CDC Anthrax Vaccine Clinical Trial

This study is a 43-month prospective, randomized, double-blind, placebo-controlled comparison
of immunogenicity and reactogenicity elicited by BioThrax given by different routes of
administration (SQ versus IM) and dosing regimens (as many as 8 doses versus as few as 4
doses). Sterile saline is used as the placebo where doses are dropped in regimens using AVA,
and in the all-placebo study group.

This study is conducted among a total of 1564 healthy adult men and women (18 to 61 years of
age) at five sites in the United States. Participants were randomized into one of 6 study
groups with 260 participants per group. One group receives BioThrax given as currently
licensed (SQ with 6 doses followed by annual boosters); another group is given placebo IM
(130 participants) or SQ (130 participants) in the currently licensed dosing regimen. The
four other groups receive BioThrax IM in modified dosing regimens; placebo is given when a
dose of BioThrax is omitted from the licensed dosing regimen. There are a total of 25
required visits for this study, during which all participants receive an injection of vaccine
or placebo (8 injections total), have a blood sample drawn (16 or 17 total), and have an
in-clinic examination for adverse events (22 total).

Immunogenicity is assessed by assaying 16 serial blood samples obtained from all participants
and a 17th sample from a subset of participants before vaccination and at other specified
times. Total anti-protective antigen IgG antibody (anti-PA IgG) is quantified using a
standardized and validated enzyme-linked immunosorbent assay (ELISA); the primary study
endpoints are 4-fold rise in antibody titer and antibody concentration relative to the
pre-vaccination titers or assay reactivity threshold. A subset of serum samples is also
assayed in an in vitro toxin neutralization assay (TNA) to measure the functional activity of
anti-BioThrax antibodies. The kinetics of the immune response to BioThrax are examined at 3
time points in the study and blood samples from a subset of participants will be further
tested in correlates of protection and immunogenetics substudies. All adverse events (AEs),
including vaccine reactogenicity, are actively monitored. While all AEs will be ascertained
among study participants, several endpoints will be defined based on the likelihood of their
occurrence and/or their clinical importance. Of primary interest is the occurrence of local
AEs such as warmth, tenderness, itching, pain, arm motion limitation, erythema, induration,
nodule, and bruise. Systemic AEs such as fever, fatigue, muscle ache, headache, temperature,
and painful axillary adenopathy are also evaluated.

This study is expected to provide the basis for consideration of change in route of BioThrax
administration from SQ to IM and reduction in number of vaccine doses required for primary
and booster immunization.

There is an interim analysis of data collected through each participant's first 7 months of
this study for consideration in changing the route of BioThrax administration from SQ to IM,
and elimination of the 2 week vaccine priming dose.

At the end of the study, the Sponsor will present the entire results of the trial to FDA for
consideration in elimination of additional doses from the licensed BioThrax schedule. At that
time, the Sponsor will also supplement these data with results from parallel non-human
primate challenge studies and additional research on immunologic correlates of protection.

Inclusion Criteria:

- Read and signed the Informed Consent Document

- Female or male, 18 to 61 years old (up to 62nd birthday)

- Females must agree to exercise adequate birth control from the time of the screening
procedures to one month after the last vaccination

- Willingness and ability to return for all follow-up visits and blood collections for
the duration of the study

- Ability to understand and comply with planned study procedures

- Agree to complete the Participant Diary (Appendix G) and to report concomitant
medications and AEs during the study period

- Have two intact upper arms with sufficient subcutaneous and intramuscular tissue in
the deltoid regions for vaccine administration.

- Potential participants with a history of the following conditions remain eligible for
study enrollment: gestational diabetes; treated, controlled, uncomplicated
hypertension; treated hypo- or hyperthyroidism; cured nonmetastatic cancer;
disease-free for 5 years (excluding hematologic malignancies); localized skin cancer,
resected (including squamous cell and basal cell carcinomas, participants with a
history of melanoma must be disease-free for 5 years); exercise-induced bronchospasm;
mild asthma: use of inhalers only for control of symptoms is acceptable (Persons who
have required hospitalization for asthma within the previous 2 years or those who
require chronic or frequent oral/parenteral steroids will not be eligible; use of low
to medium doses of inhaled steroids; history of coronary artery disease, asymptomatic
(NYHA Function Class I), on a stable medical regimen. Persons meeting these criteria
must be at least 2 years post-myocardial infarction, cardiac bypass surgery, and/or
percutaneous coronary intervention (e.g., angioplasty, stent placement, etc) in order
to qualify. Persons with a history of cardiac disease must be under the care of a
physician.

Exclusion Criteria:

- Prior history of anthrax or immunization against anthrax

- Known allergy to aluminum hydroxide, formaldehyde, benzethonium chloride, or latex

- Pregnancy or plans to become pregnant for the duration of the study and/or not
agreeing to exercise adequate birth control from the time of the screening procedures
to one month after the last vaccination

- Received experimental products within 30 days prior to study entry

- Plans to receive experimental products within 60 days after study entry

- Received a live vaccine outside this trial within 30 days prior to study entry

- Received an inactivated vaccine outside this trial within 14 days prior to study entry

- Plans to receive a live vaccine outside this trial within 60 days after study entry

- Plans to receive an inactivated vaccine outside this trial within 42 days after study
entry

- Received immunosuppressive therapy within 30 days prior to study entry

- Plans to receive immunosuppressive therapy within 60 days after study entry

- Use of cytotoxic therapy in the previous 5 years

- Plans to receive cytotoxic therapy within 60 days after study entry

- Receipt of parenteral immunoglobulin or blood products within three months of study

- Plans to receive parenteral immunoglobulin or blood products within 60 days after
study entry

- Active malignancy or history of metastatic or hematologic malignancy

- Any current diabetes

- Cardiovascular disease with a significant likelihood of progression over 5 years,
including any person with a history of cardiomyopathy or congestive heart failure

- Moderate to severe asthma, chronic obstructive pulmonary disease, other significant
pulmonary disease

- Persons who are using high doses of inhaled steroids

- Clinically recognized hepatic or renal insufficiency

- Inflammatory, vasculitic, or rheumatic disease including systemic lupus erythematosis,
polymyalgia rheumatica and rheumatoid arthritis, scleroderma

- Known HIV, hepatitis B or hepatitis C infection

- Other conditions known to produce or be associated with immune suppression

- Neuropathy or other evolving neurologic condition

- Unstable and/or moderate to severe mental illness

- Ongoing drug abuse/dependence (including alcohol)

- Seizure disorder

- In addition to the conditions listed above, moderate or severe illness and/or oral
temperature higher than 100.4˚F within 3 days of injection or chronic condition that,
in the opinion of the investigator, would render injection unsafe or would interfere
with evaluations would be considered a temporary exclusion criterion.