and evaluate the safety of the investigational vaccine at the same time

2.Participating Institutions and Responsibilities

2.1 Responsible Institution of the Clinical Trial

2.1.1 Responsibilities

The responsible institution of the clinical trial is Henan Province Center for Disease Control and Prevention, and its main responsibilities are:

-   Participate in making the clinical trial protocol and forms and cards needed for the trial;

-   Participate in drafting the information consent form for vaccine inoculation and proposing the SOP for clinical trial on-site operation, apply for approval of the ethics committee, be responsible for organizing and implementing the selection of the clinical trial site which complies with the GCP requirements, organizing the assessment of the trial site, and carrying out record filing in the “Record Filing Management Information Platform of the Drug Clinical Trial Institution”.

-   Be responsible for timely reporting the SAEs occurred during the clinical trial to the sponsor and implementing investigation and handling.

-   Participate in database lock and preserve the locked database backup for verification.

-   Be responsible for coordinating data entry.

-   Assist the sponsor to purchase the control IPV vaccine.

-   Be responsible for keeping the clinical trial data during the clinical trial period.

-   Be responsible for reporting the implementation progress of the clinical trial to related administrative departments and writing the clinical trial summary report.

-   Be responsible for keeping the related clinical trial data during the clinical period.

2.1.2 Overview of the Institution 

Henan Province Center for Disease Control and Prevention is the responsible institution of the clinical trial. The institution is a non-profit public health institution, and it has the qualifications for preventive biological product and immunization program management and vaccination qualifications. Its administration and business management are affiliated to Health Commission of Henan Province. The Center has 9 business institutes such as institute for prevention and control of infectious diseases, institute for prevention and control of the parasitic diseases, immunoprophylaxis and planning institute, health testing center, institute for prevention and treatment of sexually transmitted diseases and AIDS, institute for prevention and control of endemic diseases, institute for prevention and control of tuberculosis, institute for prevention and treatment of health education and chronic non-infectious diseases and public health institute, including 439 staff, 375 health professionals, including 27 chief physicians (technicians), 94 associate chief physicians (technicians and nurses), 14 doctors and 94 masters. The Center has 5 provincial excellent experts, 3 experts who enjoy the special government allowance and more than 20 persons who work in the national professional academic body. More than 30 business technical backbone have researched and studied abroad since 2006 until now. The vaccine clinical study center is the professional department engaged in vaccine safety and efficacy evaluation, and it can carry out the immunological, etiological, molecular biology, biochemical and routine tests.

Composition of the technical personnel of the vaccine clinical study center: 3 senior technical personnel, 2 deputy senior technical personnel, 5 intermediate technical personnel and 1 administration personnel. Education background composition of the technical personnel: 4 masters, 4 bachelors and 3 college degree personnel. Specialty composition of the technical personnel: 4 epidemiologists, 2 clinical physicians, 4 laboratory technicians and 1 other staff. All the 11 persons have obtained the national GCP training certificates. The management personnel and technical personnel of the vaccine clinical study center are familiar with the drug clinical trial procedure. The composition of the management personnel and technical personnel are reasonable, labor division is clear and complies with the requirements of the corresponding post responsibilities. The vaccine clinical study center has established and implemented the related regulations and technical training systems. The vaccine clinical study center has established the clinical trial quality control and quality assurance systems. The contents of various SOPs are complete, and cover the whole process of the clinical trial, they are operable and can ensure the implementation of the quality control and quality assurance systems of the clinical trial. Quality control can be conducted for each stage of data processing, and data integrity, accuracy, authenticity and reliability can be ensured. The center has obtained the certification for the qualifications of the clinical trial institutions of vaccines for single time from the former CFDA many times.

The vaccine clinical study center has carried out the clinical study work of more than 20 kinds of vaccines such as clinical trials of H1N1 Influenza A Vaccine (I/III), Rotavirus Vaccine (III Protective Efficacy), Group A and C Meningococcal Polysaccharide Vaccine (III), 10 μg Recombinant Hepatitis B Vaccine (III), Group ACYW135Meningococcal Polysaccharide Vaccine (III), Rabies Vaccine (Vero Cell) for Human Use, Freeze-dried (III), Haemophilus Influenzae Type b Conjugate Vaccine, Freeze-dried (III), Human Papillomavirus Bivalent (Types 16 and 18) Vaccine, Recombinant (Yeast) (III Protective Efficacy), 23-Valent Pneumococcal Polysaccharide Vaccine (III), Influenza H7N9 Vaccine (I/II), Influenza Vaccine (Split Virion), Inactivated, Quadrivalent (I/III), Poliomyelitis Vaccine (Vero Cell), Inactivated, Sabin Strain (I/II/III), Typhoid and Paratyphoid A Combined Vaccine (III (Protective Efficacy)), Varicella Vaccine, Live (I/III) and 13-Valent Pneumococcal Conjugate Vaccine (I/II) in recent years and have relatively rich experiences in clinical studies of vaccines. A Phase III Clinical Study of Trivalent Rotavirus Vaccine and Clinical Study of the Human Papillomavirus Bivalent (Types 16 and 18) Vaccine, Recombinant (Yeast) are the clinical study with large scale, large number of subjects, more enrollment doses and long monitoring period, and they are the clinical studies with great difficulty in China.

2.2 Clinical Study Site Institution 

2.2.1 Responsibilities

The clinical study sites are Xiangcheng County Center for Disease Control and Prevention and Kaifeng City Xiangfu District Center for Disease Control and Prevention, and their main responsibilities are:

-    Cooperate to carry out the assessment and record filing of the trial site;

-   Organize the personnel with corresponding professional techniques and rich clinical study experiences to participate in the work of the study site. All the participating investigators should carefully read and learned the content of the study protocol, implement the study in strict accordance with the protocol and ensure that there is adequate time to finish the clinical study within the period specified in the protocol.

-   Organize the site implementation, including organize and select the subjects, obtain the Informed Consent Form signed by the subject or the guardian of the subject, screening and enrollment, vaccine inoculation, safety visit, blood sample collection, blood separation, cryopreservation and submission for test.

-   Be responsible for data entry. Ensure that all the collected data are timely, accurate, complete, standard and true.

-   Receive the supervision and audit of the CRA or inspector designated by the sponsor and the audit and inspection of drug regulatory authorities and ensure the quality of the clinical trial.

-   Ensure that the adverse reactions/events occurred during the study period of the subjects can be appropriately handled, immediately take appropriate treatment measures for the subjects if serious adverse reaction/event occurs, implement the investigation, and report to the sponsor at the same time.

-   Be responsible for keeping the related clinical trial data during the clinical period.

2.2.2 Overview of the Institution

Brief Introduction of Xiangcheng County Center for Disease Control and Prevention:

Xiangcheng County is located in the central part of Henan Province, it is 110 kilometers away from the provincial capital, Zhengzhou, and 40 kilometers away from Xuchang to the north. The railways crisscross the territory, and the Luobao and Pingyu railways run through the territory. National highways and provincial highways such as G311, S329, Yu 20, and S103 intersect in the county in a star shape, and Xupingnan expressway passes through the border. The total area is 920 square kilometers. The county has the jurisdiction over 10 towns and 6 townships, 448 administrative villages (communities), the total population is more than 900,000 people, and the permanent resident population is more than 690,000 people.

Xiangcheng County Center for Disease Control and Prevention locates in the middle section of the central road. The institution is a non-profit public health institution, and it has the qualifications for preventive biological product and immunization program management and vaccination qualifications. Its administration and business management are affiliated to Xiangcheng County Health Commission. The office area of Xiangcheng County Center for Disease Control and Prevention is 3,652 square meters. There are 130 staff at present, including 89 professionals, 15 persons with bachelor degree, and 38 persons with college degree, 2 persons with senior technical title, 9 persons with intermediate technical title and 50 persons with primary technical title. It has 12 professional technical departments such as immunization program, prevention and treatment of epidemic diseases, prevention and treatment of endemic diseases, prevention and treatment of tuberculosis, health education and prevention and treatment of chronic diseases, prevention and treatment of AIDS, prevention and treatment of occupational diseases, environmental health department and comprehensive outpatient department. The Center has a vaccination clinic which is located in the middle section of Yingbin Road in the county. The building area is 163 square meters and there are 14 vaccination personnel. It is a demonstration vaccination clinic which has passed the inspection and acceptance of the provincial health commission.

The Center is equipped with a cold chain transportation and storage system and the advanced office and scientific research conditions such as class 10,000 sterile laboratory, large-scale test equipment, preventive vaccination informatization management, etc. The conducted clinical trial projects include A Phase III Clinical Trial of Trivalent Rotavirus Genetic Reassortment Vaccine, A Phase I Clinical Trial of Varicella Vaccine, Live and A Phase III Clinical Trial of Varicella Vaccine, Live.

The Center has established the on-site leading group and on-site emergency disposal group for the clinical studies of the vaccine, and has established the on-site organization. The composition of the management personnel and study personnel are reasonable, comply with the requirements to take the corresponding post and the labor division is clear. Many persons in the project group have participated in the GCP training organized by the senior research and study college of National Medical Products Administration and the provincial center for disease control and prevention, and the related training and examination records are available. Plan for Prevention and Treatment of the Subject Injuries and Sudden Events in the Clinical Trials of Vaccines, Emergency Plan for Rescue of Allergic Shock and Emergency Plan for Power Failure/Outage of the Clinical Study Sites of Vaccines have been established, and the working system of each function area of the clinical trial sites of vaccines has been formulated. The first aid room of the inoculation site is equipped with the first-aid medicines, emergency ambulance and first-aid instrument and equipment according to the corresponding SOP. The inoculation site is equipped with the ambulance, and Medical Rescue Green Channel Agreement has been signed with Xiangcheng People's Hospital. The archives are managed and stored in the special cabinet, and managed by the specially designated personnel. The borrowing and use record records are complete. There are dedicated cold room, low temperature refrigerator, cold storage refrigerator and freezer for storage of the vaccines and samples. The marks are clear and management system is perfect. They are managed by the specially assigned persons, and the temperature record is complete. The temporary storage place for medical wastes has been set in the on-site site, and it is equipped with the temporary storage facilities and equipment for medical wastes. The medical wastes have been disposed according to the related requirements of Regulations of Administration of Medical Wastes, and the related handover procedures are handled. The corresponding quality control system for clinical studies of vaccines has been established. The contents of various SOPs are complete and the SOPs are operable. Quality control can be conducted for each stage of the clinical studies of the vaccines so as to ensure that the data records are timely, complete, accurate and reliable. The Center is suitable to implement the clinical study through assessment.

Brief Introduction of Kaifeng City Xiangfu District Center for Disease Control and Prevention

Prevention

Xiangfu District of Kaifeng City is subordinate to Kaifeng City. It is located in the eastern part of Henan Province, on the south bank of the Yellow River. It is surrounded by the ancient city of Kaifeng on three sides and is 70 kilometers away from the provincial capital, Zhengzhou. Xiangfu District of Kaifeng City has jurisdiction over 6 towns, 9 townships, and 1 industrial cluster district, i.e. Huanglong Park. The total population of the area under administration is 820,000 people, and the permanent resident population is 778,000 people.

Kaifeng City Xiangfu District Center for Disease Control and Prevention is a non-profit public health institution, and it has the qualifications for preventive biological product and immunization program management and vaccination qualifications. Its administration and business management are affiliated to Kaifeng City Health Commission. It has 18 departments such as outpatient, disease control department, food hygiene department and department for prevention and treatment of tuberculosis. The Center has 96 staff, including 80 professionals of various specialities, 14 persons with intermediate and senior titles, 22 persons with bachelor degree, 48 persons with college degree, 15 persons with technical secondary school degree and 15 persons with high school degree. Seven persons have national level GCP training certificate. All the personnel who participate in the clinical studies of the vaccines have participated in the GCP training organized by the provincial CDC, and the related training and examination records are available. The Center has established the Emergency Plan for Standardization and Treatment of the Subject Injury and Sudden Events in the Clinical Trials of the Events, and has established the emergency treatment group. The company has established the SOPs for first-aid of various adverse reactions and adverse events in the clinical trial sites of vaccines. The first-aid room at the inoculation site is equipped with the first-aid drugs and first-aid instruments and equipment and the operation flow has been pasted according to the uniform requirements of Henan Province CDC. The inoculation site is equipped with the ambulance, and Medical Rescue Green Channel Agreement has been signed with Kaifeng City Xiangfu District People’s Hospital. The instruments and equipment of the laboratory of the center can meet the work requirements. The SOPs have been established for use of the instruments and equipment, and the use records are complete. The laboratory of the Center passed the qualification certification for Henan Province testing institutions in June 2000. The drug clinical trial management systems complies with the requirements of national GCP and related regulations. The archives are managed and stored in the special cabinet, and managed by the specially designated personnel. The borrowing and use record records are complete. There are special refrigerator and freezer for storage of vaccines and samples, the marks are clear, the management system is perfect, and they are managed by the specially designated personnel. The temperature record is complete. As the study sites, the Center has carried out A Phase III Clinical Trial of Trivalent Rotavirus Vaccine, A Phase III Clinical Trial of 23-Valent Pneumococcal Polysaccharide Vaccine, Clinical Trial of the Consistency of Three Lots of Varicella Vaccine, Live and A Phase III Clinical Trial of Group ACYW135Meningococcal Polysaccharide Vaccine, and has relatively rich clinical study experiences and good mass basis. The Center has passed the on-site investigation and assessment and is suitable to implement the clinical study.

2.3 Clinical Trial Sponsor 

2.3.1 Responsibilities

The sponsor of the clinical trial is Sinovac Biotech Co., Ltd. and its main responsibilities are:

-   Provide the preliminary protocol of the clinical trial and sign and stamp the final protocol.

-   Provide the documents used on site such as clinical study notification, investigator's brochure of the clinical trial (preclinical safety information of the product), executive criteria of the product, etc.

-   Be responsible for providing the vaccines which meet the needs of clinical study and issuing the test report of conformity or lot release certificate of biological products.

-   Be responsible for assessing and selecting the clinical trial responsible institution and site and designating the CRA to examine and certify the clinical trial site and perform the inspection responsibilities according to the GCP requirements and be ultimately responsible for the quality of the clinical trial.

-   Participate in investigation and handling of the cases with abnormal vaccine reactions and be responsible for providing medical treatment and related compensation expenses for the cases with abnormal reactions which have been clinically proved to be related to the vaccine inoculation and the disposal of other circumstances can be seen in the working agreement.

-   Carry out the antigen detection of partial 5-dose investigation vaccines used on the site.

-   Be responsible for providing the clinical study funds.

2.3.2 Overview of the Institution

Sinovac Biotech Co., Ltd. is a national high-tech enterprise jointly established by Sinovac Biotech (Hong Kong) Ltd. and Sinobioway Biomedicine Co., Ltd.. The company was registered and established in Beijing Zhongguancun Science Park in 2001, and the registered capital was RMB 141.21 million yuan. At present, Sinovac Biotech is listed on the NASDAQ Global Select Market (stock code: SVA) through its parent company Sinovac Biotech Ltd., and is the unique Chinese vaccine enterprise which has been listed in North America. It is also one of the first batch of the innovative enterprises of Zhongguancun Science Park, and the key cultivated enterprise included in the first batch of “Ten, Hundred and Thousand” project of Beijing city and “Beijing Bioengineering and Pharmaceutical Industry Spanning Development Project” (G20 Project).

With the mission of “Supply Vaccines to Eliminate Human Diseases”, Sinovac Biotech is engaged in the study, development, production and sales of vaccines for human use. It has researched and developed the first Hepatitis A Vaccine (Human Diploid Cell), Inactivated (Healive^®) with the proprietary intellectual property rights which fill the gap in China, Hepatitis A and B Combined Vaccine (Bilive^®) which is the first in China and the second all over the world, the first Pandemic Influenza Vaccine (Avian Influenza Vaccine for Human Use) (Panflu) which is synchronous with the world, the unique domestic Influenza Vaccine(Split Virion), Inactivated (Anflu™) which is free of preservative and the first H1N1 Influenza A Vaccine (PANFLU.1™) all over the world, and the global pioneered Enterovirus Type 71 Vaccine (Vero Cell), Inactivated (Inlive^®) in more than ten years after establishment. In addition, the company has also successfully developed and finished the phase I clinical study of the first inactivated SARS vaccine all over the world. The ongoing research and development projects of the company include inactivated poliomyelitis vaccine, 23-valent pneumococcal polysaccharide vaccine, 13-valent pneumococcal polysaccharide vaccine, quadrivalent influenza vaccine and quadruple vaccine, etc. at present.

Xi Jinping, Li Keqiang, Hu Jintao, Wen Jiabao, Wang Qishan, Zhang Gaoli, Jia Qinglin, Hui Liangyu, Liu Qi, Wu Yi, Chen Zhili, Guo Jinlong and leaders of relevant commissions, offices and bureaus have visited the company for inspection to learn the research and development, production and quality control situations of vaccines of Sinovac Biotech and listen to the research and development progress of the vaccines within just a few years after establishment of Sinovac Biotech.

As one of the key cultivated bio-pharmaceutical enterprises in Beijing, Sinovac Biotech has established the development goals to become “stronger” and “bigger”, has gradually formed the good situation for “providing Chinese children with international quality vaccine” and is starting a new era of “providing the children in the world with vaccines made in China”.

2.4 Test Institution of the Test Samples

2.4.1 Responsibilities

National Institute for Food and Drug Control is responsible for detecting the neutralizing antibodies of different serotypes.

2.4.2 Overview of the Institution

National Institutes for Food and Drug Control is a public institution directly affiliated to National Medical Products Administration. It is the national statutory institution for quality of the drugs and biological products and the highest technical arbitral institution, and it is “World Health Organization Drug Quality Assurance Cooperation Center” designated by World Health Organization. It undertakes the review and approval registration test, import test, supervision and inspection and safety evaluation of the products of many fields such as drugs, biological products, medical devices, foods, health foods, cosmetics, laboratory animals, packaging materials, etc. and batch release of the biological products, and is responsible for the national study, distribution and management of the drugs, medical device standard substances and bacterial and viral strains/seeds used for production and control test, and carrying out the related technical study work.

2.5 Supervision Institution

2.5.1 Responsibilities

Clinical Study Department of Sinovac Biotech Co., Ltd. is responsible for the clinical trial supervision.

-    Carry out the clinical trial supervision according to GCP, protocol and SOP.

-    Assist the sponsor to undertake the works such as screening and training of the clinical trial institutions and holding of the kick-off meeting, etc.

-    Verify the trial flow and progress.

-    Verify the signing situations of the informed consent.

-    Verify the qualifications of the investigator and effectiveness of the used equipment.

-    The related works such as transportation, storage, distribution and use, return and handling, etc. of the vaccines in the clinical trial.

-    Verify the situations of collection, storage and transportation, etc. of the biological samples.

-    Verify the handling situations of the adverse events.

-    Verify the logicality of the original records and the report documents in the trial.

-    Finish the supervision work, etc. after completion of the trial.

2.5.2 Overview of the Institution

2.6.1 Responsibilities

Shijiazhuang Horizon Medical Technology Co., Ltd. is responsible for the data management of the clinical trial.

-    Establish the data management plan and data verification plan according to the protocol requirements.

-    Carry out the data management work according to Technical Guidance for Clinical Trial Data Management Work in the process of the trial. Confirm that all the data reports and records are correct and complete.

-    Carry out data cleaning, ask question for the study data and assist the investigator to verify and clarify.

-    Write the data management report.

2.6.2 Overview of the Institution

Shijiazhuang Horizon Medical Technology Co., Ltd. (hereinafter referred to as “Horizon”) was established in 2018. It is a high-tech enterprise of clinical trial data management and statistical analysis. Horizon has high efficient, professional and stable talent team as well as complete management and quality control system. The current coverage areas include BE, phase I-IV drug and device clinical trials, and the served customers include well-known foreign and domestic research and development enterprises. It has finished more than one hundred drug and medical device clinical trial data management and statistical analysis projects. Horizon data management team has data management experiences in the international clinical trial projects, has participated in more than one hundred NMPA drug clinical registration projects and hundreds of the medical device clinical registration projects and more than 50 international scientific research cooperation projects. It has the management experiences in the international EDC system projects such as Medidata RAVE/Merge eClinical OS/OC RDC, etc. and it participates in the NMPA Clinical Data Management Working Group of China (CDMC). It has expert members in China CDISC group (C3C) SDTM group. The education background of the members of the team is bachelor degree and above and they have participated in more than 20 times of external training of the industry.

2.7 Statistical Analysis Responsible Institution

2.7.1 Responsibilities

Beijing Key Tech Statistical Technology Co. Ltd. is responsible for the statistical analysis work of the clinical trial.

-    Be responsible for writing of the randomization, sample size and statistical analysis parts in the clinical trial protocol.

-    Be responsible for writing the statistical analysis plan according to the clinical trial protocol.

-    Carry out randomization and blinding of the clinical trial.

-    Carry out the statistical analysis according to the proposed statistical analysis plan, and write the statistical analysis report.

2.7.2 Overview of the Institution

Beijing Key Tech Statistical Technology Co. Ltd. (hereinafter referred to as Key Tech” was registered in Beijing in August 2017. It is a wholly domestic-funded company which focuses on the management and statistical analysis services of the clinical trial data. With the biostatistics service of the clinical study as the core, it mainly provides the services such as statistical strategy consultation for the drug study plan, statistical design and statistical analysis of the clinical trials, etc. through the whole process of the clinical trial for the registration clinical trials. Key Tech has established offices in Beijing, Xi’an ad Nanning. There are 43 staff in total at present who are mainly graduated from the top colleges and universities in China such as the Fourth Military Medical University, Peking University, Sichuan University, etc. There are 21 statisticians/statistical programmers, 18 data management personnel, 1 quality control personnel and 3 other business personnel. The education background distribution includes 3 doctors, 6 masters and 34 bachelors.

Key Tech has assisted the sponsor to obtain 8 clinical trial approvals, and finished 12 NDA applications in total since establishment until now, including 3 category 1 new drugs of biological products, the first 13-valent pneumococcal vaccine products in China and the second adalimumab product. Of the applied projects, 6 clinical study projects of vaccines have passed the CFDI project verification and 4 projects have finished the CDE technical evaluation. Key Tech has signed the related agreements on the statistical consultation service of the Asian-Pacific region with Abbott in 2019. It has established long-term cooperative partner relationship with the main innovative pharmaceutical enterprises both at home and abroad, including Jiangsu Hengrui, Zhejiang Hisun, Chia Tai Tianqing, CSL, Chongqing Zhifei, Yunnan Walvax, etc.

1.Background and Principle

3.1 Summary

Poliomyelitis (polio) is an acute communicable disease caused by any kind of the three serotypes (type I/II/III) of poliovirus and it is mainly transmitted through the fecal-oral route and oral-oral route. Almost all the children may be infected with poliovirus infection before the invention of the poliovirus vaccine. Currently there is no cure for poliomyelitis disease and only the symptoms will be alleviated by drugs. The control of poliomyelitis mainly depends on the use of vaccines.

Ninety percent of those infected with the poliovirus have no clinical symptoms or only very mild clinical symptoms, including fever, headache, vomiting, fatigue, neck stiffness, and pain in the limbs. On average, one of every 200 infected patients has paralytic poliomyelitis , usually due to viral entry into the central nervous system and replication of the virus in the anterior horn cells (motor neurons) of the spinal cord. Temporary paralysis or permanent paralysis may occur due to different degree and extent of motor nerve damage. The part of paralysis mainly centralizes in legs and more seriously it may extend to the trunk of the patients, including the paralysis of the chest and abdominal muscles and the most serious symptom is the damage of the central nervous system caused after poliovirus invasion of the brain cells which leads to dysphagia and pararthria. Of the patients with paralytic poliomyelitis, 5% - 10% of the children and 15%~30% of the adolescents and adults died due to respiratory muscle paralysis and. About 25 - 50% of the patients with disability due to poliomyelitis may experience more poliomyelitis sequelae within 15 to 30 years, including the further muscle atrophy, aggravation of feeling of fatigue and pain of muscle and joint tissues. Risk of paralysis may be increased by hypoimmunity, pregnancy, tonsillectomy, intramuscular injection, overexercise and injury.

3.2 Virology

Three serotypes of poliovirus are very similar in other aspects except the immunogenicity. Poliovirus is a enterovirus of the family of Picornaviridae and it contains the single-stranded positive-sense RNA genome. The protein capsid is an icosahedron stereo symmetrical structure without envelope and it is composed of 60 subunit fragments. The capsid structure of each fragment is composed of 4 kinds of capsid proteins (VP1 - 4) . Three main kinds of protein (VP1, VP2 and VP3) have the same basic structure and the smallest VP4 protein locates in the virus. Poliovirus antigens divide to two classes such as Density (D) antigen and Coreless, (C) antigen. D antigen can induce the antibody to produce neutralizing antibody and therefore it is also called neutralization antigen, but C antigen cannot stimulate antibody to produce the neutralization antibody. The peptide loops extended from the outer surfaces VP1, VP2 and VP3 structural proteins of the viral particles are sites to form the neutralization antigen.

The biochemical and physiological properties of poliovirus are same as other enteroviruses. Poliovirus can be stable for 1 to 3 hours under acidic pH (3.0~5.0) conditions and some common detergents or disinfectants (lipid solvents such as soap, nonionic detergents and ethanol, ethyl ether, trichloromethane, etc.) cannot inactivate virus. Poliovirus is easy to be inactivated by 0.3% formaldehyde or 0.5 ppm free chlorine under the dry, low humidity and ultraviolet ray exposure conditions. The infectivity of the viruses can be stable for several weeks at 4℃ and can be stable for several days at 30℃.

3.3 Epidemiology

In history, occurrence and prevalence of poliomyelitis cases occurred in almost all the regions all over the world. Poliomyelitis was completely eliminated in American continent, European region and Western Pacific region in 2016. The number of poliomyelitis cases caused by the wild-type strain was sharply decreased from 350,000 cases in 1988 to 370,000 cases and the cases were only distributed in 3 countries, i.e., Pakistan (20 cases), Afghan (13 cases) and Nigeria (4 cases). The wild poliovirus type II was eliminated in 1999. The wild poliovirus type 3 (WPV3) did not recur after the last case occurred in Nigeria on November 10, 2012.

There was no local report of the wild poliovirus case in 1994 after long-term inoculation for large-scale since oral poliovirus vaccine (OPV) was included in planned immunization since 1970s in China. The Western Pacific Region including China was proved to be the poliovirus-free region 2000. However, prevalence of wild virus still exists in Afghanistan and Pakistan which are close to China. Introduced case of poliovirus also occurred in Xinjiang region in China 2011. Therefore, WHO has also listed China as one of the most risky countries.

On the other hand, though use of OPV in China has played an important role for elimination of poliovirus in China, inoculation of OPV will cause the vaccine-derived poliovirus (VDPV) because the OPV contains the attenuated live poliovirus and risk will be caused for the population who has not been immunized. The threatens of the vaccine-associated paralytic poliomyelitis (VAPP) and VDPV caused by inoculation of OPV always exist in the use process of OPV. From January 2015 to May 2016, the number of the countries with occurrence of VDPV was increased from 4 to 7, and the new cases occurred in Ukraine (VDPV1, 2 cases), Burma (VDPV2, 2 cases), Guinea (VDPV2, 7 cases), Laos (VDPV1, 1 case) and Madagascar (VDPV1, 10 cases).

3.4 Production and Application of sIPV

Several breakthroughs have been obtained at the end of 1940s and at the beginning of 1950s for development of the poliovirus vaccine. Based on the breakthroughs, Dr. Jonas Salk studied and proved that poliovirus could be completely inactivated according to the first-order reaction rate after the aggregated virus particles have been filtered out. Trivalent inactivated poliovirus vaccine (IPV) was successfully registered and marked in US in 1955. The manufacturing process of IPV was relatively mature since IPV was developed in last century and Vero cell was used as the production substrate and there were few significant changes since then. Because both the production and inoculation (injection) costs for IPV are relatively high, wild strains are used as the production raw material for IPV, the requirements for biosafety grade are very strict and the number of the manufacturers of IPV is also strictly limited, the production and use of IPV are mainly limited to the developed countries at present and it is difficult to promote the production. There is only one IPV supplier, Pasteur, in Chinese market and it mainly centralizes in the private market.

In order to realize the strategy to completely block the contamination of poliovirus, strengthen the immunization and gradually discontinue OPV, WHO recommends the developing countries to use a novel inactivated poliovirus vaccine manufactured using an attenuated strain (Sabin strain) to replace OPV at the last stage of elimination of poliomyelitis so as to thoroughly eliminate the occurrence of VDPV and VAPP caused by inoculation of OPV. This strategy has been implemented in China at present. The planned immunization strategy of the current stage is 1 dose of sIPV (IPV) + 3 doses of OPV, and sIPV will completely replace OPV with the increase of the production capacity. The Sabin-IVP (sIPV) manufactured using the attenuated strain has more production safety and lower cost compared to the IPV manufactured using the wild-type strain (Salk strain) and it is more suitable to be popularized and used in the developing countries. Global use of inactivated poliovirus vaccine is an necessary approach to realize the global elimination of poliomyelitis and sIPV is an necessary supplement of the currently available IPV. Therefore, the development of sIPV of the manufacturers has obtained the support and encouragement of WHO. In order to support this plan, WHO starts to fund Netherlands Vaccine Institute (NVI), i.e., the current Institute for Translational Vaccinology (hereinafter referred to as “Intravacc”) to develop sIPV since 2008 and provides technology transfer for the vaccine manufacturers in the developing countries selected by WHO.

The number of manufacturers of sIPV in China will be very limited because of limited virus seed lot. There are mainly five domestic manufacturers of sIPV, including Institute of Medical Biology, Chinese Academy of Medical Sciences (Kunming Institute), National Vaccine & Serum Institute Co., Ltd. (National Vaccine & Serum Institute), Wuhan Institute of Biological Products Co., Ltd., Sinovac Biotech Co., Ltd. and Beijing Minghai Biotechnology Co., Ltd. (Beijing Minhai). The vaccines manufactured by Kunming Institute and National Vaccine & Serum Institute have been marketed in 2016 and 2017, and the clinical trials of the vaccines manufactured by Sinovac Biotech, Wuhan Institute and Beijing Minhai are ongoing. The sum of the production capacities of the marketed products and the products which will be marketed recently is inadequate to meet the global supply and domestic requirements and therefore sIPV has great market potential.

Sinovac has obtained the technology transfer qualification of WHO Sabin-IPV project through competitive bidding and on-site examination. Then Sinovac carried out due diligence investigation for the Netherlands Intravacc and finally decided to introduce the sIPV technology from the Netherlands. The sIPV of Intravacc has been developed by the mature IPV production technology and has production experiences for decades of years. The development of sIPV has relatively high technical maturity and the optimized sIPV yield is equivalent to that of IPV. The phase I/IIa clinical trial of the product has proved that the product is safe and effective and the target dose has been determined. Sinovac and the Netherlands Intravacc has been explicitly stipulated the content of technology transfer and responsibilities of both parties when they have business negotiation. The important biological materials, technical data and personnel training related to sIPV are all within the scope of technology transfer and laid the foundation for project promotion.

Sinovac has been engaged in development and production of inactivated virus vaccines for many years, for example, Hepatitis A Vaccine (Human Diploid Cell), Inactivated and Enterovirus Type 71 Vaccine (Vero Cell), Inactivated. Sinovac has large scale cell and virus culture, purification and inactivation technology as well as the registration and clinical experiences which play an important basic role for conduct of the sIPV project. The production workshop of sIPV with annual production capacity of 20 million doses have been constructed at present, 2 cell production lines have been established and the maximum culture scale is 1,000 L. Manufacturing process validation has been finished in the commercial production workshop and the validation results comply with the setting specification.

The cell substrate used for the sIPV developed by Sinovac is Vero cells, and the primary cells are from WHO and have production qualification. The primary cell generation is the generation 134, the master cell bank prepared with the primary cells is generation 138, the working cell bank is generation 142 and the generation used for vaccine production is generation 145.

3.5 Considerations on the Inoculation Population and Immunization Schedule

The target population of the investigational vaccine is the 2-month-old infants and it is mainly based on that the requirements for the age in months of the inoculation objects of poliomyelitis vaccine in the national immunization program and the age in months of the inoculation objects of the similar products which have been marketed in China.

The immunization schedule of the investigational vaccine is 3 does for primary immunization at month 0, month 1 and month 2 and 1 dose for booster immunization at month 18, and it has been established by referring to the immunization schedule of the similar vaccines which have been marked in China.

The vaccines inoculated in the trial are inconsistent with the immunization schedule of poliomyelitis vaccine in the national immunization schedule at the current stages. All the vaccines used in the full immunization of the trial are inactivated vaccines and the vaccines used in the full immunization in the normal national immunization schedule include first dose of the inactivated vaccine + other doses of attenuated vaccine, but the prevented diseases are the same.

4.Preclinical Studies and Laboratory Evaluation of Vaccines

4.1 Safety

Single dose acute toxicity tests, acute active systemic anaphylaxis test and local irritation test have been conducted according to the requirements of the former CFDA Good Laboratory Practice (GLP). The results revealed that no obvious toxicity was observed after intramuscular injection of the 5-dose sIPV in mice, active systemic anaphylaxis reaction was not caused in guinea pigs after intramuscular injection of the 5-dose sIPV, and intramuscular injection of the 5-dose sIPV in rabbits had no irritation effect on the muscular tissue of the injection site. The 5-dose sIPV had good safety in the body of the test animals.

4.1.1 Single Dose Toxicity Tests

Acute toxicity test of intramuscular injection of the 5-dose sIPV was conducted in ICR mice according to the requirements of the former CFDA GLP. The dose of the investigation vaccine was 10 ml/kg which is equivalent to 160-fold of the human dose (the body weight each child is calculated as 8 kg), and intramuscular injection is conducted. The test sample was the 5-dose sIPV and the blank control was 0.9% sodium chloride injection. There were 20 animals in each group, 10 female and 10 male, and the animals were continuously observed for 14 days post dosing. The results showed that all the animals were survived, food intake and body weight were not affected, and it showed that the 5-dose sIPV did not have acute toxicity reaction for ICR mice.

4.1.2 Active Systemic Anaphylaxis Test

Active systemic anaphylaxis test of intramuscular injection of the 5-dose sIPV was conducted in guinea pigs according to the requirements of former CFDA GLP. The 5-dose sIPV group, negative control group and positive control group were established, 18 Hartley guinea pigs were selected, 6 animals in each group, 3 female and 3 male. 0.9% Sodium Chloride Injection was administered to the negative control group and 10 mg/ml bovine serum albumin was administered to the positive control group. The sensitization administration volume was 0.5 ml/guinea pig, dose was administered every other day, 3 times in total, and the administration dose for provocation is 2-fold of the sensitization dose. The results showed that all the animals in the positive control group died and the anaphylaxis reactions were very strongly positive and the active systemic anaphylaxis reactions of the guinea pigs in the negative control group and the 5-dose sIPV test group were negative.

4.1.3 Local Irritation Test

Irritation test of intramuscular injection of sIPV was conducted in rabbits according to the requirements of the former CFDA GLP. Six big ear white rabbits were selected, half female and half male. Self-comparison method of the left side and right side of the body was adopted. The left side was the administration side with injection of the 5-dose sIPV and the right side was the control side with injection of equal volume of Sodium Chloride Injection. The injection site was the bilateral quadriceps femoris muscles, the administration volume was 0.5 ml/rabbit and administration was conducted once. Three rabbits were anatomized 48 h post dosing and 21 days post dosing. The muscular stimulation reactions of the administration site were rated and histopathological examination was performed. The results showed that no visible irritation reaction of the injection site quadriceps femoris muscle was observed 48 h post dosing. Neither visible irritation reaction nor the histopathological change of the injection site quadriceps femoris muscle was observed 21 days post dosing. The results showed that the 5-dose sIPV had no irritation effect on the muscular tissue of the injection site.

4.2 Immunogenicity

4.2.1 Immunogenicity Comparability Study of the 5-Dose sIPV and Single Dose sIPV

The 5-dose sIPV (each human dose contains type I 15 DU/type II 45 DU/type III 45 DU) and single dose sIPV (type I 15 DU/type II 45 DU/type III 45 DU) of Sinovac Biotech were diluted for different concentrations and inoculated to the rats to compare the immunogenicity.

The results showed that the type I, type II and type III antibody ED₅₀ ratios after immunization with the 5-dose sIPV and single dose sIPV were 118%, 110% and 102%, respectively which were all within the range of 50 - 200%. The results showed that the immunogenicity results of the two strengths of sIPV were comparable at the same dose. Therefore, it has been determined the antigen content of the 5-dose sIPV is same as that of the single dose sIPV, i.e., the type I/type II/type III antigen content is 15/45/45 DU/dose. See 

Table 1.

Table 1 Comparison of Immunogenicity of the Rats after Inoculation with the 5-Dose sIPV and Single Dose sIPV of Sinovac Biotech

sIPV of Sinovac Biotech

4.2.2 Comparison with the Similar Products

The 5-dose sIPV (each human dose contains type I 15 DU/type II 45 DU/type III 45 DU) of Sinovac Biotech, sIPV (type I 15 DU/type II 45 DU/type III 45 DU) of National Vaccine & Serum Institute, sIPV (type I 30 DU/type II 32 DU/type III 45 DU) of Kunming Institute and IPV (type I 40 DU/type II 8 DU/type III 32 DU) were inoculated in rats to compare the immunogenicity.

The results showed that the N ratios of each type (type I, type II and type III) of the sIPV of National Vaccine & Serum Institute and the 5-dose sIPV of Sinovac Biotech were 117%, 59% and 158%, respectively which were all within the range of 50% - 200%, and the immunogenicity results of the two kinds of the vaccine were comparable. The N ratios of each type (type I, type II and type III) of the sIPV of Kunming Institute and the 5-dose sIPV of Sinovac Biotech were 209%, 73% and 115%, respectively, the immunogenicity of type I of the sIPV of Kunming Institute was superior to that of the 5-dose sIPV of Sinovac Biotech, and the immunogenicity results of type II and type III were comparable with that of Sinovac Biotech. The N ratios of each type (type I, type II and type III) of the IPV of Pasteur and the 5-dose sIPV of Sinovac Biotech were <43%, 255% and 158%, respectively, the immunogenicity of type I of the IPV of Pasteur was inferior to the 5-dose sIPV of Sinovac Biotech, the immunogenicity of type II of the IPV of Pasteur was superior to that of the 5-dose sIPV of Sinovac Biotech and the immunogenicity of type III of the IPV of Pasteur was equivalent to that of the 5-dose sIPV of Sinovac Biotech.

Table 2 Comparison of Immunogenicity of the 5-Dose sIPV and the Marketed Similar Products

4.2.3 Test Results of the Vaccines Used for the Clinical Study

Test of all the items has been conducted for the vaccines used for the clinical study according to the requirements of Manufacturing and Control Test Procedure of Poliomyelitis Vaccine (Vero Cell), Inactivated, Sabin Strain (Draft).

4.3 Antigen Stability and Safety Study of Reuse

Considering that the 5-dose sIPV should be drawn 5 times to inject 5 persons in the process of use, the maximum risk is the contamination of the remaining vaccine in the vaccine vial after many times of drawing. The worst case for on-site use of the 5-dose sIPV was simulated in the laboratory to carry out the antigen stability and safety study. Setting of the worst case: It was drawn for the most times (4 times) on day 1, the interval between the first time of drawing and the last time of drawing was at least 6 h, so that the exposure duration was longest (28 days: the longest time allowed for storage after opening of the vaccine). The safety index (sterility test) and efficacy index (D-antigen content) were selected to study the evaluation method.

The results showed that the sterility results were all sterile on day 0 (the day of the test), day 1 (next day), day 14 and day 28. D-antigen content was determined on day 0 (the day of the test) and day 28, all the results complied with the specification, the D-antigen content did not have obvious decrease. The specific results are provided in Figure 1.

Figure 1 2 - 8°C Stability Trend Analysis Chart of the D-Antigen Content of sIPV

1.Preliminary Clinical Study of the Single Dose sIPV

The clinical study progress and results of the single dose sIPV are briefly summarized as follows:

5.1 Phase Ⅰ/Ⅱ Clinical Trial

The phase I/phase II clinical trial was divided to 2 stages. The first stage was a single-center, 

open-label clinical trial in which 108 healthy subjects were selected and divided to 3 age groups, including 24 adults, 24 children and 60 infants. The subjects received the sequential inoculation of the investigational vaccine according to the order of adults, children and infants from low dose to high dose so as to evaluate the safety of the vaccine in different populations. The second stage was a single-center, blind, randomized, double parallel controlled clinical trial. Six hundred 2-month-old infants were selected and divided to 5 groups. There were 120 persons each group and the subjects received the low dose of investigational vaccine, middle dose of investigational vaccine, high dose of investigational vaccine, control sIPV and control IPV. The immunization schedule is 3 doses at month 2, month 3 and month 4. Adverse reactions were actively monitored from day 0 to day 7 after inoculation of each dose of vaccine, the adverse reactions/events were collected by the way of active reporting from day 8 to day 30 so as to evaluate the safety of the investigational vaccine. Blood was collected before primary immunization and after 30 days of primary immunization to detect the neutralizing antibody so as to evaluate the immunogenicity of the vaccine in phase 2.

The analysis of the safety results revealed that the dose-effect relationship of the investigational vaccine was obvious incidences of the investigational vaccine low and middle dose groups were comparable with the control vaccine group and sIPV had relatively good safety. For the antibody positive seroconversion rate after immunization, the type I, type II and type III antibody positive seroconversion rates of the middle dose group (15 DU/45 DU/45 DU) were 96.30%, 97.22% and 100.0%, respectively. The type I antibody positive seroconversion rate of the IPV control group was lowest (95.45%), the type I antibody positive seroconversion rate of the high dose group was highest (100.0%) and there was statistically significant intergroup difference (P=0.0291); the type II antibody positive seroconversion rate of the sIPV control group was lowest (82.69%), the type II antibody positive seroconversion rate of the middle dose investigational vaccine group was highest (97.22%) and there was statistically difference between each group (P=0.0017); the type III antibody positive seroconversion rate of each group was within the range of 97.12% - 100.0%, and there was no statistically significant intergroup difference (P=0.2109). The type I, type II and type III antibody GMTs after immunization of the middle dose group were 4, 634.60, 341.56 and 2, 217.91, respectively. A obvious dose-effect relationship was shown in low, middle and high dose groups of the investigational vaccine and GMT increased with increase of dose. The results revealed that there was obvious dose-effect relationship between the type I, type II and type III antibodies of the investigational vaccine low, middle and high dose groups, the immunogenicity of type I, type II and type IIII antibodies of the middle dose group were all superior or equivalent to the marketed IPV control vaccine and sIPV control vaccine.

In combination with the safety and immunogenicity results, the middle dose sIPV investigational vaccine was selected as the target dose in the phase III clinical trial and sequential trial. The difference between the 5-dose sIPV and single dose sIPV was that the preservative 2-phenoxyethanol was added for preparation of final bulk, and therefore the middle dose 5-dose sIPV vaccine was used as the target dose.

5.2 Phase III Clinical Trial

A randomized, double-blind, positive controlled design is adopted for the phase III clinical trial, 1,200 2-month-old infants have been enrolled and divided to 2 groups according to the ratio of 1:1 and 600 subjects in each group. The subjects have received the middle dose investigational sIPV and IPV control . Each subject received inoculation of 4 of the of the vaccine, including 3 doses for primary immunization at month 0, 1 and 2 and 1 dose for booster immunization when the subjects were 18 months old. The 7-day safety observation was conducted after inoculation of each dose. Spontaneous reporting method was adopted to collect the adverse reactions/events from day 8 to day 30 and the SAE monitoring has been finished. About 3.0 ml of venous blood have been collected from all the subjects before primary immunization, 30 days after primary immunization, before immunization and 30 days after booster immunization. The serum has been for detection of the neutralizing antibodies against poliovirus type I, type II and type III so as to evaluate the primary immunization effects, immune persistence and booster immunization effects.

(1) Immunogenicity Evaluation

The antibody positive seroconversion rates of types I - III of the trial group and control group were 98.01% vs 94.13%, 94.76% vs 83.99% and 98.92% vs 97.69%, respectively and the positive seroconversion and ≥1:64 rates were 98.01% vs 93.95%, 93.67% vs 78.47% and 98.92% vs 97.15%, respectively. The positive seroconversion rate and positive seroconversion and ≥1:64 rates of all the types the trial group reached non-inferiority, in addition, except the positive seroconversion rate of type III antibody, the positive seroconversion rate and positive seroconversion and ≥1:64 rates of the antibodies of other types reached superiority. After correction of those with positive antibody using the maternally transferred antibody before immunization using the maternally transferred antibody, the positive seroconversion rates of all the types of the trial groups were all more than 98%, the positive seroconversion and ≥1:64 rates were more than 96%, the positive seroconversion rates and positive seroconversion and ≥1:64 rates of all the types reached non-inferiority in which the positive seroconversion and ≥1:64 rates of type II antibody reached superiority.

The trial results revealed that the investigational vaccine had good immunogenicity and the immunogenicity of antibody of each type was equivalent or superior to the marketed IPV control vaccine.

(2) Safety Evaluation

The incidence rates of the overall adverse reactions of the trial group and control group were 66.44% and 56.67%, respectively. There was statistically significant difference between the two groups (P=0.0006). The adverse reactions were mainly grade 1. The incidence rates of grade 1, grade 2 and grade 3 adverse reactions were 41.53%, 19.02% and 1.00%, respectively. The incidence rates of grade 1, grade 2 and grade 3 adverse reactions were 42.57%, 23.37% and 0.50%, respectively in the trial group and 40.50%, 14.67% and 1.50%, respectively in the control group. There was statistically significant difference of the grades of adverse reactions between the two groups.  The adverse reactions were mainly solicited, redness was the main local reaction and fever was the main the systemic reaction. The incidence rate of fever was 55.71% and the incidence rates of the trial group and control group were 61.60% and 49.83%, respectively. There was statistically significant difference between the two groups (P<0.0001). The incidence rate of serious adverse events was 2.25% during the whole clinical trial period and the incidence rates of the trial group and control group were 2.34% and 2.17%, respectively. There was no statistically significant difference between the two groups (P=0.8488). No serious adverse reaction occurred during the trial.

The trial results revealed that the incidence rate of fever of the investigational group was slightly higher than those of the control group, but the incidence rates of grade 1 and grade 2 adverse reactions were mainly increased and the incidence rates of adverse reactions were similar between the two groups. The results were similar to the results of other marketed sIPV and it revealed that the safety of the vaccine was good.

5.3 Sequential Clinical Trial

The sequential clinical trial was the supplemental trial of the pivotal phase III clinical trial, 

and the randomized, double-blind, positive controlled design is adopted, including the “1+2” sequential schedule and “2+1” sequential schedule, and the control vaccine was the IPV manufactured by Pasteur. The 2 months old infants were selected as the objects to carry out the clinical trial, and 240 subjects were enrolled in total. For the “1+2” sequential schedule, the subjects were randomly divided into the trial group and positive control group according to the ratio of 1:1. The subjects received 3 doses of the vaccine according to the immunization schedule of month 0, month 1 and month 2, i.e., received sIPV or IPV for the first dose and received the bivalent oral poliovirus vaccine (bOPV) for the second dose. For the “2+1” sequential schedule, sIPV or IPV was inoculated for the first dose and second dose and bOPV was inoculated for the third dose. The 30-day safety observation will be conducted after inoculation of each dose of vaccine. Combination of active reporting and passive observation will be adopted within the first 7 days (14 days for bOPV) after inoculation of sIPV or wIPV, active reporting will be adopted on day 8 to day 30 (day 15 to day 30 for bOPV), the adverse reactions/events will be will be About 3.0 ml of venous blood will be collected before immunization and after 30 days of immunization of 3 doses and the serum will be used to determine the neutralizing antibodies against poliovirus type I, type II and type III so as to carry out the immunogenicity evaluation.

The study results showed that the overall incidence rates of adverse reactions of the “1+2” sequential and “2+1” sequential trial groups were 69.17% and 82.50%, respectively, and there was no statistically significant difference compared to the control group. The results showed that the two kinds of inoculation schedules had good safety. The clinical trial with two kinds of sequential inoculation was combined with the results of the phase III pivotal clinical trial. For type I and type III antibodies, relatively good response could be obtained for the “1+2” sequential schedule, “2+1” sequential schedule and the sIPV immunization schedule of 3 doses, the positive seroconversion rate was close to 100% and GMT was more than 1:1,000. The differences in GMT were relatively great with different immunization schedules, and “2+1” sequential >“1+2” sequential >3 doses of sIPV were manifested for both the investigational sIPV and control IPV. For the type II antibody, the immunogenicity increased with increase of the inoculation doses of sIPV, the positive seroconversion rate and GMT of the “1+2” sequential were significantly low, the positive seroconversion rate was 54.21% and GMT was 1:27.70. Though the “2+1” sequential schedule was superior to the “1+2” sequential schedule, the positive seroconversion rate was only 81.36%, and the antibody levels of 16.95% of the subjects were <1:64. Though causes caused by type II wild poliovirus (WPV) disappeared all over the world after 1999, the type II circulating vaccine-derived poliovirus (VDPV) in the external environment and the second generation human-to-human transmission cases of the circulating vaccine-derived poliovirus (cVDPV) was persistent, and it may still have certain risk once exposure occurs.

1. Brief Introduction of the Product Characteristics

6.1 Preparation Process and Formulation of the Vaccine

Five-dose sIPV is a trivalent liquid vaccine prepared by inoculating the type I, type II and type III Sabin poliovirus in the Vero cells followed by culture, virus harvest, concentration purification and formaldehyde inactivation and mixing in proportion.

Five-dose sIPV is a clear liquid packaged in vials and each vial contains 2.5 ml (5 human doses). Each human dose is 0.5 ml which contains type I antigen 15 DU, type II antigen 45 DU and type III antigen 45 DU. The non-active substances include medium 199, glycine, formaldehyde, sodium chloride, potassium chloride, calcium chloride, magnesium sulfate, disodium hydrogen phosphate, sodium dihydrogen phosphate and 2-phenoxyethanol. . Inoculation of the vaccine can induce the body to produce the active immunity and prevent the poliomyelitis caused by type I, type II and type III poliovirus. The vaccine is prepared by Beijing Sinovac Biotech Co., Ltd. and it complies with the for Manufacturing and Control Test Procedure of Poliomyelitis Vaccine (Vero Cell), Inactivated, Sabin Strain (Draft) through the test of the National Institutes for Food and Drug Control.

6.2 Vaccine Stability

All the test results comply with the specification after the 5-dose sIPV has been stored at 2 - 8°C for 18 months, stored at 25°C for 6 months and stored at 37°C for 7 days and the contents of all the types of antigens had no obvious decrease trend. The 2 - 8°C long-term stability study is still ongoing. The shelf life of the 5-dose sIPV has been temporarily determined as 36 months by referring to the Manufacturing and Control Test Procedure of Poliomyelitis Vaccine (Vero Cell), Inactivated, Sabin Strain (Draft).

6.3 Control Vaccine

IPV is a trivalent liquid vaccine prepared by inoculating the type I (Mahoney strain), type II (MEF-1 strain) and type III (Saukett strain) in the Vero cells followed by culture, virus harvest, concentration purification and formaldehyde inactivation and mixing in proportion. Each vial contains 0.5 ml of vaccine and contains type I antigen 40 DU, type II antigen 8 DU and type III antigen 32 DU. It is manufactured by Pasteur, has been tested by National Institutes for Food and Drug Control and complies with the requirements. Shelf life is 36 months.

Single dose sIPV is a trivalent liquid vaccine prepared by inoculating the type I, type II and type III Sabin poliovirus in the Vero cells followed by culture, virus harvest, concentration purification and formaldehyde inactivation and mixing in proportion. sIPV is a clear liquid packaged in vials, 0.5 ml each vial, and it contains type I antigen 15 DU, type II antigen 45 DU and type III antigen 45 DU. The non-active substances include medium 199, glycine, formaldehyde, sodium chloride, potassium chloride, calcium chloride, magnesium sulfate, disodium hydrogen phosphate and sodium dihydrogen phosphate. Inoculation of the vaccine can induce the body to produce the active immunity and prevent the poliomyelitis caused by type I, type II and type III poliovirus. The vaccine is prepared by Beijing Sinovac Biotech Co., Ltd. and it complies with the for Manufacturing and Control Test Procedure of Poliomyelitis Vaccine (Vero Cell), Inactivated, Sabin Strain (Draft) through the test of the National Institutes for Food and Drug Control. Shelf life is 36 months.

6.4 Storage and Transportation of the Vaccine

Protect from light, store and transport at 2-8°C and do not freeze.

6.5 Inoculation Route and Schedule of the Vaccine

The eligible subjects received injection of single dose of 0.5 ml of the investigational vaccine or the control vaccine.

It is used for intramuscular injection in the deltoid muscle of the upper arm for adults and children with the immunization schedule of one dose. The 3 doses for primary immunization of infants are intramuscularly injected to the anterolateral aspect of thigh for infants and the immunization schedule is month 0, month 1 and month 2. Booster immunization is conducted when the subjects are 18 months old, and the vaccine is intramuscularly injected in the deltoid muscle of the upper arm, 0.5 ml/dose/time. Sufficiently shake well before use.

6.6 Information of the Trial Products

The information of the product used for the clinical trial is shown in the following table. The vaccine in trial group 1 is used only for the trial in phase I.

Table 3 Information of the Vaccine Used for the Clinical Trial

Note: The details of the batch number and shelf life of the vaccine are provided in the certificate of analysis of the vaccine and batch release certificate.

6.7 Vaccine Packaging

The vaccine is packaged in the boxes with labels. The vaccines used at phase I and phase II are separately packaged. The vaccines used for primary immunization and booster immunization are also separately packaged. The vaccine label patterns are shown as follows:

The pattern of the packaging box is as follows:

1.Trial Objective

Evaluate the safety of the 5-dose sIPV in different populations and lot consistency, immunogenicity and safety of 3 consecutive lots of the 5-dose sIPV manufactured with commercial scale in 2 months old infants (aged 60 - 89 days) and evaluate that the investigational vaccine was non-inferior to the control IPV of Pasteur and the single dose sIPV of Sinovac Biotech.

Primary Objective:

(1) Evaluate the lot consistency after primary immunization with 3 consecutive lots of the 5-dose sIPV manufactured with commercial scale in 2 months old infants, i.e., the GMTs after 30 days of primary immunization are equivalent between the lots (equivalence margin 0.67 - 1.5).

(2) Evaluate that the immunogenicity after primary immunization with the 5-dose sIPV manufactured with commercial scale in 2 months old infants was non-inferior to the control vaccine IPV, i.e., the positive seroconversion rate after 30 days of the basic immunization with the 5-dose sIPV is non-inferior to the IPV control group (non-inferiority margin -10%).

Secondary Objectives:

(1) Evaluate that the immunogenicity after primary immunization with the 5-dose sIPV manufactured with commercial scale is non-inferior to the control vaccine single dose sIPV in 2 months old infants.

(2) Evaluate the safety of the 5-dose sIPV.

(3) Immune persistence after primary immunization until the booster immunization with the 5-dose sIPV.

(4) Immune effects after booster immunization with the 5-dose sIPV when the subjects are 18 months old.

2.Test Design

8.1 Design

8.1.1 Overall Design

The project is divided into 2 phases, open-label design is adopted for phase I and randomized, blinded and controlled design is adopted for phase II.

8.1.2 Estimation of the Sample Size

Calculate the sample size according to the related requirements in Provisions for Drug Registration, Good Clinical Practice and Technical Guidelines for Clinical Trials of Vaccines.

8.1.2.1 Phase I Clinical Trial

Carry out the early clinical trial according to the requirements of the above regulations and Clinical Trial Notification. The sample size has been determined as 72 persons, 24 of each of the adults aged 18 to 49 years, children aged 6 years and infants aged 2 months (60 to 89 days), and mainly evaluate the safety of the vaccine.

8.1.2.2 Phase II Clinical Trial

Calculate the sample size by referring to the preliminary clinical trial results of the single dose trial vaccine and similar vaccines.

The strategy of sequential test is adopted for calculation of the sample size, consistency between three lots of the 5-dose sIPV of the commercial scale will be evaluated first. If the lot consistency is valid, the three lots of the 5-dose sIPV should be combined and non-inferiority comparison should be conducted with IPV control vaccine, and therefore correction of type I errors and type II errors will not be conducted.

(1) Lot Consistency of 3 Lots of the 5-Dose sIPV

Use the antibody GMT of the subjects after 30 days of the primary immunization as the observation index to carry out the comparison for the antibodies of 3 serotypes (including type I, type II and type III) between every two lots. If the 95% CI of the antibody GMT ratio 30 days after the primary immunization of the subjects is within the range of 0.67 - 1.5, the inter-lot equivalence is considered. The test level is two-sided α=0.05, the total power is 80%, and the power of each test corrected by Bonferroni method is 1-β/9=1-0.2/9=97.78%. Based on the preliminary clinical study data, the antibody logarithmic transformation value standard deviation = 0.5 and assume that the antibody levels between the lots are comparable. It has been calculated by the NCSS-PASS software that: each group = 251 subjects.

(2) Non-inferiority Comparison of the 5-Dose sIPV and Control IPV

If the 5-dose sIPV investigational vaccine reaches the evaluation criteria for lot consistency between 3 lots, combine the results of the 5-dose sIPV trial groups to carry out the non-inferiority comparison with the IPV control group. Use the antibody positive seroconversion rate of the subjects 30 days after primary immunization as the observation variable and the antibodies of 3 serotypes (including type I, type II and type III) should be compared between each . Assume that the antibody positive seroconversion rate after 30 days of immunization of the IPV control group is 90%, and the antibody positive seroconversion rate of the trial group is comparable to the IPV control group. N_T:N_C =3:1, the combined sample size of the 5-dose sIPV trial group is 753 subjects and there are 251 subjects in the IPV control group according to the calculation results of the sample size of last step. With α=0.025 (one-sided) and non-inferiority margin δ of -10%, Miettinen & Nurminen method is adopted to calculate using NCSS-PASS software and the results reveal that the test has the power of 99.81% to obtain the conclusion that the 5-dose sIPV trial group is non-inferior to the IPV control vaccine.

Therefore, in conclusion, considering the drop-out rate of about 15%, 300 subjects are required for each group and 1,500 subjects in total.

8.2 Trial Endpoints

Determine the neutralizing antibody levels before and after immunization of the subjects, calculate the neutralizing antibody positive seroconversion rate, positive rate and GMT of each group after immunization and evaluate the immunogenicity of the 5-dose sIPV.

Observe the clinical symptoms and vital signs of the subjects, calculate the incidences of adverse reactions/events and evaluate the safety of the 5-dose sIPV.

8.2.1 Primary Study Endpoints

-    Serum neutralizing antibody GMT 30 days after primary immunization.

-    Serum neutralizing antibody positive seroconversion rate 30 days after primary immunization (the criteria of positive seroconversion rate can be seen in Section 10.9 Immunogenicity Evaluation).

8.2.2 Secondary Study Endpoints

-    Incidence rates of adverse reactions occurred within 0 to 30 days after inoculation of each dose of the investigational vaccine;

-    Incidence rates of adverse reactions occurred within 0 to 7 days after inoculation of each dose of the investigational vaccine;

-    Incidence rates of the SAEs during the safety observation period;

-    Serum neutralizing antibody positive rate, GMI and percentage of subjects with titer of the neutralizing antibody ≥1:64 30 days after primary immunization;

-    Neutralizing antibody positive rate, GMT and percentage of subjects with titer of the neutralizing antibody ≥1:64 before the booster immunization (14 months after the basic immunization);

-    Neutralizing antibody positive seroconversion rate, positive rate, GMT, GMI and percentage of subjects with titer of the neutralizing antibody ≥1:64 30 days after the booster immunization.

8.3 Study Hypothesis and Evaluation Criteria

8.3.1 Primary Study Hypotheses

The clinical trial mainly has the following primary study hypotheses:

Hypothesis Test 1: 30 days after primary immunization with 3 lots of the 5-dose sIPV in the subjects, the immunogenicity GMTs between lots in the pairwise comparison of 3 serotypes of each lot of the investigational vaccine are equivalent (the equivalent margin is 0.67 - 1.5).

Hypothesis Test 2: 30 days after primary immunization of the subjects in the 5-dose sIPV trial group, the antibody positive seroconversion rates of 3 serotypes are non-inferior to the IPV control group (non-inferiority margin is -10%).

8.3.2 Evaluation Criteria

(1) Evaluation criteria for lot consistency: when the 95% CI of the GMT ratios of 3 serotypes 30 days after primary immunization of the subjects in the 5-dose sIPV trial group of 3 lots is within the range of 0.67 - 1.5, inter-lot equivalence is considered.

(2) Non-inferiority evaluation criteria: The lower limit of the 95% CI of the differences in the antibody positive seroconversion rates of 3 serotypes 30 days after primary immunization is ≥-10%.

8.4 Study Plan

The project is divided into two phases.

Phase I: Carry out the clinical trial with adults aged 18 to 49 years, children aged 4 years and infants aged 2 months (60 to 89 days old) as the subjects. Inoculate 1 dose or 4 doses of the trial vaccine under the premise that informed consent has been obtained from the subjects or their guardians with the objective to evaluate the safety of the investigational vaccine in different populations. Seventy-two healthy subjects were selected, including 24 adults, 24 children and 24 infants. Carry out the study for adults, children and infants in turn. Firstly, 24 adults are selected to receive the one dose of the investigational vaccine. Under the circumstances that the 7-day safety observation has been assessed, and it has been preliminarily confirmed to be safe, choose 24 children to receive the inoculation of one dose of the investigation vaccine. Under the circumstances that the 7-day safety observation has been assessed, and it has been preliminarily confirmed to be safe, choose 24 infants to inoculate 4 doses of the trial vaccine according to the immunization schedule of month 0, month 1 and month 2 for primary immunization and booster immunization when the subjects are 18 months old.

Phase II: The enrollment of the subjects of phase II should be started under the premise that the 7-day safety observation has been finished for the subjects in the infant group in phase I after inoculation of the first dose and safety has been preliminary confirmed through assessment and the results comply with the protocol. Under the premise that the informed consent has been obtained from the guardians of the subjects, recruit 1,500 2 months old infants and randomly divide the subjects into 5 groups according to the ratio of 1:1:1:1:1:1: trial group 1, trial group 2, trial group 3, IPV control group and single dose sIPV control group in which the subjects in the 3 trial groups should receive inoculation of 3 consecutive lots of the 5-dose sIPV manufactured at the commercial scale, the IPV control group will receive the IPV manufactured by Pasteur and the single dose sIPV control group will receive inoculation of the single dose sIPV manufactured by Sinovac Biotech. All the subjects will receive the inoculation of 4 doses of the investigational vaccine or control vaccine according to the immunization schedule of month 0, month 1 and month 2 for primary immunization and booster immunization when the subjects are 18 months old.

Observe the 30 min immediate reaction, systemic and local solicited adverse reactions from day 0 to day 7 and unsolicited adverse events from day 0 to day 30 after inoculation of each dose after inoculation of each dose of all the subjects in phase I and phase II and finish the SAE monitoring during the safety observation period.

Blood will not be collected for subjects in phase I. About 2.5 ml of venous blood should be collected from all the subjects in phase II before primary immunization, 30 days after primary immunization, before booster immunization and 30 days after booster immunization. The serum is used for the detection of the neutralizing antibodies against poliovirus type I, type II and type III so as to evaluate the primary immunization effects, immune persistence and booster immunization effects.

Unblinding of the clinical trial will be finished first after the completion of the primary immunization and the summary report of the primary immunization part will be written. The content of the booster immunization part will be subsequently submitted in the form of supplemental report.

Table 4 Clinical Trial Design of Phase I

Table 5 Clinical Trial Design of Phase II

According to the approval requirements, in order to assess whether antigen content occurs after reuse of the 5-dose vaccine for many times on the site, it is proposed to determine the antigen of one lot of the retention sample of the vaccine used on the site during the inoculation period of each dose of the primary immunization. This lot of vaccine will be used to inoculate 1 to 4 subjects, and the remaining retention samples of the vaccine will be tested (not less than 10 vials for each kind of circumstance). Sample will not be retained for another vaccine on the site, and each vial of the 5-dose sIPV vaccine will be used to inoculate 5 subjects in principle.

8.5 Randomization and Blind Method

8.5.1 Randomization and Numbering

Phase I (Single Group Open-label Trial Design)

Randomization is not conducted. The vaccine in trial group 1 is used. One vial of the 5-dose investigational vaccine is used for 1 subject only.

The numbering principle of the subjects in phase I is “2-digit serial number”, 01 - 24 for the adult group, 25- 48 for the child group and 49 - 72 for the infant group.

The vaccine numbering rule in phase I is “P+3-digit (4-digit) serial number”. Continuous numbers are used, and standby vaccine will not be additionally set. One dose of the vaccine is required for adults and children. Three doses of vaccine are required at the primary immunization stage of infants and the vaccine numbers are P001 - P150. One dose of vaccine is required for the booster immunization of infants. One dose of the investigational vaccine is used, and the vaccine numbers are P1001 - P1030.

Phase II (Randomized, Blinded and Controlled Trial Design)

The subjects screened and enrolled after informed consent will randomly receive the inoculation of different lots of the investigational vaccine or control vaccine (including trial group 1, trial group 2, trial group 3, IPV control group and single dose sIPV control group) under the blind state with the ratio of 1:1:1:1:1.

The stratified block randomization method is adopted for the trial, and site is used as the stratification factor, and Interactive Web Response System (IWRS) is used to finish the subject randomization and distribution of the trial vaccines. The subject random table of the subjects is produced by the randomization statistician with the SAS software, and it will be input into the IWRS system by the system engineer. In addition, the system engineer will input the mapping relationship table between the vaccine numbers and pseudo vaccine numbers provided by the randomization statistician into the IWRS system. An random number will be assigned by the investigator to each subject who participates in the trial after successful screening. The non-blind staff will login the IWRS system to input the random number of the subject to obtain the vaccine number and pseudo vaccine number. The randomization statistician should enable the emergency unblinding function of the system at the same time when the blind codes of the subjects are prepared. The blind codes are in duplicate and should be sealed and separately stored by the sponsor and study institution.

The numbering principle of the random number of the subject is “4-digit serial number”, i.e., 0001 - 1500 in phase II. If the obtained vaccines are damaged or the 5-dose sIPV vaccine is used out in advance in the process of the trial, the study personnel on each trial site should obtain the new vaccine number through the IWRS system for subject inoculation.

The numbering rule of the vaccine number is “Subject Group Code + 3-digit (4-digit) Serial Number” in phase II, continuous numbers are used, and standby vaccine will not be additionally set. Three doses of the vaccine are required at the primary immunization stage, A001 - A600, B001 - B600 and C001 - C600 for the trial groups of 3 lots, D001 - D990 for the IPV control group and E001 - E990 for the sIPV control group. One dose of the vaccine is required for the booster immunization stage, A1001 - A1330, B1001 - B1330 and C1001 - C1330 for the 3 trial groups, D1001 - D1330 for the IPV control group and E1001 - E1330 for the single dose sIPV control group. The numbering rule of the pseudo vaccine number is G + 5-digit serial number ranged from G00001-G10980

8.5.2 Blind Method

The blind state of the subjects is realized through the non-blind vaccine taking personnel and IWRS system randomization and vaccine distribution, and blind coding of the vaccine is not required. In the process of the trial, only the non-blind vaccine taking personnel can obtain the login permission of the IWRS system, and take and allocate the vaccines used for the trial. The investigators on each site can login the IWRS system to obtain the random number of the subjects and cannot contact the number of the vaccines used for the trial so as to maintain the blind state of the study team.

Considering that many subjects will be inoculated with the 5-dose sIPV, the 5-dose sIPV and single dose sIPV control vaccine are packaged in vials, the IPV control vaccine is packaged in the prefilled syringes, and partial investigators or some guardians of the subjects will know the subject grouping situations. In order to reduce the influences of such circumstances on the study effects, the following measures should be taken to keep the blind state: (1) the external packaging boxes of the 5-dose sIPV, IPV control vaccine and single dose sIPV must be consistent, and (2) vaccine number and pseudo vaccine number should be designed to maintain the blind state of the trial. Vaccine number is the actual ID number of the trial vaccine, and only the non-blind vaccine taking personnel and randomization statistician can contact with it. The pseudo vaccine number is the assumed number of the vaccine injected for each subject. One vial of the 5-dose sIPV vaccine corresponds to 5 pseudo vaccine numbers. IPV control vaccine and single dose sIPV vaccine only correspond to one pseudo vaccine number. The pseudo vaccine numbers are used for the sticking of the related forms and cards, and can be obtained by the investigators on the site. The subject study number corresponds to the pseudo vaccine number one by one. For the 5-dose sIPV vaccine to be tested, set 1 - 5 pseudo vaccine numbers according to the requirements of trial design in Section 8.4. The mapping relationship table between the vaccine numbers and pseudo vaccine numbers is generated by the randomization statistician. The pseudo vaccine number distribution personnel should distribute the pseudo vaccine number to each vaccine package, and only the randomization statistician, vaccine taking personnel and the pseudo vaccine number distribution personnel can contact the mapping relationship table between the vaccine numbers and pseudo vaccine numbers and seal it after completion of distribution. (3) The investigators who obtain the vaccine numbers from the IWRS system, personnel of the vaccine inoculation working group (vaccine taking/preparation personnel and inoculation personnel), quality control personnel and the non-blind CRA must sign the confidentiality agreement and cannot participate in other works related to the study information of the subjects in the clinical trial, and (4) the vaccine preparation and inoculation staff should operate in the independent partition area. The vaccine preparation personnel should submit the prepared vaccine to the vaccine inoculation personnel after it has been checked that there is no mistake for the information of the subject. The vaccine inoculation personnel should check the information of the subject again, and carry out inoculation after it has been confirmed that there is no mistake. (5) The used syringes and empty vaccine vials should be timely returned/destroyed and records should be made.

8.5.3 Emergency Unblinding

Under the circumstances when emergency unblinding is required during the study period, the specific grouping information of the subject should be obtained through the emergency unblinding module of the IWRS system. Operate according to the prompt and carry out the emergency unblinding, and make the related records. The subject with the study number who terminates the trial will be handled as drop-out , and the investigator should record the reasons for termination in the case report form. IWRS system records the emergency unblinding occurred in the process of trial.

8.5.4 Unblinding Requirements

Primary unblinding method is adopted for this study. After completion of the inoculation for primary immunization, 30-day safety observation after inoculation of each dose, blood collection and determination of the neutralizing antibody in the serum samples, the data files will pass the blind review, and will be locked after it has been confirmed that there is no mistake. After the database is locked, the parties such as the sponsor and principal investigator will jointly implement the unblinding, and keep the unblinding record, and each group has been inoculated with each kind of the vaccine will be obtained after unblinding.

8.6 Flow Chart of the Clinical Trial

8.7 Study Time

8.7.1 Duration of the Clinical Trial

Table 6　Duration of the Clinical Trial

8.7.2 Expected Participation Time of the Subject in the Trial

The expected participation time is not less than 1 month for the adult and children subjects and the expected time is not less than 17 months for the infant subjects.

8.8 Trial Discontinuation and Early Termination

Trial Discontinuation Criteria:

-    One or more than one case of the grade 4 (local, systemic) adverse reactions related to vaccine inoculation occur.

-    More than 15% of the subjects in each group experience the adverse reactions of grade 3 and above, including local reactions, systemic reactions and vital signs.

Early Termination Criteria of the Trial:

-    The investigator and sponsor will jointly discuss and decide whether the trial should be terminated after the clinical trial is suspended.

-    The sponsor requires to fully terminate the trial and has explained reasons;

-    The ethics committee requires to fully terminate the trial and has explained reasons;

-    The administrative departments in charge require fully terminating the trial and has explained reasons.

8.9 Protocol Violations and Deviations

The list of the protocol violations is as follows (including but not limited to):

Appropriate informed consent has not been conducted for the subjects.

The subject who does not meet the inclusion criteria or meets the exclusion criteria has been enrolled in the study.

The subject has received inoculation of the wrong vaccine.

SAE has not been reported within the specified time.

The list of the protocol deviations is as follows (including but not limited to):

The subject has not received the inoculation of the trial vaccine within the window period.

Blood has not been collected within the window period.

The interval from the inoculation of other vaccines is inadequate, except the emergency inoculation for rabies, tetanus, etc.

1. Subject Population

9.1 Subject Inclusion Criteria

9.1.1 Inclusion Criteria for Adult Subjects

-    Healthy adults aged 18 - 49 years;

-    Provide the statutory identity certificate documents;

-    The subjects have the ability to learn and have signed the informed consent form.

9.1.2 Inclusion Criteria for Children Subjects

-    Healthy children aged 4 years;

-    The children have finished the primary immunization with 3 doses of poliomyelitis vaccine;

-    Provide the vaccination certificate and statutory identify certificate documents;

-    The guardians of the subjects have the ability to learn and have signed the informed consent form.

9.1.3 Inclusion Criteria for the Infant Subjects

-    Healthy infants aged 2 months (60 to 89 days);

-    Provide the vaccination certificate and statutory identify certificate documents;

-    The guardians of the subjects have the ability to learn and have signed the informed consent form.

9.2 Subject Exclusion Criteria

9.2.1 Exclusion Criteria for the Adult Subjects

-    Female subjects aged 18 years to 49 years with positive urine pregnancy test, pregnant and lactating women or the women who plan to be pregnant within 3 months;

-    Past medical history of poliomyelitis;

-    Those with allergy history, history of asthma, including allergy history to vaccine or components of the vaccine, serious adverse reactions of the vaccine such as urticaria, dyspnea, angioneurotic edema or stomachache, etc.

-    Congenital malformation or developmental disorder, genetic defect, serious malnutrition, etc.;

-    Autoimmune disease or immunodeficiency/immunosuppression.

-    Patients with thyroid disorder, history of thyroidectomy, asplenia, functional asplenia and asplenia or splenectomy caused by any circumstances.

-    Patients with serious chronic diseases, serious cardiovascular diseases, hypertension (systolic pressure is >14 mmHg and diastolic pressure is >90 mmHg) and diabetes which cannot be controlled with drugs, liver and kidney diseases, malignant tumors, etc.

-    Patients with family history of mental disorders, serious nervous system disorders (epilepsy, convulsion or tic) or mental disorders.

-    Abnormal coagulation functions (such as coagulation factor deficiency, blood coagulation disease and blood platelet disorders) or obvious bruise or blood coagulation disorders diagnosed by the doctors;

-    Those who have received immunosuppressant therapy, cytotoxic drug therapy and inhaled corticosteroid therapy (excluding the corticosteroid aerosol therapy for allergic rhinitis and surface corticosteroid therapy for acute non-complicated dermatitis) in the past 6 months;

-    History of excessive drinking or drug abuse for long time;

-    The volunteer has received blood products within 3 months before inoculation of the trial vaccine;

-    The volunteer has received other study drugs within 30 days before inoculation of the trial vaccine;

-    The volunteer has received live attenuated vaccines within 14 days before inoculation of the trial vaccine;

-    The volunteer has received subunit or inactivated vaccines within 7 days before inoculation of the trial vaccine;

-    Various acute diseases or acute exacerbation of chronic diseases within recent 7 days;

-    The patient who has fever before inoculation of the trial vaccine, axillary temperature >37.0℃;

-    The volunteer has any other factors which are unsuitable for participation in the clinical trial as judged by the investigator.

9.2.2 Exclusion Criteria for Children Subjects

-    The children have been inoculated with 4 doses of poliomyelitis vaccine;

-    Past medical history of poliomyelitis;

-    Those with allergy history, history of asthma, including allergy history to vaccine or components of the vaccine, serious adverse reactions of the vaccine such as urticaria, dyspnea, angioneurotic edema or stomachache, etc.

-    Congenital malformation or developmental disorder, genetic defect, serious malnutrition, etc.;

-    Autoimmune disease or immunodeficiency/immunosuppression.

-    Patients with thyroid disorder, history of thyroidectomy, asplenia, functional asplenia and asplenia or splenectomy caused by any circumstances.

-    Patients with serious cardiovascular diseases, diabetes, liver and kidney diseases, malignant tumors, etc.

-    Patients with family history of mental disorders, serious nervous system disorders (epilepsy, convulsion or tic) or mental disorders.

-    Abnormal coagulation functions (such as coagulation factor deficiency, blood coagulation disease and blood platelet disorders) or obvious bruise or blood coagulation disorders diagnosed by the doctors;

-    Those who have received immunosuppressant therapy, cytotoxic drug therapy and inhaled corticosteroid therapy (excluding the corticosteroid aerosol therapy for allergic rhinitis and surface corticosteroid therapy for acute non-complicated dermatitis) in the past 6 months;

-    History of excessive drinking or drug abuse for long time.

-    The volunteer has received blood products within 3 months before inoculation of the trial vaccine;

-    The volunteer has received other study drugs within 30 days before inoculation of the trial vaccine;

-    The volunteer has received live attenuated vaccines within 14 days before inoculation of the trial vaccine;

-    The volunteer has received subunit or inactivated vaccines within 7 days before inoculation of the trial vaccine;

-    Various acute diseases or acute exacerbation of chronic diseases within recent 7 days;

-    The patient who has fever before inoculation of the trial vaccine, axillary temperature >37.0℃;

-    The volunteer has any other factors which are unsuitable for participation in the clinical trial as judged by the investigator.

9.2.3. Exclusion Criteria for the Infant Subjects

-    The volunteer has received inoculation of poliomyelitis vaccine;

-    Past medical history of poliomyelitis;

-    Those with allergy history, history of asthma, including allergy history to vaccine or components of the vaccine, serious adverse reactions of the vaccine such as urticaria, dyspnea, angioneurotic edema or stomachache, etc.

-    Infants with premature labor (delivery before week 37 of gestation) and low body weight (birth body weight is <2,300 g for girls and <2,500 g for boys);

-    Infants with difficult labour at birth, asphyxiation rescue and history of nervous system injury;

-    Congenital malformation or developmental disorder, genetic defect, serious malnutrition, etc.

-    Autoimmune disease or immunodeficiency/immunosuppression;

-    Patients with thyroid disorder, history of thyroidectomy, asplenia, functional asplenia and asplenia or splenectomy caused by any circumstances.

-    Patients with serious cardiovascular diseases, diabetes, liver and kidney diseases, malignant tumors, etc.

-    Patients with family history of mental disorders, serious nervous system disorders (epilepsy, convulsion or tic) or mental disorders.

-    Abnormal coagulation functions (such as coagulation factor deficiency, blood coagulation disease and blood platelet disorders) or obvious bruise or blood coagulation disorders diagnosed by the doctors;

-    Those who have received immunosuppressant therapy, cytotoxic drug therapy and inhaled corticosteroid therapy (excluding the corticosteroid aerosol therapy for allergic rhinitis and surface corticosteroid therapy for acute non-complicated dermatitis);

-    The volunteer has received blood products before inoculation of the trial vaccine;

-    The volunteer has received other study drugs within 30 days before inoculation of the trial vaccine;

-    The volunteer has received live attenuated vaccines within 14 days before inoculation of the trial vaccine;

-    The volunteer has received subunit or inactivated vaccines within 7 days before inoculation of the trial vaccine;

-    Various acute diseases or acute exacerbation of chronic diseases within recent 7 days;

-    The patient who has fever before inoculation of the trial vaccine, axillary temperature >37.0℃;

-    The volunteer has any other factors which are unsuitable for participation in the clinical trial as judged by the investigator.

9.3 Exclusion Criteria for Inoculation of the Second Dose, Third Dose and Fourth Dose for Infant Subjects

The subjects with any of the adverse event (AE) in the following (1) to (4) are forbidden to continue the inoculation of the vaccine, but they can continue other study steps according to the judgment of the investigator’s judgment. For the subjects who experience any of the adverse events in the following (5) and (6), the investigator will judge whether inoculation will be continued. For the subjects who experience the adverse events in the following (7) to (10), inoculation can be delayed within the time window specified by the protocol.

(1) The subject has received the inoculation of the poliomyelitis vaccine other than the trial vaccines or the combined vaccines containing the component of poliomyelitis vaccine.

(2) Any serious adverse reaction which has causal relationship with the inoculation of the investigational product.

(3) Serious hypersensitivity or hypersensitivity reaction after vaccine inoculation.

(4) Any confirmed or suspected autoimmune disease or immunodeficiency disease, including human immunodeficiency virus (HIV) infection.

(5) Acute or newly onset chronic disease occurs during vaccine inoculation.

(6) Other reactions (including serious pain, serious swelling, serious activity limitation, continuous hyperthermia, serious headache or other systemic or local reactions) occur after vaccine inoculation.

(7) The volunteer has acute disease when vaccine is inoculate (acute diseases means the moderate or severe disease with or without fever).

(8) Axillary temperature >37.0℃ when vaccine is inoculated.

(9) The subject has received the subunit or inactivated vaccine within 7 days or has received the live attenuated vaccines within 14 days.

(10) The subject has any other factors which are unsuitable for inoculation as judged by the investigator

9.4 Subject Discontinuation and Termination Criteria

-    The guardian of the subject requires to discontinue the trial.

-    Intolerable adverse events, whether they are related to the investigational drug.

-    The subject is not allowed to participate in this trial due to the health status.

-    The subject has any abnormal clinical manifestation, whether it is judged as related to the vaccine by the investigator, the investigator will judge whether the subject should terminate the clinical trial in advance.

-    Any other reason considered by the investigator.

If a subject who terminates the trial in advance have received the test vaccine, the clinical trial data of this subject will be used for safety analysis. The subject cannot be replaced in the trial. After the subjects who have received the vaccines used in the clinical trial discontinue or terminate the trial, the investigator should provide necessary guidance for any clinical situation occurred related to the trial and carry out the follow-up of the subject until the diagnosis is confirmed/disease state is stable/the subject is healed.

2. Methods and Procedure

10.1 Recruitment and Informed Consent

Issue the recruitment notification to the volunteers who meet the inclusion criteria or their guardians. Explain the informed consent form to the volunteer or the guardian in detail, and the volunteer or guardian or the study doctor should jointly sign the “informed consent form” in duplicate. The volunteer or the guardian will keep the duplicate copy.

Recruit the subjects of phase I first. Start the recruitment of the subjects of phase II if the safety evaluation results after 7 days of the inoculation of the first dose for infants comply with the protocol requirements.

10.2 Screening and Randomization

Carry out the preliminary inquiry and screening of the volunteers who have signed the informed consent form according to the inclusion and exclusion criteria. An enrollment number will be assigned for each eligible subject according to the enrollment order. In phase I, the subject numbers are 01 - 24 for the adult group, 25- 48 for the child group and 49 - 72 for the infant group. In phase II, the subject numbers are 0001 - 1500.

10.3 Blood Sample Collection before and after Immunization

Collect the venous blood samples from the subjects before the primary immunization, 30 days after the primary immunization, before booster immunization and 30 days after booster immunization of all the subjects, and separate the serum to determine the antibody level in phase I. Collect about 2.5 ml of blood sample each time and the sample number is “subject number + sample collection code”. The collection codes of the samples collected before the primary immunization, 30 days after primary immunization, before the booster immunization and after 30 days of booster immunization are expressed by “-0”, “-1”, “-2” and “-3”. For example, the number of the sample collected from subject 0001 before primary immunization is “0001-0”.

10.4 Vaccine Inoculation

In phase I, one vial of the 5-dose investigational vaccine is used for one subject. The vaccine taking/preparation personnel should take the 5-dose investigational vaccine, open the external package, and check the number information on the vial label of the vaccine and that on the label of the external package. Take the vaccine after the information has been confirmed to be consistent, take out the vaccine number label from the packaging box and submit it along with the vaccine to the vaccine inoculation personnel. The vaccine inoculation personnel should inoculate the subjects, paste the vaccine number label on the corresponding position of the original record and record the inoculation information in the original record form.

In phase II, the vaccine taking/preparation personnel should obtain the corresponding vaccine number in the IWRS system according to the study number of the subject, find out the vaccine of the corresponding number and open the external package, and check the number information on the vaccine vial label and the number information on the label of the external package. Take the vaccine after the information has been confirmed to be consistent, take out one pseudo vaccine number label from the packaging box and submit it along with the vaccine to the vaccine inoculation personnel. The vaccine inoculation personnel should inoculate the subjects, paste the pseudo vaccine number label on the corresponding position of the original record and record the inoculation information in the original record form.

Use one vial/syringe of the vaccine for each subject in booster immunization.

The inoculation site and route are provided in “6.5 Inoculation Route and Schedule of the Vaccine”. The injection site should be disinfected with 75% alcohol before inoculation and injection should be conducted after skin is dry in the air. One vial of the 5-dose investigational vaccine can be used to inoculate at most 5 subjects, and draw 0.5 ml to inoculate one subject each time. The vaccine inoculation personnel should receive related training and guidance in order to ensure that the drawing quantity of the investigational vaccine is accurate.

Take back the contact card before inoculation of the second dose and third dose of the vaccine and review the adverse events. The subsequent exclusion criteria should be inquired before the inoculation of the subsequent doses, and the eligible subjects will receive the vaccine inoculation.

The immunization schedule can be seen in “8.4 Study Plan”.

10.5 Medical Observation

Observe the adverse events occurred within 30 min after inoculation of each dose of the vaccine on the site, and use the diary card and contact card to collect the adverse events occurred from day 0 to day 7 and from day 8 to day 30. The doctor should explain the judgment of the adverse event, measurement method, record method, precautions, reporting way, etc., distribute the diary card, scale and thermometer, train the subjects to use the thermometer, observe the adverse events, complete the diary card, and appoint the time to return the diary card. The subjects should return the diary card and take the contact card 8 days after inoculation. Submit the contact card 30 days after inoculation.

10.6 Safety Observation and Follow-up

-    Observe the subjects on the site after inoculation of each dose of the vaccine and   distribute the diary card. The investigator should explain the observation and completion method, inform the subjects of the return time of the diary card and the contact method with the investigator under emergency.

-    Carry out the telephone visit once 6 - 24 h after inoculation of each dose of the vaccine, and inquire the subject of the occurrence of the adverse reaction.

-    Carry out the face-to-face visit of the subject once within 1 to 3 days after inoculation of each dose of the vaccine, and observe and guide the subject to correctly measure and complete the diary card.

-    Carry out the telephone visit of the subject once within 4 to 7 days after inoculation of each dose of the vaccine. If the adverse events and adverse reactions of grade 3 and above are informed via telephone, carry out the face-to-face visit within 24 h.

-    On day 8 after inoculation of each dose of the vaccine, the investigator will review the completion situations of the diary card during the period and provide corresponding guidance, take back the diary card, and distribute the contact card at the same time.

-    From day 8 to day 30 after inoculation of each dose of the vaccine, the investigator should carry out the safety observation in the form of the follow-up once weekly combined with the spontaneous reporting of the subject, and take back the contact card on day 30 after inoculation of each dose of the vaccine.

-    The SAEs occurred since day 31 after inoculation of the third dose until booster immunization of the infant subjects are collected in the form of the follow-up once weekly combined with the spontaneous reporting of the subject.

The subjects should be informed to record the clinically significant adverse events at any time. The occurrence of the acute allergic reactions, adverse events of grade 3 and above and SAEs should be reported to the investigator at any time and the investigator should carry out investigation, verification and follow-up after he/she is informed of such as adverse events until the events have been solved and finally finish the detailed investigation and follow-up record.

-    Description of the of the Adverse Event

-    Start Time and End Time of the Adverse Event

-    Intensity Grading

-    Correlation with Vaccine Inoculation

-    Laboratory Test Results

-    Handling Measure

If acute allergic reaction and adverse events of grade 3 and above occur after inoculation, active treatment and handling should be timely provided so as to relieve pain for subjects. If SAEs occur after inoculation, green channel for medical rescue should be initiated, medical rescue should be timely provided. The drug treatment and medical treatment of each follow-up should be recorded in detail.

10.7 Safety Evaluation

10.7.1 Safety Observation Variables

Adult Group and Child Group:

Solicited local adverse events: Pain, induration, redness, swelling, rashes (injection site) and pruritus

Solicited systemic adverse events (including vital signs): Fever (axillary temperature), acute allergic reactions, skin and mucosa abnormality, diarrhea, anorexia, nausea, vomiting, muscle pain (non-inoculation site), headache, cough, fatigue and asthenia.

Infant Group:

Solicited local adverse events: Tenderness, redness, swelling, rashes (injection site), induration and pruritus.

Solicited systemic adverse events (including vital signs): Fever (axillary temperature), acute allergic reactions, skin and mucosa abnormality, irritability or suppression, new onset of seizures, anorexia and vomiting.

The details are provided in “10.7.7 Safety Evaluation Criteria”.

10.7.2 Definition of the Adverse Reaction/Event

The safety of the vaccine will be evaluated according to the scope, intensity and severity of the adverse reactions of the local reactions, systemic reactions and vital signs, and correlation with the adverse reactions/events.

All the adverse events occurred in the process of the trial (e.g., since signing of the informed consent form) should be collected and recorded and should be reported to the sponsor and CRA by the investigator.

(1) Adverse event (AE): Refer to all the adverse medical events emergent after the subjects of the clinical study have received the investigational vaccine which can be manifested as the symptoms, vital signs, diseases or abnormal laboratory tests, but they may not necessarily have a causal relationship with the trial vaccine.
 (2) Adverse reaction: Any reaction which is harmful to human or is unexpected reaction which may be related to the investigational vaccine occurred in the clinical trial. There is at least one reasonable possibility for the causal relationship between the investigational vaccine and the adverse event, i.e., the correlation cannot be ruled out.
(3) Serious adverse event (SAE): Refer to the untoward medical event occurred after the subjects has received the investigational vaccine which may result in death, life-threatening, persistent or significant disease or incapacity, require inpatient hospitalization or prolongation of existing hospitalization, as well as a congenital anomaly or birth defect.

(4) Suspected and unexpected serious adverse reactions: Refer to the suspected and unexpected serious adverse reactions, the nature or severity of which are not consistent with the available data information in the investigator's brochure of the investigational product, insert or summary of product characteristics of the marketed drugs.

(5) Solicited/unsolicited adverse events: The soliciting period is from day 0 to day 7 after inoculation of each dose and the unsoliciting period is from day 8 to day 30 after inoculation of each dose in this trial. The solicited symptoms occurred during the soliciting period are solicited adverse events. Other symptoms occurred during the soliciting period and all the symptoms occurred during the unsoliciting period are unsolicited adverse events.

10.7.3 Outcomes of Adverse Events

The outcomes of the adverse events include: (1) recovered, (2) not recovered, (3) recovered but has sequela, (4) death and (5) loss to follow-up/unknown.

10.7.4 Correlation between the Adverse Event and Vaccine

The investigator should try best to explain the adverse events and assess the possible causal relationship, namely, the causal relationship between investigational vaccine inoculation and the superseding cause (e.g., history of the underlying disease, concomitant treatment). It is applicable to all the AEs, including serious and very serious AEs.

The assessment of causal relationship will be determined according to the degree at which the event can be reasonably explained in one or many of the following aspects:

-    Reactions with similar nature have been observed for the similar products;

-    The same event has been reported in the literatures of the drug products of the similar type;

-    The event appeared with inoculation of the investigational vaccine and recur after reinoculation of the investigational vaccine;

According to the definition, all the solicited AEs (i.e., all the local adverse reactions in the solicited reports) appeared on the inoculation site will be considered to be related to the investigational vaccine.

The causal relationship of AE should be assessed by the investigator according to the following questions, whether there is rational possibility that the AE is caused by vaccine inoculation according to your judgment:

(1) Absolutely unrelated: The occurrence of adverse event is caused by other factors, for example, the clinical status of the subjects, other treatments or accompanying drugs.

(2) Possibly unrelated: The occurrence of adverse event may be caused by other examples, for example, the clinical status of the subjects, other treatments or accompanying drugs, inconsistency with the known information of the investigational product.

(3) Possibly related: The adverse event complies with the known information of the investigational vaccine and has causal relationship with the trial vaccine, but it may also be related to other factors.

(4) Probably related: The adverse event complies with the known information of the trial vaccine and has causal relationship with the investigational vaccine and cannot be explained with other factors such as clinical status of the subjects, other treatments or accompanying drugs.

(5) Absolutely related: The adverse event complies with the known information of the investigational vaccine and has causal relationship with the trial vaccine and such relationship cannot be explained with other factors such as clinical status of the subjects, other treatments or accompanying drugs. In addition, the adverse event recurs after the subject reuses the investigational vaccine.

10.7.5 Treatment of Adverse Reactions/Events

The reactions such as redness, swelling, pain or (and) fever and general malaise below grade 2 usually can spontaneously disappear and special treatment is not required.

The investigator will carry out the investigation and medical follow-up such as disease history, physical examination and necessary laboratory tests and handling and follow-up if the investigator experiences any clinically significant disease/event after inoculation of vaccine for the adverse reaction/event of grade 3 and above occurs from start of immunization until within 30 days after immunization of the subjects until the event has been solved and detailed investigation record should be finished. The content of the investigation record should include symptoms, vital signs, diagnosis and laboratory test results.

10.7.6 Treatment and Reporting of Serious Adverse Events

The monitoring and reporting of the adverse events in the clinical trial of the vaccine are jointly finished by the subject, adverse event investigator, trial site and responsible institution at different observation time points.

Sponsor is the responsibility entity of clinical trial safety information monitoring, evaluation and SAE reporting. Designate the responsible persons as the clinical trial safety information monitoring and SAE reporting administrator who will jointly establish the standard operating procedure for the clinical trial safety information monitoring and SAE reporting with the investigator. Grasp the latest status of the safety information of the whole trial and timely report to all the clinical trial institutions/investigators and regulatory departments.

If the correlation between SAE and the vaccine is difficult to be judged or doubt has been raised for judgment of the correlation and judgment should be made again, it should be demonstrated through the expert demonstration meeting and then judgment should be made.

(1) On-site Handling Measures

The emergency plan for treatment of SAE in the process of the clinical trial should be established in the trial site, and all the related personnel should be trained. If the subject experiences the serious adverse event, the investigator should immediately take appropriate measures for the subject and make records. The investigator must have the measures to be timely informed of any clinically significant disease/event occurred after vaccine inoculation of the subjects, and ask the subject to timely to the designated hospital to receive the appropriate treatment according to relevant national requirements.

The investigator of the trial site should follow up the serious adverse events/reactions until the symptoms disappear or symptoms are stable. Record the progress process and outcome of all the symptoms in detail. All the drug treatments and medical treatments will be recorded in any time of follow-up. The investigator should truthfully record the serious adverse events, and make evaluation and discussion in the final report after completion or termination of the trial.

If the subject experiences the physical injury caused by the vaccine related serious adverse reactions confirmed by the expert investigation group in the whole process of observation, the sponsor will provide corresponding compensation according to Regulations on the Administration of Circulation and Inoculation of Vaccines and Basic Insurance Compensation Measures for Abnormal Vaccination Reactions of Henan Province (Trial).

(2) Reporting Procedure of the Serious Adverse Events

① Investigator Reporting Procedure

The investigator must submit the initial report of the Serious Adverse Event Report Form to the sponsor via fax, E-mail or EDC system or personal delivery for any serious adverse event no matter whether it is related to the investigational vaccine. Then the follow-up report of the Serious Adverse Event Report Form should be periodically submitted until the completion of the event. Report all the situations in the Serious Adverse Event Report Form in the form of written form report, including the description of the adverse reactions/events, occurrence time and type, duration, intensity, causal relationship with vaccine inoculation, results, treatment method (symptomatic treatment) and other related clinical and laboratory data.

After the report of the serious adverse event/reaction is received, the investigator and the sponsor will decrease whether the subject will continue to participate in the trial or terminate the trial in advance based on the comprehensive consideration on the duration, scope, intensity and outcome of the adverse event and willing of the subject.

② Sponsor Reporting Procedure

The sponsor should rapidly report the serious adverse events which are absolutely related to the investigational drug or suspected unexpected serious adverse reactions (SUSAR) to the study institution, ethics committee, Henan Medical Products Administration and Center for Drug Evaluation, etc. during the drug clinical trial period. The investigator should immediately submit the SUSAR report provided by the sponsor to the ethics committee once it is received. If the sponsor and investigator cannot reach an agreement in judgment of the causal relationship between the adverse event and the drug and any party judges that the relationship to the investigational drug cannot be excluded, expedited reporting should be also conducted by the sponsor.

For the fatal or life-threatening SUSAR, the sponsor should report as soon as possible after it is informed for the first time and should be not more than 7 days, and report and improve the follow-up information within the subsequent 8 days (note: the day when the sponsor is informed for the first time is day 0). For the SUSARs that are not fatal or life-threatening, the applicant should report them as soon as possible but no later than 15 days after the adverse reaction is informed for the first time. For other potential serious safety risk information, the sponsor should also report to the national drug evaluation institution as soon as possible, and should make the medical and scientific judgment for all the kinds of circumstances. After submitting the initial report, the sponsor should continue to follow up the serious adverse reaction and timely submit related new information or change information of the previous report in the form of follow-up report within15 days after the new information is available. The sponsor cannot change the judgment of the correlation between the SAE and vaccine made by the investigator without permission.

10.7.7 Safety Evaluation Criteria

The grading of the adverse reactions mainly refer to National Medical Products Administration Guidelines for Grading Criteria of Clinical Trial Adverse Events of the Preventive Vaccines (2019)”, as shown in the following table:

(1) Adult Group (adults aged 18 to 49 years)

Table 7 Grading of the Inoculation Site (Local) Adverse Events of the Adults

* The diameters should be directly measured for grading assessment of induration and rash, and the progress change of the measurement results should also be recorded.

# The maximum measurement diameter or area should be used for the induration, swelling, rash and redness. The evaluation and grading should be based on the function level and actual measurement results, and the index with higher grade should be selected.

 Table 8 Grading of the Non-inoculation Site (Systemic) Adverse Events and Vital Signs of Adults

*Refer to the type I hypersensitivity reaction

(2) Child Group (applicable to the children aged 4 years)

Table 9 Grading of the Inoculation Site (Local) Adverse Events of Children

* The diameters should be directly measured for grading assessment of induration and rash, and the progress change of the measurement results should also be recorded.

# The maximum measurement diameter or area should be used for the induration, swelling, rash and redness. The evaluation and grading should be based on the function level and actual measurement results, and the index with higher grade should be selected.

Table 10 Grading of the Non-inoculation Site (Systemic) Adverse Events and Vital Signs of Children

*Refer to the type I hypersensitivity reaction

(3) Infant Group (applicable to the infants aged 18 months and younger)

Table 11 Grading of the Inoculation Site (Local) Adverse Events of Infants

* The diameters should be directly measured for grading assessment of induration and rash, and the progress change of the measurement results should also be recorded.

# The maximum measurement diameter or area should be used for the induration, swelling, rash and redness. The evaluation and grading should be based on the function level and actual measurement results, and the index with higher grade should be selected.

 Table 12 Grading of the Non-inoculation Site (Systemic) Adverse Events and Vital Signs of Infants

*Refer to the type I hypersensitivity reaction

For the clinical abnormalities which have not been involved in the above grading table, carry out the intensity grading assessment for the adverse reactions according to the following criteria:

Grade 1 (mild): transient discomfort (<48 h) or slight discomfort, activities are not affected and treatment is not required.

Grade 2 (moderate): mild or moderate limitation of activity, doctor visit may be required, treatment is not required or only mild treatment is required.

Grade 3 (severe): activities are significantly limited, doctor visit is required and treatment should be received, and hospitalization may be required.

Grade 4 (critical): it may be life-threatening, activities are seriously limited and monitoring and treatment are required.

Grade 5: Death.

10.8 Concomitant Medication and Vaccines

10.8.1 Concomitant Medication

-    If adverse event occurs during the trial period, necessary drug treatment and medical treatment are allowed.

-    If serious allergic reaction or life-threatening event occurs, first aid measures must be immediately taken.

-    The investigator should record the information of any concomitant medication, including name, dosage form, dosage and administration, administration time, etc.

10.8.2 Concomitant Vaccines

-    If the subjects should have routine vaccination during the study period, they can receive vaccine inoculation according to the requirements of the product insert, but certain interval is required between the inoculation time and inoculation of the investigational vaccine. Other vaccines should be inoculated at least 7 days after inoculation of the investigational vaccine.

-    If the subject should receive the emergency inoculation of vaccines such as rabies vaccine and tetanus vaccine due to emergency event during the trial period,

-    related information of the concomitant vaccine should be recorded in detail, including name, administration time, inoculation time, etc. of the vaccine.

10.8.3 Records of the Concomitant Medication and Vaccines

In order to learn and excluded the influences of the used drugs on safety and immunogenicity of the vaccine, and collect the adverse events which may be related to vaccine inoculation without missing. The investigator should take measures to collect the subject medication situations and guide the subject or guardian to record the doctor visit and medication situations in the diary card and contact card as possible. When SAE occurs, the copies of the related medical records and medication records should be collected and kept.

10.9 Immunogenicity Evaluation

Collect the venous blood samples from the subjects before the primary immunization, 30 days after the primary immunization, before booster immunization and 30 days after booster immunization of all the subjects, and separate the serum to determine the antibody level.

10.9.1 Evaluation Criteria

The evaluation criteria of positive seroconversion of neutralizing antibody of each type of poliovirus are as follows:

Those with neutralizing antibody titer <1:8 before immunization have positive seroconversion if the neutralizing antibody titer after immunization is ≥1:8; or those with neutralizing antibody titer ≥1:8 before immunization have 4-fold increase of the neutralizing antibody after immunization have positive seroconversion.

10.9.2 Laboratory Tests

Determine the poliovirus antibody by the neutralizing antibody method.

Separate the serum and inactivate in a 56℃ water bath for 30 minutes before use. Carry out the 2-fold dilution of the serum with cell maintenance solution from 1:4 to the suitable degree of dilution and carry out the parallel dilution for 2 wells for each portion of sample. Dilute the virus to 100 CCID₅₀/0.05 ml according to the titer. Mix the serum of different degrees of dilution with virus solution (50 μl+50 μl) and incubate in the 35.0℃ 5%CO₂ incubator for 3 hours. Add 100 μl of Hep-2 cell suspension (control the cell concentration at 0.8~1.0×105 cells/ml) to each well after completion of incubation and incubate in the 35.0℃ 5%CO₂ for 7 days. Negative serum control, positive reference serum control and normal cell control are set in the test and virus back titration test has been set to detect the virus count. Observe the cytopathic effect 5 to 7 days after completion of culture, determine the neutralizing antibody titer in the serum samples to be examined according to the observation results of the cytopathic effects and the result is positive when the serum neutralizing antibody is ≥1:8.

10.10 Data Management

10.10.1 Raw Name

The raw data should include the informed consent form, diary card, original record form, etc. Record the following basic data:

-       Trial name and subject code

-       Demographic data

-       Inclusion/exclusion criteria

-       Vaccine inoculation record

-       Follow-up date and trial discontinuation date of the subject

-       Adverse event/reaction and treatment and outcome

-       Concomitant medical treatment and inoculation of other vaccines

All the data should have original records. The investigator should properly keep the original records in a dedicated space. The raw data should be archived in the study site and it is the true and complete basis for the clinical trial participation and data of the subjects.

The investigator should carefully, accurately and timely make the original record. All the collected original data should be recorded on the day. The raw data should be completed using the blank sign pen, and the completion mistake cannot be altered. The mistake should be ruled out, the correct content should be complete beside it and name and date should be signed.

10.10.2 Electronic Case Report Form (eCRF)

“Electronic data capture System (EDC)” is adopted to establish the electronic CRF in this trial. Electronic CRF is the data to record the clinical trial, it is an important component of the clinical trial and study report and it should be entered using the normative language according to the instruction for use of the EDS system and completion instruction for CRF.

All the data on the electronic CRF should be sourced from the raw data and consistent with the raw data. The entry, verification, modification, cleaning and quality control process of any electronic CRF data will be recorded in the EDC system. The investigator should confirm the data in each copy of electronic CRF and sign with electronic signature after completion of data cleaning.

Only the investigator and the approved staff are allowed to access the EDC system during the trial period.

10.10.3 Data Lock

Two times of data lock are involved in the clinical trial. After completion of all the data entry, verification and data cleaning work of primary immunization, carry out the final data verification. Determine the analyzed population according to the evaluation criteria, determine the protocol violation situations and the influences on the analysis data sets. Then carry out the first time of data lock, and carry out the unblinding flow after completion of the database lock process. The details are provided in “8.5.4 Unblinding Requirements”. The second time of database lock is conducted after completion of all the data entry, verification and data cleaning work of booster immunization. The database lock flow is consistent with the first time of database lock, but only the booster immunization data can be revised.

10.11 Statistical Analysis

10.11.1 Analysis Sets

(1) Full Analysis Set (FAS) at the Primary Immunization Stage: The subject population determined according to the intent to treat (ITT) principles, including all the subjects who have been randomized, have received inoculation of at least one dose of the vaccine, and have finished the blood collection before/after immunization at least once and have effective antibody titer values. Carry out the immunogenicity evaluation according to the randomized groups for the subjects with wrong vaccine inoculation based on the ITT principle.

(2) Per Protocol Set (PPS) at the Primary Immunization Stage: It is a subset of FAS, including all the subjects who have not violated the inclusion/exclusion criteria, have been randomized, have good protocol compliance, do not have major protocol violations, have received the inoculation of the vaccine for primary immunization and blood sample collection within the time window period required in the protocol and have obtained the test results of the blood samples before and after primary immunization. The subject who meet the following criteria cannot enter the PPS:

-    The subject who violates the trial protocol;

-    The subject with wrong vaccine number inoculation;

-    The subject who uses the vaccine or drug prohibited by the protocol;

Ø  Other investigational or unregistered products (drugs or vaccines) other than the investigational vaccine

Ø  The poliomyelitis vaccine other than the trial vaccines or the combined vaccines containing the component of poliomyelitis vaccine

Ø  Immunosuppressor or other immunoregulation drugs for long time (lasts for longer than 14 days) (use of inhaled or topical steroids is allowed)

Ø  Immunoglobulin or blood products

-    Newly confirmed autoimmune diseases, including human immunodeficiency virus (HIV) infection;

-    Other circumstances which affect the immunogenicity evaluation of the vaccine.

The FAS and PPS data sets at the primary immunization stage are mainly used for the immunogenicity evaluation at the primary immunization stage of the vaccine. The full analysis set at the primary immunization stage and the per protocol set at the primary immunization stage are separately defined for type I, type II and type III poliovirus antibodies.

(3) Safety Set (SS) at the Primary Immunization Stage

Safety evaluation should be conducted for any subject who has received vaccine inoculation and has safety evaluation information, and those subjects should be included in the safety set. Safety evaluation will be conducted according to the vaccine groups which are actually inoculated by the subjects according to the All Subjects as Treated (ASaT) principles for the subjects with wrong vaccine inoculation.

The safety evaluation at the primary immunization stage is mainly used for the safety evaluation of the vaccine at the primary immunization stage. The safety analysis of each dose at the primary immunization stage is conducted for the number of the actually inoculated subjects each time in this trial. The safety set of the first dose at the primary immunization stage includes the subjects who have received the inoculation of the first dose of the trial vaccine, the safety set of the second dose at the primary immunization stage includes all the subjects who have finished the inoculation of the second dose of the trial vaccine, and the safety set of the third dose at the primary immunization stage includes all the subjects who have finished inoculation of the third dose of the trial vaccine.

(4) Immune Persistence Set (IPS)

It includes all the subjects who have finished the whole course vaccine inoculation, entered the immune persistence evaluation, have finished the blood collection before booster immunization and have effective antibody values.

IPS is mainly used for the immune persistence evaluation. IPS is separately defined for type I, type II and type III poliovirus antibodies.

(5) Full Analysis Set for Booster (bFAS) at the Booster Immunization Stage: All the subjects who have finished the vaccine inoculation for primary immunization, have entered the booster immunization stage, have finished the vaccine inoculation for the booster immunization and have at least one time of blood collection before and after immunization and have effective antibody values. Carry out the immunogenicity evaluation according to the randomized groups for the subjects with wrong vaccine inoculation based on the ITT principle.

(6) Per Protocol Set for Booster (bPPS) at the Booster Immunization Stage: Including all the subjects who have not violated with the inclusion/exclusion criteria, have finished the vaccine inoculation for primary immunization within the time window period required in the protocol, have entered the booster immunization stage, have finished the vaccine inoculation for booster immunization, have blood collection before and after immunization and effective antibody titer values. The subject who meets the following criteria cannot enter the bPPS:

-    The subject who violates the trial protocol;

-    The subject with wrong vaccine number inoculation;

-    The subject who uses the vaccine or drug prohibited by the protocol;

Ø  Other investigational or unregistered products (drugs or vaccines) other than the investigational vaccine

Ø  The poliomyelitis vaccine other than the trial vaccines or the combined vaccines containing the component of poliomyelitis vaccine

Ø  Immunosuppressor or other immunoregulation drugs for long time (lasts for longer than 14 days) (use of inhaled or topical steroids is allowed)

Ø  Immunoglobulin or blood products

-    Newly confirmed autoimmune diseases, including human immunodeficiency virus (HIV) infection;

-    Other circumstances which affect the immunogenicity evaluation at the booster immunization stage.

bFAS and bPPS datasets are mainly used for the immunogenicity evaluation of the vaccine at the booster immunization stage. The full analysis set at the booster immunization stage and the per protocol set at the booster immunization stage are separately defined for type I, type II and type III poliovirus antibodies.

(7) Safety Set for Booster (bSS)

Including all the subjects who have finished the whole course of primary immunization and entered the booster immunization stage and have received inoculation of one dose of the vaccine for booster immunization. Safety assessment will be conducted according to the vaccine groups which are actually inoculated by the subjects according to the All Subjects As Treated (ASaT) principles for the subjects with wrong vaccine inoculation number.

The safety evaluation at the booster immunization stage is mainly used for the safety evaluation of the vaccine at the booster immunization stage.

The principal investigator, sponsor, statistics party and data management party should jointly discuss all the analysis sets at the primary immunization stage and make the decision in the blind data review meeting before lock of the database at the primary immunization stage. The principal investigator, sponsor, statistics party and data management party should jointly discuss the immune persistence set and the analysis sets at the booster immunization stage before lock of the database at the booster immunization stage.

10.11.2 Statistical Analysis Method

10.11.2.1 General Principles

The statistical description of the measurement data should be conducted with mean, standard deviation, median, maximum value and minimum value. The enumeration data or grading data are expressed with frequency number and frequency.

All the statistical analyses are conducted using the statistical software SAS 9.4.

The database will be locked after completion of the primary immunization stage and booster immunization stage in this trial, then the statistical analysis will be conducted and the statistical analysis report will be written. Combine the data of the subjects in phase I and phase II to carry out analysis.

10.11.2.2 Characteristics of the Subject Population

Summarize the number of the screened subjects, number of the enrolled subjects and number of the subjects who have finished the trial, number of the subjects included in each statistical analysis data set and analyze the reasons for drop-out of the drop-out subjects. Make the list of the subjects with screening failure, list of the drop-out subjects and list of the subjects who have not been included in the analysis sets.

10.11.2.3 Immunogenicity Evaluation

(1) Primary Immunization Stage

Ø  Immunogenicity Evaluation between Different Lots:

The analysis of covariance (ANCOVA) model is used to carry out the statistical analysis of the lot consistency of the antibodies of 3 serotypes (including type I, type II and type III). The antibody GMT after primary immunization after logarithmic transformation is used as the dependent variable, the logarithmic transformation value of the antibody GMT before primary immunization is used as the concomitant variable, and the grouping of each lot is used as the fixed effects in the model. Calculate the logarithmic transformation value of the antibody GMT after primary immunization of each lot and the least square mean of the difference value between every two lots according to the model. Carry out the antilogarithmic transformation to calculate the antibody GMT after primary immunization through the least square correction and the antibody GMT ratios between the lots (lot 1/lot 2, lot 1/lot 3 and lot 2/lot 3) and the 95% confidence interval to carry out the equivalence comparison. If the 95% confidence interval of the corrected ratios between every 2 lots falls within the range of 0.67 - 1.5, the three lots are considered to be equivalent.

Use the geometric mean and two-sided 95% confidence interval to carry out the statistical description of the antibody GMT after immunization and antibody GMT increase fold (i.e., GMI) after immunization of all the populations, negative population before immunization and positive population before immunization for the antibodies of 3 serotypes (including type I, type II and type III) , and carry out the statistical test of the intergroup difference with the analysis of variance after logarithmic transformation. Draw the inverse distribution map of antibody titer before and after the primary immunization.

Calculate the antibody positive rate after the primary immunization, percentage of the subjects with antibody ≥1:64 after primary immunization, positive seroconversion rate after the primary immunization of the negative population before immunization, percentage of the subjects with positive seroconversion of the antibody and ≥1:64 in the negative population before immunization, positive seroconversion rate after primary immunization of the positive population before immunization and percentage of the subjects with positive seroconversion and ≥1:64 after primary immunization in the positive population before immunization of the antibodies of 3 serotypes (including type I, type II and type III) of each lot of the 5-dose sIPV. The two-sided 95% confidence interval is calculated by Clopper-Pearson method and statistical comparison is conducted for the differences between the lots with Chi-square test/Fisher exact probability test.

Ø  Immunogenicity Comparison between the 5-Dose sIPV Group and IPV Control Group and between the 5-Dose sIPV Group and Single Dose sIPV Control Group

Under the circumstances that the lot consistency of 3 lots of the 5-dose sIPV is valid, combine 3 lots to the 5-dose sIPV group to carry out the immunogenicity comparison with the IPV control group and single dose sIPV control group.

Calculate the antibody positive rate after primary immunization, the percentage of subjects with antibody ≥1:64 after primary immunization, positive seroconversion rate of the antibody after primary immunization of the negative population before immunization, percentage of the subjects with positive seroconversion and ≥1:64 after primary immunization in the negative population before immunization, positive seroconversion of the antibody after primary immunization of the positive population before immunization and percentage of the subjects with positive seroconversion of the antibody and ≥1:64 after primary immunization in the positive population before immunization. The two-sided 95% confidence interval is calculated by Clopper-Pearson method and statistical comparison is conducted for the differences between the groups with Chi-square test/Fisher exact probability test. Carry out the following two non-inferiority tests:

Ø  Calculate the two-sided 95% confidence interval of the difference of the positive seroconversion rate of the antibody after immunization (5-dose sIPV group - IPV control group), and carry out the non-inferiority comparison. If the lower limit of the 95% confidence interval is more than ∆=-10%, the non-inferiority test is considered to be successful, otherwise the non-inferiority test fails.

Ø  Calculate the two-sided 95% confidence interval of the difference of the positive seroconversion rate of the antibody (5-dose sIPV group - single dose sIPV control group) after immunization, and carry out the non-inferiority comparison. If the lower limit of the 95% confidence interval is more than ∆=-10%, the non-inferiority test is considered to be successful, otherwise the non-inferiority test fails.

Sensitivity Analysis: Considering the influences of the maternal antibody on the antibody titer before inoculation, add the following corrected sensitivity analysis for the immunogenicity evaluation of the primary immunization stage: correct the antibody before immunization of the positive population before immunization for 3 serotypes (including type I, type II and type III) according to WHO guidelines. The correction formula is as follows:

Corrected Antibody before Immunization = Actual Measured Value/2ⁿ, where n = (Blood Collection Date after Immunization - Inoculation Date of the First Dose)/28.

(2) Immune Persistence Stage

Calculate the antibody positive rate before booster immunization and the percentage of subjects with antibody ≥1:64 before booster immunization for the antibodies of 3 serotypes (including type I, type II and type III) of the 5-dose sIPV group, IPV control group and single dose sIPV group in the immune persistence stage. Calculate the two-sided 95% confidence interval by the Clopper-Pearson method and carry out the statistical comparison of the intergroup difference with Chi-square test/Fisher exact probability test.

Use the geometric mean and two-sided 95% confidence interval to carry out the statistical description of the antibody GMT before booster immunization and increase fold of the GMT before booster immunization compared to 30 days after the primary immunization stage for the antibodies of 3 serotypes (including type I, type II and type III) of the 5-dose sIPV group, IPV control group and single dose sIPV control group. Carry out the statistical test of the intergroup difference with analysis of variance after logarithmic transformation.

(3) Booster Immunization Stage

Calculate the antibody positive rate after the booster immunization, percentage of the subjects with antibody ≥1:64 after booster immunization, positive seroconversion rate after the booster immunization of the negative population before immunization, percentage of the subjects with positive seroconversion of the antibody and ≥1:64 in the negative population before booster immunization, positive seroconversion rate after booster immunization of the positive population before booster immunization and percentage of the subjects with positive seroconversion and ≥1:64 after booster immunization in the positive population before immunization of the antibodies of 3 serotypes (including type I, type II and type III) of the 5-dose sIPV group, IPV control group and single dose sIPV group in the booster immunization evaluation. The two-sided 95% confidence interval is calculated by Clopper-Pearson method and statistical comparison is conducted for the differences between the groups with Chi-square test/Fisher exact probability test.

Use the geometric mean and two-sided 95% confidence interval to carry out the statistical description of the antibody GMT after booster immunization and antibody GMT increase fold (i.e., GMI) after booster immunization of all the populations, negative population before immunization and positive population before immunization for the antibodies of 3 serotypes (including type I, type II and type III) of the 5-dose sIPV group, IPV control group and single dose sIPV group, and carry out the statistical test of the intergroup difference by with the analysis of variance after logarithmic transformation. Draw the inverse distribution map of antibody titer before and after the booster immunization.

10.11.2.4 Safety Analysis

MedDRA is adopted for the medical coding of the adverse events. Statistical analysis is mainly conducted for the treatment emergency adverse events in this trial, and the adverse events occurred before inoculation are listed in the form of list.

Calculate the occurrence case-time, case number and incidence rate of all the adverse events, the adverse events related to the investigational vaccine, adverse events unrelated to the investigational vaccine and adverse events of different severities of each group. Carry out the statistical comparison of the intergroup difference by the Fisher exact probability test. Calculate the occurrence case-time, case number and incidence rate of the adverse events of different severities, solicited adverse events and unsolicited adverse events at different time points (including within 30 min, day 0 - day 7, day 8 - day 30, day 0 - day 30) after inoculation in each group. Make the list of the adverse events related to the investigational vaccine and list of the adverse events unrelated to the investigational vaccine. Carry out the statistical analysis of the adverse events after inoculation of each dose. The analysis of the adverse events of each dose will be based on the safety set of each dose.

Calculate the occurrence case-time, case number and incidence rate of all the serious adverse events, the serious adverse events related to the investigational vaccine and the serious adverse events unrelated to the investigational vaccine of each group. Carry out the statistical comparison of the intergroup difference by the Fisher exact probability test. Make the list of the serious adverse events.

10.11.2.5 Multiplicity Problem

The sequential test strategy is adopted for this study:

(1) Evaluate the consistency between 3 lots of the 5-dose sIPV of the commercial scale. If the lot consistency is established for all the type I, type II and type II antibodies, the lot consistency between 3 lots of the 5-dose sIPV can be considered to be valid, and therefore type I error will not be adjusted.

(2) If the consistency between 3 lots of the 5-dose sIPV is valid, further combined the 5-dose sIPV trial groups of 3 lots to the 5-dose sIPV group, and carry out the non-inferiority comparison with the IPV control group. Otherwise, if the consistency between 3 lots of the 5-dose sIPV is invalid, non-inferiority comparison will not be conducted for the 5-dose sIPV group and IPV control group.

In other immunogenicity evaluation and safety evaluation results, the calculated P value is only the nominal P value. It is mainly used to describe the evaluation endpoint and the intensity of the correlation between the groups, and it is not used as the basis for statistical inference.

10.11.2.6 Subgroup Analysis

Subgroup analysis is not planned in this trial.

10.11.2.7 Processing of the Missed Data

Data complement is conducted by the last observation carried forward (LOCF) method for the subjects with missed immunogenicity results after primary immunization and booster immunization in the statistical analysis of the FAS at the primary immunization stage and bFAS at the booster immunization stage. Data complement is conducted with the maximum value of the antibody before primary immunization or booster immunization for the missed immunogenicity antibody values before the primary immunization or booster immunization. However, the antibody data complemented before booster immunization is not used for the immune persistence evaluation. Complement of the missed data is not considered in the immune persistence evaluation. The missed data in the safety endpoint are not processed in the safety endpoint.

1. Monitoring of the Clinical Trial

11.1 Responsibilities of the Sponsor

The sponsor should implement and maintain the quality assurance and quality control systems, write the quality management documents and ensure that the trial can be implemented according to the requirements and the data, records and reports should comply with the regulations such as GCP and protocol requirements.

11.2 Responsibilities of the Investigator

The principal investigator should carry out management and clear division of labour for all the personnel who participate in the clinical trial. The investigator should keep secretes for the personal data the subject. The documents provided to the sponsor can only be identified by subject code and subject number. The investigator should keep the identification list of the subjects in the investigator documents. According to GCP principles, the raw data of each subject are allowed to be inspected, audited and reviewed.

11.3 Personnel Training

The sponsor and investigator should train the personnel who participate in the trial in the form of meeting before the start of the trial. The content of training should include: clinical trial synopsis, trial implementation procedure, schedule, precautions for operation and completion of the trial data. The newly added clinical research associate or investigator in the process of the trial should be separately trained. Retraining should be conducted under the circumstances considered to be necessary by the sponsor or principal investigator. Training record should be made for each time of training.

11.4 Subject Compliance Guarantee

Establish the concise, clear and well-organized volunteer recruitment and informed consent form according to the clinical trial protocol.

Train the informed consent form explanation doctors so that they can communicate with the volunteers or guardians of the volunteers with the plain language, and realize sufficient informed consent.

Screen the subjects in strict accordance with the inclusion and exclusion criteria.

The follow-up personnel should have high sense of responsibility and professional ethics and their communication skills and affinity should be enhanced through training. Take measures to guarantee the effective contact between the subjects and investigators in the process of safety follow-up, timely find the found adverse reactions, and provide the related health consultation for the subjects.

11.5 Management of the Clinical Trial Vaccines

11.5.1 Receiving of the Trial Vaccines

The sponsor should send the vaccines used for the clinical trial to the trial sites. The investigator must sign the vaccine receipt form. The information of the received vaccine should be briefly described in the receipt certificate (package is intact and cold chain system indication is normal).

If the investigator finds that the vaccine is damaged or deteriorated or the cake mass which cannot be dispersed by shaking, do not use it, separately store and mark with “×”, the vaccine cannot be used and should be returned to the sponsor. The vaccine cannot be used if the cold chain system is damaged in the process of vaccine transportation, and such vaccines should be separately stored. Report to the sponsor, and whether the vaccine can be continuously used should be decided after assessment of the sponsor.

11.5.2 Management of the Trial Vaccines

The trial vaccines should be managed by the dedicated personnel and supervised by the clinical research associate. The quantity of the received vaccines, inoculated quantity for the subjects, remaining quantity or loss quantity included in the “Warehouse-in and Warehouse-out Standing Book of the Vaccines”. The investigator should calculate the quantity of all the vaccines used for the trial at the end of the trial.

The remaining vaccines used for the trial should be counted and returned to the sponsor after completion of the study on the site.

The trial vaccines cannot be used for the non-clinical study population.

The 5-dose sIPV vaccine with proposed antigen detection should be timely sent back to the sponsor during the trial period. In order to analyze the corresponding antigen contents at different time points after opening of the vaccine, it is planned to submit the vaccines after different days of opening such as 1 day, 2 days, 3 days...to carry out the test at the same time. Considering that the longest opening duration of the vaccine is 28 days and the duration for submission and test, the longest time from opening to use of the vaccine is not more than 20 days.

11.6 Management of the Clinical Trial Samples

The blood samples collected on the site should be timely sent to the laboratory and handed over with the laboratory staff. Serum should be timely separated for the collected blood samples and divided into two tubes (the set A serum is 0.5 ml per tube which is the serum submitted for test, other samples are filled into the set B serum tubes as the standby serum). Make records. The serum should be timely frozen at -20°C or below after separation, and serum handover, separation and storage should be recorded.

All the serum samples of the enrolled subjects should be submitted to National Institutes for Food and Drug Control. The serum samples should be at the frozen state in the process of transportation. Complete the submission record for the serum samples when the serum samples are submitted, and keep the temperature control record in the process of serum submission.

The serum samples of this clinical trial are only used for antibody detection for immunogenicity evaluation, and consent of the guardians of the subjects and approval of the ethics committee should be obtained for other studies. Except the serum submitted for test, the remaining serum should be kept on the trial site until the completion of the clinical trial and submitted to the sponsor to be destroyed according to the predetermined SOP.

11.7 Storage of the Clinical Trial Data

The data in the clinical trial must be stored according to the GCP requirements. The sponsor, responsible institution and trial site should keep the clinical trial data at least 5 years after the investigational product has been approved for marketing.

11.8 Completion Criteria of the Clinical Trial

-    The serum samples have been submitted to National Institutes for Food and Drug Control and the test report has been issued.

-    All the subjects have finished the specified visits and the original data and documents of the clinical trial have been transferred to the data administrator for archiving and keeping.

-    The number of the remaining quantity of the trial vaccines is accurate, and they have been handed over to the sponsor.

-    The statistical analysis report and summary report comply with the requirements of the sponsor.

12. Schedule

(1) Visit Schedule for Adults and Children

Table 13 Clinical Trial Schedule of the Adult and Children Subjects

a)   Inclusion/exclusion criteria screening must be conducted before inoculation of each dose.

b)  The subjects will stay in the observation room for 30 min so as to determine whether there is adverse event especially the acute allergic reaction and then have periodically follow-up according to the requirements.

c)   The safety observation includes adverse reaction/event assessment and body temperature measurement. Body temperature should be measured every day from day 0 to day 7 and when fever is suspected after inoculation. The subjects or their guardians should record the safety observation data in the diary card and contact card within 30 days after inoculation of each dose. The investigator should carry out periodical face-to-face visit of the subjects, verify and record the adverse reactions/events and use records of the concomitant drugs/vaccines.

d)  The window period can be seen in the “Visit Plan”.

Visit Plan (Adults and Children in Phase I):

Visit 1 - Day 0 - Inoculate the first dose.

Visit 2 - Day 8 after inoculation of the first dose - Check the safety observation, medication and inoculation record of other vaccines.

Visit 3 - Day 30 after immunization of the first dose (day 28 - day 42) - Check the safety observation, medication and inoculation record of other vaccines.

(2) Visit Plan of Infants

Table 14 Clinical Trial Time Schedule of the Infant Subjects

a)   Inclusion/exclusion criteria screening must be conducted before inoculation of each dose.

b)   The subjects will stay in the observation room for 30 min so as to determine whether there is adverse event especially the acute allergic reaction and then have periodically follow-up according to the requirements.

c)   Blood is not collected for the subjects in phase I.

d)   The safety observation includes adverse reaction/event assessment and body temperature measurement. Body temperature should be measured every day from day 0 to day 7 and when fever is suspected after inoculation. The guardians of the subjects should record the safety observation data in the diary card and contact card within 30 days after inoculation of each dose. The investigator should carry out periodical face-to-face visit of the subjects, verify and record the adverse reactions/events and use records of the concomitant drugs/vaccines.

e)   Collect the SAEs and use record of the concomitant drugs when SAEs occur only from day 91 until booster immunization.

f)    The window period can be seen in the “Visit Plan”.

Visit Plan (Blood is not collected for the infant subjects in phase I)

Visit 1 - Day 0 - Inoculate the first dose and collect blood before the primary immunization.

Visit 2 - Day 8 after inoculation of the first dose - Check the safety observation, medication and inoculation record of other vaccines.

Visit 3 - Day 30 after immunization of the first dose (day 28 - day 42) - Inoculate the second dose; check the safety observation, medication and inoculation record of other vaccines.

Visit 4 - Day 8 after inoculation of the second dose - Check the safety observation, medication and inoculation record of other vaccines.

Visit 5 - Day 30 after immunization of the second dose (day 28 - day 42) - Inoculate the third dose; check the safety observation, medication and inoculation record of other vaccines.

Visit 6 - Day 8 after inoculation of the third dose - Check the safety observation, medication and inoculation record of other vaccines.

Visit 7 - Day 30 after immunization of the third dose (day 28 - day 42) - Collect blood after primary immunization and evaluate immunogenicity; check the safety observation, medication and inoculation record of other vaccines.

Subsequent SAE Monitoring Period Visit－Day 31 after primary immunization until booster immunization－Verify the SAE observation and other special circumstances.

Visit 8 - 18 months old (18 month old + 30 days)－Collect blood before booster immunization and evaluate the immune persistence, follow-up the serious adverse event and inoculate the fourth dose for booster immunization.

Visit 9 - Day 8 after inoculation of the fourth dose - Check the safety observation, medication and inoculation record of other vaccines.

Visit 10 - Day 30 after immunization of the fourth dose (day 28 - day 42) - Collect blood after booster immunization and evaluate and effects of booster immunization. Check the safety observation, medication and inoculation record of other vaccines.

3. Ethics Approval

13.1 Review and Approval

The clinical trial protocol should be approved by the local ethics committee. The principal investigator should submit the clinical protocol and all the necessary attached documents to the ethics committee and the investigator will provide one cop of the approval certificate of the ethics committee to the sponsor after the ethics committee has reviewed and approved.

13.2 Implementation of the On-site Supervision

The ethics committee should supervise whether there are some problems which may damage the ethics aspect of the subjects and whether the subjects will obtain treatment, compensation and corresponding measures when they are injured due to the trial during the whole process of the trial and evaluate the degree for the subjects to bear risk at the same time.

13.2.1 Informed Consent Form and Informed Consent

Ensure that the subject enrollment method and the related information and data provided to the subjects/guardians/legal representative are complete and easy to understand; ensure that the method to obtain the informed consent is appropriate.

13.2.2 Potential Risks and Risk Minimization

If adverse reactions are considered to be related to vaccine inoculation (abscess of the inoculation site, rashes after inoculation), the subjects will be timely treated according to related requirements. If life-threatening event occurs, the subject should be immediately sent to the hospital for treatment and the event should be reported.

The trained and experienced medical staff should carry out inoculation and venous blood collection according to the specified procedure under strict supervision and reduce the injury and pain (including pain and local infection of the intravenous puncture part with very small probability) caused by inoculation and blood collection of the subjects.

13.2.3 Subject Compensation

The compensation way for the subjects should be explained in the informed consent form. If the subjects arrive at the site by oneself, traffic allowance will be provided. Small gifts will be distributed when inoculation or blood collection is conducted. The ethics committee will supervise whether the distribution of the allowance or articles of the subjects has been standardly implemented.

13.3 Confidentiality

Ensure that the personnel confidentiality of the subjects will not be disclosed in the process of trial conduct, collection of the biological sample, report and publications. Only subject code, blood sample number, blood collection time and test indexes will be recorded for the blood samples. Only the main test personnel can obtain the electronic or written form copies.

4.  Clinical Trial Protocol Amendment

If any amendment has been conducted for the protocol after the sponsor and investigator have signed the clinical trial protocol, the principal investigator and sponsor should sign name and date again for all the revised protocols and the protocol before revision should be attached.

All the revised protocols should be reported to the ethics committee and can only be implemented after approval has been obtained from the ethics committee. Whether it is necessary to revise the informed consent form and electronic CRF should be pointed out at the same time when the protocol is revised.

5. Disclosure and Publication of the Data

If the trial results should be disclosed and/or published after completion of the clinical trial, the positive results and negative results will be disclosed and/or published together.

16. References

[1] The Global Polio Eradication Initiative http://www.polioeradication.org/Polioandprevention.aspx

WHO Position paper on polio vaccines and polio immunization (February 2014). http://www.who.int/wer/2014/wer8909.pdf?ua=1

[2] Plotkin S., Chapter 25 Poliovirus vaccine-inactivated. Vaccine (5th Edition) 2008. Philadelphia: Elsevier-Saunders, P606.

[3] Liu Jinhua. Research progress of poliomyelitis vaccine. Prog in Microbiol Immunol Jun. 2011, Vol. 39 No.2.

[4] Sutter RW et al. Poliovirus vaccine-live. In OW Plotkin SA, Vaccines (6th edition)2013. Philadelphia: Elsevier-Saunders, 598 – 645.

[5] Donaldson et al. Independent Monitoring Board of the Global Polio Eradication Initiative. Polio’s Last Stand. 2012 P11 - 13.

[6] Aylward B. The polio endgame 2013-2018 presentation slides on 11th WHO/UNICEF consultation with OPV/IPV Manufactures and NRAs. 2012. Geneva.

[7] De Jesus NH Epidemics to eradication: the modern history of poliomyelitis.2007. Virol. J. 4 (1): 70 The Global Polio Eradication Initiative 2010.

[8] Plotkin S Chapter 25 Poliovirus vaccine-inactivated Vaccine 5th Edition Saunders Elsevier 2008 PP605-625

[9] WHO global action plan to minimize poliovirus facility associated risk after eradication of wild polioviruses and cessation of routine OPV use Draft 2009.

[10] Insert of Inactivated Poliovirus Vaccine. Sanofi Pasteur S. A. Approved Date: April 09, 2009, Revised Date: July 25, 2011, January 06, 2012.

[11] Liao G. Y. et al. Safety and Immunogenicity of Inactivated Poliovirus Vaccine Made From Sabin Strains: A Phase II, Randomized, Positive-Controlled Trial. The Journal of Infectious Diseases 2012;205:237 – 43.

[12] National Medical Products Administration, Good Clinical Practice, 2020.

[13] China Food and Drug Administration, Technical Guidelines for Clinical Trials of Vaccines, 2004.

[14] China Food and Drug Administration, Guidelines for Grading Criteria of Clinical Trial Adverse Events of the Preventive Vaccines, 2019.

[15] China Food and Drug Administration, Provisions for Drug Registration, 2007.

[16] China Food and Drug Administration, Guidelines for Quality Management of Clinical Trials of Vaccines (Trial), 2013.

[17] European Committee for Medicinal Products for Human Use. Note for guidance on harmonization of requirements for influenza vaccines (CPMP/BWP/214/96) [online]. Available from URL: http://www.ema.europa.eu/pdfs/human/bwp/021496en.pdf [Accessed 2010 Mar 24].