Study Protocol

A prospective cohort study of the collection of convalescent plasma from patients who

have recovered from COVID-19 to be used as a treatment of passive antibodies against

SARS-CoV-2

The PROTECT Trial

27 APRIL 2020

The PROTECT Trial

Marion Vermeulen1, Karin van den Berg1, Siemi Prithvi Raj1, Greg Bellairs2, Caroline Hilton2, Anne

Von Gottberg3

1The South African National Blood Service (SANBS)

2Western Cape Blood Service (WCBS)

3National Institute Communicable Diseases (NICD)

Organizational Committee:

SANBS WCBS

Jabu Jaza Glynis Bowie

Robyn Du Plessis Tania Paarman

Kobus Strydom Natasha Brits

Renetha van der Walt Shaldine Sutton

Tinus Brits Russell Cable

Cordelia Mmenu Renier Myburgh

Charl Coleman

James Cowley

Prudence Herandien

Itumeleng Phayane

Funded by: South African National Blood Service, Western Cape Blood Service

Study Sites

1. Collection centres

The South African National Blood Service (SANBS) and the Western Cape Blood Service (WCBS)

are both accredited by the South African National Accreditation System (SANAS) to collect whole

blood (WB) and apheresis Platelets (PLT). For the purposes of this study SANBS and WCBS will

collect the convalescent plasma (CP) from patients with recovered Coronavirus disease 2019

(COVID-19) using plasmapheresis (SP) procedures according to the SANBS standard operating

procedures (SOP’s). Multi-disciplinary centres for the collection of source plasma at SANBS and

the headquarter collection centre at WCBS will be used. A list of all sites is attached as appendix

1.

2. Processing sites

SP collected by SANBS will be shipped to the processing centre in the Egoli zone at SANBS to

perform pathogen reduction procedures. SP collected by the WCBS headquarter clinic will

undergo pathogen reduction procedures at the on-site processing centre. Products produced

from SP collections will only be issued to patients who have been enrolled in SAHPRA and HREC

approved open label phase 2 clinical trials, and only upon receipt of the appropriate requisition

form and copy of participant study consent.

Confirmation of trial protocol / Signature Page

Study title: A prospective cohort study of the collection of convalescent plasma from patients

who have recovered from COVID-19 to be used as a treatment of passive antibodies against

SARS-CoV-2

The purpose of this protocol is to describe the process of collection of plasma from patients who

have recovered from novel coronavirus 2019 disease (COVID-19) to be used in prospective

randomized clinical trials as therapeutic convalescent plasma for the passive transfer of

immunoglobulins.

The signatories declare that they agree to conduct their responsibilities within this trial in

accordance with local law, the declaration of Helsinki, and the study protocol as presented.

Approved by the following:

Coordinating Investigator Signature Date

Co-Investigator Signature Date

Sponsor Signature Date

Sponsor Signature Date

Introductory Remark:

Currently the developments regarding SARS-CoV-2 and COVID-19 are dynamic. This refers to the

international spread of SARS-CoV-2, the measures taken by health authorities worldwide and in

particular the enormous and extremely fast accumulation of knowledge on epidemiological

aspects, genetics of the virus, interaction between host genetics and immune response, mode of

entry to host cells, diagnostics, clinical presentation and course of the disease, clearance of the

virus, predictive factors and treatment. The data described for this version of the protocol is April

7, 2020.

Given the dynamic nature and availability of new information, a regular review and potential

revisions of the protocol will be required. Early reports on COVID-19 which were published in

January and February 2020 focused on description of the clinical presentation of COVID-19 and

the initial course including complications. Only very recently, the first data on outcome and risk-

factors were published and it is expected that more information in this area will become

available over the next weeks, with several scientific journal soliciting publications with

assurances of expedited peer review and on-line publication. In the past week the International

Society for Blood Transfusion (ISBT) has formed a working party to develop guidelines for

protocols regarding the collection, testing, production and use of COVID-19 convalescent plasma.

The primary investigators of this study are members of the working party. This will be particularly

important for the assumptions the sample size calculation is based on. Thus critical review and

modifications might become advisable as more information on COVID-19 is gained.

In addition, it is important to note that a separate SAHPRA approved open label phase 2 clinical

trial protocol will be developed by the SANBS/WCBS team in collaboration with a national group

of interested clinicians, including representative of the National Institute of Communicable

Diseases (NICD) as well as the South African Medical Research Council (SAMRC). This clinical trial

will aim to assess the efficacy and safety of CP in the treatment of COVID-19.

Table of content

Table of Contents

1. Protocol Summary ...................................................................................................................................7

1.1 Collection Summary .........................................................................................................................7

2. Background ........................................................................................................................................... 10

3. Methods ................................................................................................................................................ 14

3.1 Production of SARS-CoV-2 convalescent plasma (Investigational Medicinal product (IMP)) ...... 14

3.1.1 High Level Study Flowchart ................................................................................................... 14

3.1.2 Recruitment and enrolment ................................................................................................. 15

3.1.3 Eligibility ................................................................................................................................ 15

3.1.4 Pre-Testing ............................................................................................................................ 16

3.1.5 Donation collection ............................................................................................................... 16

3.1.6 Donation testing ................................................................................................................... 17

3.1.7 Processing ............................................................................................................................. 17

3.1.8 Storage of additional samples ............................................................................................... 17

3.1.9 Traceability ............................................................................................................................ 18

3.2 Recipient Population and Monitoring ........................................................................................... 18

3.2.1 Recipient Population ............................................................................................................. 18

3.3 Data Management ........................................................................................................................ 18

3.3.1 NICD recovered patient data: ............................................................................................... 18

3.3.2 Data from Doctors of referred patients ................................................................................ 18

3.3.3 SANBS / WCBS operating systems ........................................................................................ 18

3.4 Statistical Considerations .............................................................................................................. 19

3.5 Ethical Considerations ................................................................................................................... 19

3.6 Budget ........................................................................................................................................... 20

3.7 Timeline......................................................................................................................................... 20

3.8 References .................................................................................................................................... 21

3.9 Appendixes .................................................................................................................................... 23

3.9.1 Appendix 1: List of Collection sites ....................................................................................... 23

3.9.2 Appendix 2: History of COVID 19 infection ........................................................................... 26

3.9.3 Appendix 3: Informed consent form for donation of convalescent plasma by recovered

COVID-19 patient. ................................................................................................................................. 27

1. Protocol Summary

1.1 Collection Summary

Long title: A prospective cohort study of the collection of convalescent plasma from patients

who have recovered from COVID-19 to be used as a treatment of passive antibodies against

SARS-CoV-2

Short title: PROTECT

Study Population: Patients who had confirmed COVID-19 by a positive nasopharangeal swab PCR

assay and have subsequently had two negative nasal swab PCR tests performed more than 24

hours apart and an additional 14 days to develop sufficient neutralizing antibodies.

Study Duration: May 1, 2020 to December 31, 2022

Study Design: This prospective cohort study will assess the ability of SANBS and WCBS to collect

anti- SARS-CoV-2 convalescent plasma to be used as treatment of COVID-19 in randomized

clinical trials in South Africa.

Inclusion Criteria: Patients must meet the standard eligibility criteria for donating source plasma.

Patients must have had confirmed COVID-19 by a positive PCR test. In addition 14 days must

have lapsed since their 2 negative nasal swab PCR tests or in the event that PCR tests are in short

supply, 28 days must have lapsed since their symptoms resolved.

Exclusion Criteria: Patients who do not meet the routine blood donation criteria, are <18 years

old, do not provide informed consent or are parous females with clinically significant HLA or HNA

antibodies.

The following will be assessed in all subjects prior to donation:

Serum/Plasma antibody titre to SARS-CoV-2 if test is available otherwise stored serum

and/or plasma will be tested retrospectively

Routine blood donor screening for transfusion transmissible infections; HIV, HBV, HCV

and Syphilis

Routine blood group tests for ABO, Rh and irregular antibodies

HLA and HNA antibody tests for parous females if required to meet CP demand

The following will be assessed on all donations:

All routine blood screening tests as above

Serum antibody titre to SARS-CoV-2 if test is available otherwise stored serum and/or

plasma will be tested retrospectively

A blood sample for SARS-CoV-2 using PCR if test is available otherwise stored serum or

plasma will be tested retrospectively

A Stored serum and DNA sample will be collected for additional SARS-CoV-2 testing as

may become available over time.

In addition to the above pathogen reduction using either the Intercept or Mirasol systems will be

performed on all plasma products used for convalescent plasma in place of the double tested

quarantine system currently used at SANBS to mitigate the risk of transfusion transmissible

infections.

Study Agent:

SARS-CoV-2 convalescent plasma (1 unit; ~650 mL divided into 200-250 mL aliquots,

collected by apheresis from a volunteer who recovered from COVID19 disease and when

validated tests are available for neutralizing antibodies, a titre of neutralizing antibody

>1:64)

Primary Efficacy Objective: Convalescent plasma of sufficient quality and quantity to meet the

requirements as an investigational medicinal product (IMP) for the use in SAHPRA approved

randomized clinical trials.

Primary Safety Objective: Donors will be evaluated for adverse events during the trial as per the

routine procedures at SANBS and WCBS and will be reported to the investigators immediately.

Primary Safety Endpoints:

1. Deterioration of general health

2. Vasovagal episodes

3. Haematoma

4. Pregnancy

Secondary Objectives:

1. Compare the anti-SARS-CoV-2 convalescent plasma titres over time.

2. Compare the titres and duration of anti-SARS-CoV-2 neutralizing antibody levels and avidity

between patients who had mild, moderate or severe COVID-19.

3. Evaluate SARS-CoV-2 viremia by PCR and Viral load over time

4. Evaluate serological SARS-CoV-2 assays

Sample size: The sample size will be determined from the approved randomized clinical trial

protocols. The product will also be provided outside of the trial setting in dire need as

compassionate use but will be provided as an IMP product until the studies show conclusively

that the treatment is effective and then the product can be manufactured and provided routinely

by SANBS and WCBS.

2. Background

On 31st December 2019, the World Health Organization (WHO) was alerted to a cluster of

patients with pneumonia of unknown aetiology in Wuhan City, Hubei Province, China. One week

later the novel coronavirus (severe acute respiratory syndrome coronavirus 2: SARS-CoV-2) was

identified as the cause. The resulting illness was named Coronavirus disease 2019 (COVID-19) on

the 11th February 2020.[1] The clinical spectrum of COVID-19 ranges from an asymptomatic or

mild flu-like illness to a severe pneumonia requiring critical care.

SARS-CoV-2 is a betacoronavirus closely related to SARS-CoV and Middle-East Coronavirus

(MERS-CoV). It is an enveloped, non-segmented, positive sense RNA virus. It is thought to have

originated in bats but the animal that mediated transmission to humans remains unknown.[2]

80% of symptomatic patients develop mild disease, an estimated 15% develop severe disease

(with hypoxaemia, dyspnoea and tachypnoea) while 5% become critically ill (with respiratory

failure, septic shock and/or multiorgan dysfunction). At the time of writing this protocol, there

were 1,431,912 cases worldwide of which 82,083 patients had died and 302,209 had made a full

recovery. In South Africa 1,749 cases have been identified with 95 in full recovery and 13 deaths.

Thus, SARS-Corona Virus-2 poses significant threats to international health. Algorithms for

diagnostic measures, triage and therapeutic measures have been proposed [3-6]. So far the

therapeutic interventions include supportive treatment, non-invasive or invasive ventilation if

needed, prevention and treatment of secondary infections and treatment of complications like

hypotension, shock, renal failure and others [7].

Several treatment schedules include antiviral drugs. However, none of the antiviral drugs has

proven clinical efficacy against SARS-CoV-2 yet (as of April 7, 2020), e.g. a large randomized trial

comparing lopinavir and ritonavir which did not show treatment beyond standard care [8].

Development of a vaccine and monoclonal antibodies against spike proteins of SARS-CoV-2 have

started [9]. It has been demonstrated that SARS-CoV-2 uses the SARS-CoV receptor ACE2 for

entry the serine protease TMPRSS2 for S protein priming. Inhibition of this serine protease might

constitute a treatment option [10]. More recently there has been discussion about whether

chloroquine, an anti-malarial drug, could be used to treat COVID-19 [11-13]. However, it is still

unclear if and by when these options will become available in general clinic practice and whether

they prove to be efficacious.

Passive antibody therapy involves the administration of antibodies against a given infectious

agent to a susceptible or ill individual for the purpose of preventing or treating an infectious

disease caused by that agent. In contrast, active vaccination requires the induction of an immune

response that takes time to develop and varies depending on the vaccine recipient. Some

immunocompromised patients fail to achieve an adequate immune response. Currently there are

no vaccines available and it is thought that they will only be available late in 2020 or early 2021

when the epidemic may have ended. Thus, passive antibody administration, in some instances,

represents the only means of providing immediate immunity to susceptible persons and more

predicable immunity for highly immunocompromised patients. While there is no proven

treatment available for COVID-19, the only antibody type that is currently available for immediate

use is that found in human convalescent plasma. Plasma collected from patients in the

convalescent phase of infection has been used as passive treatment with promising results in

China [14]. During the current ongoing COVID-19 outbreak, plasma collected from patients who

have recovered from COVID-19 has been prioritized for investigation, as one of the treatment

modalities [15, 16]. In addition, China has sent 90,000 Litres of convalescent plasma to Italy to

use in the current epidemic. The concept that this treatment could be efficacious is biologically

plausible, as convalescent plasma has been used successfully for the treatment of a variety of

infectious agents such as Ebola, SARS-CoV and MERS-CoV. Previous randomized clinical trials of

treatment with convalescent plasma for SARS-CoV, MERS-CoV and H1N1 have shown that early

treatment has provided the best result [17-22]. A recent meta-analysis identified 32 studies of

SARS and severe influenza infections with convalescent plasma [20]. Exploratory post hoc meta-

analysis showed a statistically significant reduction in the pooled odds of mortality after

convalescent plasma compared to placebo or no therapy (odds ratio 0.25; 95% confidence

interval 0.14 to 0.45) [20]. In one retrospective case-comparison study of SARS-CoV infections, a

reduction of mortality after plasma treatment reached statistical significance (risk reduction by

23%, 95% confidence interval 6%-42%) [23]. In studies on use of convalescent plasma to treat

SARS-CoV infections the absolute reduction of risk of mortality varied from 7% to 23% [20, 23-

27]. Patients who received convalescent plasma had a higher chance of early discharge from

hospital [24, 27, 28]. In one study, the likelihood of discharge by day 22 was 54% greater (95%

confidence interval, 25% to 85%) after convalescent plasma therapy [23] . Also rapid decrease of

SARS-CoV load in the respiratory tract has been reported in patients who received convalescent

plasma. Subgroup analysis in a case series suggested that early treatment is beneficial [28].

These studies suggest that convalescent plasma may have a clinically relevant impact on reducing

viral load, length of hospital stay and mortality in patients with severe acute respiratory tract

infections of viral etiology including SARS-CoV infections [20]. However, these studies were at

high risk of bias [20]. The allocation of treatment was mostly based on the physician´s decision

and the availability of convalescent plasma.

COVID-19 however is a much milder disease than the previous respiratory viruses and therefore

it may not be necessary to treat early on, as with all treatment, there are risks and these may

outweigh the benefits. Risks, albeit small, such as transfusion transmitted infections and

transfusion related acute lung injury (TRALI) can occur[15]. The extent of the effectiveness of

treating at the time when a patient is in a critical state is unknown, but there are some anecdotal

evidence that if multi organ failure and cytokine storm has occurred treatment may be

detrimental.

In addition, convalescent plasma has been shown to be effective as a prophylactic treatment for

those at risk of contracting the virus such as health care workers [15]. There is preliminary

evidence that prophylactic convalescent plasma resulted in measurable levels of antibodies

against the virus in the recipient with a peak in SARS-CoV antibody occurring 3-5 days following

receipt of a single dose of convalescent plasma in 3 healthcare workers [27].

So far, information on immune response to SARS-CoV-2 is rather limited. A recent report provide

a detailed analysis of 9 cases with mild upper respiratory tract symptoms who are part of a

cluster of epidemiologically-linked cases that occurred end of January 2020 in Munich [29]. In

these cases seroconversion occurred 6-12 days after onset of symptoms. Both IgG and IgM

against SARS-CoV-2 were detected by immunofluorescence using cells expressing the spike

protein of SARS-CoV-2. Antibodies were not detectable in sera taken between day 3 and 6.

Patients with a sample taken two weeks after the onset of symptom, all showed neutralizing

antibodies. The finding in this patient group with a SARS-CoV-2 infection suggests a timing of

seroconversion similar to or slightly earlier than in SARS-CoV infection [30] . In the same cohort,

IgM was not detected significantly earlier than IgG in immunofluorescence, similar to the

observations reported in SARS and MERS. It seems that seroconversion early in week 2 coincides

with a slow but steady decline of sputum viral load [29]. The titre of neutralizing antibodies in

these cases did not suggest correlation with the clinical course. However, all patients had mild

clinical course of COVID-19 without complications. The issue of correlation between severity of

disease and time course as well as antibody titres needs to be re-visited in a larger patient cohort

with a broader spectrum of clinical symptoms.

Also a detailed analysis of a case with non-severe but symptomatic disease confirmed the

breadth of concomitant immune response including SARS-CoV-2 binding antibodies which

became detectable prior to resolution of symptoms. (Thevarajan In press)

Passive immunotherapy with convalescent plasma or hyperimmune intravenous immunoglobulin

(H-IVIG) are potential therapeutic options. As more individuals contract COVID-19 and recover, the

number of potential donors will continue to increase.

Clinical trials of convalescent plasma for patients with severe COVID-19 are being rolled out in

the China, Italy, Netherlands, Germany, USA and Denmark. Clinical trials for use as a prophylactic

treatment for health care workers is being developed in the USA. The USA have recently

submitted protocols to treat mild, moderate and severe COVID-19 for approval. At the time of

writing, we could find no evidence of protocols to treat patients with moderate COVID-19 who

are more likely to progress to severe disease.

SANBS implemented the collection of source plasma through plasmapheresis in 2018. However

even with advanced blood-collection processes, collecting convalescent blood products during an

epidemic crisis creates substantial organizational difficulties and requires adequate preparation.

Besides the routine processes of blood donation, collection of convalescent plasma includes

ensuring the donor is clinically and virally free of SARS-CoV-2 and with a sufficient antibody titre

to be therapeutically effective.

We aim to 1) collect convalescent plasma from patients with recovered COVID-19 to make

available for therapeutic and prophylactic randomized clinical trials 2) assess and compare the

duration and titre of neutralizing anti-SARS-CoV-2 antibodies between patients affected with

mild, moderate and severe COVID-19 3) assess levels of SARS-CoV-2 RNA in the blood and 4) use

samples collected at time of donations to evaluate and validate serological SARS-CoV-2 assays in

collaboration with NICD.

3. Methods

3.1 Production of SARS-CoV-2 convalescent plasma (Investigational Medicinal product

(IMP))

3.1.1 High Level Study Flowchart Recovered Patient

2 x PCR Negative and 14 days post negative test OR 28 days since last symptoms

Meets minimum criteria for CP

donation

NICD obtain consent for SANBS to contact

Do not contact

NoYes

No consent

Explain study to recovered patient and make appointment for

pre-testing

Consent

Obtain initial telephonic informed consent

Take samples for TTI, Ab neutralization, ABO, Rh, Irregular Ab s

Take additional plasma and serum tubes for validation of serological assays

Thank Patient/ Donor for their time

No

Test results meet criteria for CP?

No

Make appointment for CP Donation (650ml)

Collect CP

Make appointment for 1-2 weeks time

Yes

Process collection into PR aliquots

All test results acceptable

Label product IMP

Update all data and store CP for use in Approved RTC

Take additional HLA & HNA Ab samples if parous female and required for

study

Yes

Go to donor centre and sign documented consent

Yes

No

Abbreviations: CP = Convalescent plasma, RTC= randomized clinical trial, PR= Pathogen reduction, TTI =

Transfusion transmissible infections, Ab = Antibody, IMP = investigational medicinal product

3.1.2 Recruitment and enrolment

Initially, NICD will refer patients who have recovered from COVID-19 and who meet the

minimum criteria for donating source plasma (SP). A set of minimum criteria will be provided to

NICD to help in their recruitment of recovered patients. A recovered patient from COVID-19 is

defined as having two negative PCR SARS-CoV-2 tests from nasopharangeal swabs a minimum of

2 days apart and an additional 14 days post negative PCR test. In the case where there is limited

supply of SARS-CoV-2 PCR tests, a recovered patient is defined as 28 days since last symptoms.

NICD will refer recovered patients to SANBS or WCBS. In order to correlate donor characteristics

with the level of anti-SARS-CoV-2 antibodies and the response of recipient patients to CP, a

minimum set of data on the previous SARS-CoV-2 infection of the donor will be collected through

NICD and will be provided to the BS’s at the time of full study consent (Appendix 2). Treating

doctors may also refer recovered patients as potential donors to the BS after obtaining verbal

consent from the patient.

A BS research nurse will contact referred patients and provide them with the detailed

information about the study. Potential donors who meet all the criteria and who are willing to

donate, will be referred to the nearest donor centre using an appointment system. The potential

donors would be required to give the usual informed consent for donating blood, but also a

study specific informed consent (Appendix 3). Donations would be from voluntary non-

remunerated blood donors only.

3.1.3 Eligibility

The eligibility of a donor to donate convalescent plasma will be assessed according to the

Standards of Practice for Blood Transfusion in South Africa and routine standard operating

procedures for SP collection. Two waivers to the normal criteria will be in place; the first is that

donors <18 years old will not be eligible to donate CP and secondly the COVID-19 recovery

deferral of 28 days will not be required if 2 negative PCR SARS-CoV-2 tests are available. Two

specific criteria for eligibility to donate CP are 28 days must have passed since the onset of

symptoms AND 14 days must have occurred since the last symptoms (if 2 negative PCR SARS-

CoV-2 tests are available) or 28 days must have since the last symptoms. In addition additional

training will be provided to SANBS and WCBS to assess the patients’ health and ability to donate

considering their recent illness.

3.1.4 Pre-Testing

Routine testing will include the testing for transfusion transmissible infections such as HIV, HBV,

HCV and syphilis, ABO and Rh blood grouping, a test for irregular antibodies and a total protein

test. Irregular antibody screening will be performed on the eFlexis or WADiana instruments. In

addition to the standard test tubes collected for SP, three samples (2x serum gel separator &

1xEDTA gel separator, volume 5-9 ml) will be collected and stored at +4°C for serological testing

for SARS-CoV-2 antibodies. If the serological assays are not yet available and validated these

additional 3 test tubes will be centrifuged and frozen at -80° C until tests become available. A

blood test for SARS-CoV-2 RNA will be performed, however this may also be done

retrospectively. The yield and efficacy of antibodies against SARS-CoV-2 is crucial to the success

of this therapy. We expect a similar time course to development and peak of antibody titre as

seen in SARS-CoV of a week and 2 to 4 months respectively. All tests must meet the criteria for

continued donation.

3.1.5 Donation collection

Plasmapheresis will be performed according to the SANBS institutional standard operating

procedures ensuring full traceability of all aspects of the collection process. In addition to the

routine criteria and procedures for SP collection, frequency and inter-donation intervals, and

monitoring of repeat donors for serum protein concentration will be performed (SOP-DSC-108).

Additional three samples (2x serum & 1xEDTA gel separator, volume 5-9 ml) will be collected and

stored at +4°C for serological testing for SARS-CoV-2 antibodies. If the serological assays are not

yet available and validated these additional 3 test tubes will be centrifuged and frozen at -80° C

until tests become available. A blood test for SARS-CoV-2 RNA will be performed, however this

may also be done retrospectively.

A volume of ~650ml will be collected for SP donations. The IMP product collected will be called

“Source plasma COVID-19 Convalescent Plasma” (SPCCP). Routine fresh frozen plasma for patient

use is stored in a quarantine system until the donor returns and tests negative for all TTI’s at

SANBS. SPCCP will be pathogen reduced instead of being placed in the quarantine system to

ensure the majority of viruses are inactivated.

3.1.6 Donation testing

The same tests as performed in the pre-testing would be repeated on the donation except the

anti-SARS-CoV-2 antibody titre test can be waivered in the first plasmapheresis donation. The

standard molecular and serological assays for HIV, HBV and HCV will be performed as per all

donations made at the BS. Irregular antibodies will be tested using commercial reagents instead

of in-house reagents.

3.1.7 Processing

Source plasma can be stored for 40 days at 2-8°C or frozen into FFP within 24 hours of collection

and stored at -18°C for up to 12 months. Prior to Pathogen reduction a 50 ml sample will be

collected using sterile connectors and stored for further testing. Each product will be pathogen

inactivated using either the amatosolen-based Intercept (Cerus) or the riboflavin-based Mirasol

(Terumo BCT) systems and sampled into a maximum of three aliquots of at least 200ml each. The

product SPCCP will be processed to PRCCP (Pathogen reduced COVID-19 convalescent plasma)

which will become available for use when all test results are completed. The label of each

product after pathogen reduction and test results will meet the normal requirements of a FFP

product for patient use. In addition, the label will include that the product is an investigational

medicinal product (IMP) and a statement for use in a clinical trial and, the Human Research

Ethics Committee (HREC) registration number for this protocol

The additional label of the primary packaging will have the following content:

Name and address of the sponsor (tbd )

Phone number of the sponsor (tbd)

Protocol code: PROTECT

Declaration, that the product is an IMP for the use in approved clinical trials only.

In the event any convalescent plasma is left over with no patients left to treat after the epidemic,

the plasma will be provided to NBI

3.1.8 Storage of additional samples

Additional sample will be taken at time of donation as well as pre and post pathogen reduction.

These samples will be used for research for COVID-19 or pathogen reduction in the future

3.1.9 Traceability

A 100% traceability is implemented for the administration of every blood product. Transfusion of

a unit of convalescent plasma will be reported back to SANBS and WCBS. The reporting of the

administration of the study drug at the study site is the responsibility of the clinical collaborators.

The collaborators may delegate this responsibility to other appropriate personnel. The

responsible person will ensure that the study product is used only in accordance with the

relevant study protocol.

3.2 Recipient Population and Monitoring

3.2.1 Recipient Population

CP will be issued to clinicians who are part of an approved phase 2 clinical trial. It may also be

issued as an investigational medicinal product for compassionate use in dire situations. The

phase 2 randomized clinical trials will determine eligibility and outcomes.

3.3 Data Management

This study will have three data sources. Data from these sources will be integrated and managed

by the Business Intelligence (BI) Division of SANBS. The BI team will prepare patient monitoring

reports for the DSMB as well as the final analytic dataset. At enrolment, each CP donor, COVID

participant will be assigned a participant study identification number which will, inter alia, be

used to link the various datasets.

3.3.1 NICD recovered patient data:

Potential CP donor information will be received from the NICD via email which will be sent and

received on password protected computers and email accounts. Appendix 2 provides the data

variables required

3.3.2 Data from Doctors of referred patients

As above potential CP donor information will be received from the referring doctor via email

which will be sent and received on password protected computers and email accounts. Appendix

2 provides the data variables required

3.3.3 SANBS / WCBS operating systems

Donors: Once potential CP donors consent to participate, they will be registered on the BS

operating systems using existing procedures for registering blood donors, ensuring that all

information is recorded accurately. CP donor must complete a donor questionnaire at each

donation. Copies of each donor questionnaire will be kept in the donor participant file. All CP

donor information, including SARC-CoV-2 PCR and antibody titre results will be captured in their

computer profile from where it will be extracted and collated by the SANBS BI team.

Recipients: Demographic, clinical and ordering data for CP recipients will be captured in the BS

operating system using existing procedures for blood transfusion recipients. Copies of each

requisition form will be kept in the recipient participant file. Recipient data will be extracted by

the SANBS BI team and merged with the clinical dataset.

3.4 Statistical Considerations

Convalescent plasma will be collected and stored. Each randomized clinical trial will determine

sample size and statistical methods to be used for the analysis of the data.

3.5 Ethical Considerations

Ethics approval will be obtained from the SANBS Human Research Ethics Committee. All

measures will be implemented to protect the privacy and confidentiality of participants,

including using unique donor numbers instead of names on all study questionnaires, and blood

sample labels, maintaining a secure database and limiting the number of research staff with

access to participant identifiers to staff who need to be able to contact participants and manage

the collected material

Protection against risks:

• Pre testing. The laboratory which will perform the pre- testing, is an accredited laboratory

which performs the tests routinely and is accredited by SANAS.

• Participant historical COVID-disease questionnaire. The greatest risk to participants in

these study components is a loss of confidentiality with the small risk of stigmatisation as a

recovered COVID patient. Access to the data is limited to staff members directly involved in the

study and is encrypted and password protected.

• Confidentiality. All measures will be implemented to protect privacy and confidentiality

including using donor numbers instead of names on all study questionnaires and blood sample

labels, maintaining a secure database, limiting the number of research staff with access to donor

identifiers needed for contact.

• Data storage. SANBS has existing measures in place for the secure storage of data

pertaining to donor test results, with a graded access policy through which data of increasing

sensitivity is limited to certain designated roles and positions within SANBS. In addition, all

SANBS systems are firewall protected, with access to systems allocated through individual user

ID and passwords. SANBS computers are all user ID and password protected and configured to

lock after specified periods of inactivity.

Potential Benefits to Participants:

There is no direct benefit to participants for participating in this study, other than the altruism in

participating in a project aimed at providing an alternative treatment option to patients with

COVID-19.

Importance of knowledge to be gained:

Significant benefit to public health relating to better understanding of the safety and efficacy of

CP in the treatment of COVID-19. If proven effective, this product may potentially save the lives

of numerous patients in South Africa, especially considering the severe shortage of ICU beds and

ventilators within the resource constrained public health sector.

3.6 Budget

The blood services have agreed to absorb the costs involved in the collection, processing, testing

and making ready for transfusion of the CP IMP product. Some of the costs, such as the

neutralizing antibody test and SARS-CoV-1 PCR are not yet known.

Male and nulliparous female donors Convalescent Plasma ¬R5500 (excluding overheads covered

by WB collections)

Female parous donors Source Plasma ¬R16000 (this will only be done in extreme cases)

3.7 Timeline

Plan to get expedited HREC approval. Require a 3 week lead time to set up Meditech, write or

revise SOP’s, train staff and ship in pathogen reduction consumables

3.8 References

1 Coronaviridae Study Group of the International Committee on Taxonomy of V: The species Severe acute respiratory syndrome-related coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2. Nat Microbiol 2020.

2 Yuen KS, Ye ZW, Fung SY, et al.: SARS-CoV-2 and COVID-19: The most important research questions. Cell Biosci 2020; 10: 40.

3 Cheng ZJ, Shan J: 2019 Novel coronavirus: where we are and what we know. Infection 2020. 4 Li G, De Clercq E: Therapeutic options for the 2019 novel coronavirus (2019-nCoV). Nat Rev Drug

Discov 2020; 19: 149-50. 5 Zu ZY, Jiang MD, Xu PP, et al.: Coronavirus Disease 2019 (COVID-19): A Perspective from China.

Radiology 2020: 200490. 6 Zhang J, Zhou L, Yang Y, et al.: Therapeutic and triage strategies for 2019 novel coronavirus disease

in fever clinics. Lancet Respir Med 2020; 8: e11-e2. 7 Zhang L, Liu Y: Potential interventions for novel coronavirus in China: A systematic review. J Med

Virol 2020; 92: 479-90. 8 Cao B, Wang Y, Wen D, et al.: A Trial of Lopinavir-Ritonavir in Adults Hospitalized with Severe Covid-

19. N Engl J Med 2020. 9 Tian X, Li C, Huang A, et al.: Potent binding of 2019 novel coronavirus spike protein by a SARS

coronavirus-specific human monoclonal antibody. Emerg Microbes Infect 2020; 9: 382-5. 10 Hoffmann M, Kleine-Weber H, Schroeder S, et al.: SARS-CoV-2 Cell Entry Depends on ACE2 and

TMPRSS2 and Is Blocked by a Clinically Proven Protease Inhibitor. Cell 2020. 11 Cortegiani A, Ingoglia G, Ippolito M, et al.: A systematic review on the efficacy and safety of

chloroquine for the treatment of COVID-19. J Crit Care 2020. 12 Wang M, Cao R, Zhang L, et al.: Remdesivir and chloroquine effectively inhibit the recently emerged

novel coronavirus (2019-nCoV) in vitro. Cell Res 2020; 30: 269-71. 13 Colson P, Rolain JM, Raoult D: Chloroquine for the 2019 novel coronavirus SARS-CoV-2. Int J

Antimicrob Agents 2020; 55: 105923. 14 Duan K, Liu B, Li C, et al.: The feasibility of convalescent plasma therapy in severe COVID-19 patients:

a pilot study. 2020. 15 Casadevall A, Pirofski LA: The convalescent sera option for containing COVID-19. J Clin Invest 2020. 16 Chen L, Xiong J, Bao L, et al.: Convalescent plasma as a potential therapy for COVID-19. The Lancet

Infectious Diseases 2020. 17 Arabi Y, Balkhy H, Hajeer AH, et al.: Feasibility, safety, clinical, and laboratory effects of

convalescent plasma therapy for patients with Middle East respiratory syndrome coronavirus infection: a study protocol. Springerplus 2015; 4: 709.

18 Arabi YM, Al-Enezi F, Longuere KS, et al.: Feasibility of a randomized controlled trial to assess treatment of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection in Saudi Arabia: a survey of physicians. BMC Anesthesiol 2016; 16: 36.

19 Arabi YM, Hajeer AH, Luke T, et al.: Feasibility of Using Convalescent Plasma Immunotherapy for MERS-CoV Infection, Saudi Arabia. Emerg Infect Dis 2016; 22: 1554-61.

20 Mair-Jenkins J, Saavedra-Campos M, Baillie JK, et al.: The effectiveness of convalescent plasma and hyperimmune immunoglobulin for the treatment of severe acute respiratory infections of viral etiology: a systematic review and exploratory meta-analysis. The Journal of infectious diseases 2015; 211: 80-90.

21 Simmons C, Bernasconi N, Suguitan A, et al.: <Prophylaxis and Therapeutic Efficacy.pdf>. PLoS medicine 2007; 4.

22 Stockman LJ, Bellamy R, Garner P: SARS: systematic review of treatment effects. PLoS medicine 2006; 3: e343.

23 Soo YO, Cheng Y, Wong R, et al.: Retrospective comparison of convalescent plasma with continuing high-dose methylprednisolone treatment in SARS patients. Clin Microbiol Infect 2004; 10: 676-8.

24 Zhou XZ, Zhao M, Wang FS, et al.: [Epidemiologic features, clinical diagnosis and therapy of first cluster of patients with severe acute respiratory syndrome in Beijing area]. Zhonghua Yi Xue Za Zhi 2003; 83: 1018-22.

25 Nie QH, Luo XD, Hui WL: Advances in clinical diagnosis and treatment of severe acute respiratory syndrome. World J Gastroenterol 2003; 9: 1139-43.

26 Wong VW, Dai D, Wu AK, et al.: Treatment of severe acute respiratory syndrome with convalescent plasma. Hong Kong Med J 2003; 9: 199-201.

27 Yeh KM, Chiueh TS, Siu LK, et al.: Experience of using convalescent plasma for severe acute respiratory syndrome among healthcare workers in a Taiwan hospital. J Antimicrob Chemother 2005; 56: 919-22.

28 Cheng Y, Wong R, Soo YO, et al.: Use of convalescent plasma therapy in SARS patients in Hong Kong. Eur J Clin Microbiol Infect Dis 2005; 24: 44-6.

29 Wolfel R, Corman VM, Guggemos W, et al.: Virological assessment of hospitalized cases of coronavirus disease 2019. Online Source 13-3-2020 2020.

30 Peiris JS, Lai ST, Poon LL, et al.: Coronavirus as a possible cause of severe acute respiratory syndrome. Lancet 2003; 361: 1319-25.

3.9 Appendixes

3.9.1 Appendix 1: List of Collection sites

Zone Cost

Centre Name

Donor

Centre

Mnemonic

Collections

Devices

Eastern Cape 13000 Berea DC ELD001 1

Eastern Cape 13010 Becon Bay DC ELD003 1

Eastern Cape 17011 Walker DC EWD003 1

Eastern Cape 17001 PE HQ DC EED003 3

Egoli 51040 Bedfordview DC GBD007 1

Egoli 51032 Lenasia DC GCD002 1

Egoli 90802 Maponya Mall DC GCD006 1

Egoli 51043 Beacon Road DC GCD007 1

Egoli 51044 Germiston DC GFD001 1

Egoli 51042 Southdale DC GFD003 1

Egoli 51041 Krugersdorp DC GQD001 1

Egoli 51046 The Colony DC GTD003 1

Egoli 51038 Alberton DC GFD002 2

Egoli 51051 Fourways DC GTD001 2

Egoli 51058 Westgate DC GQD002 3

Egoli 51069 Northgate DC GTD004 3

FSNC 51091 Bethlehem DC FKD001 1

FSNC 51060 Bloem Plaza DC FJD001 2

FSNC 51061 Hypermarket DC FJD002 2

FSNC 51065 Kimberley DC NLD001 2

KZN 1202 Newcastle DC KCD001 1

KZN 1303 Ladysmith DC KCD002 1

KZN 1205 PineCrest DC KHD003 1

KZN 1211 Hillcrest DC KHD003 1

KZN 1204 North Durban DC KND005 1

KZN 1208 Shelly Beach DC KSD006 1

KZN 1201 Musgrave DC KSD007 1

KZN 90801 Umlazi DC KSD010 1

KZN 2000 SDS Pinetown KSX001 1

KZN 1200 Loop St DC KMD002 2

KZN 1210 Southway Mall DC KSD005 2

Mpumalanga 51021 Middleburg DC MGD001 1

Mpumalanga 51110 Safeways DC MGD005 1

Mpumalanga 51025 Riverside DC MHD004 1

Mpumalanga 51024 Lydenburg DC MHD005 1

Mpumalanga 51030 Secunda DC MSD002 1

Mpumalanga 51027 Bethal DC MSD005 1

Mpumalanga 51026 Ilanga Mall DC MHD006 2

Northern 51011 Centurion DC GKD002 1

Northern 51012 Hatfield DC GKD001 2

Northern 51005 Polokwane DC RVD001 2

Northern 51017 Rustenburg DC WPD004 2

Northern 51015 Wonderpark DC WRD002 2

Northern 51014 Kolonnade DC WRD006 2

Northern 51010 Atterbury DC GID006 4

Vaal 51055 River Square DC GED003 1

Vaal 51037 Springs DC GGD001 1

Vaal 51036 Kempton Park DC GDD002 2

Vaal 51035 East Rand Square DC GDD005 2

Vaal 51033 Benoni DC GGD002 2

Vaal 51049 Potchefstroom Dnr WOD002 2

Vaal 53032 Carnival Mall DC GGD004 3

Western

Cape Blood

Service

Specialized donations

Department

1

3.9.2 Appendix 2: History of COVID 19 infection

Patient details

Name: Date:

ID number: Date of Birth:

Patient Number (NICD) Gender:

Date Symptoms started: Date of Diagnosis:

Date of last symptoms: Date of discharge:

Treatment hospital: Discharge status:

Severity of disease:

Main treatment protocols:

Nasal/ pharangeal PCR Test: Date:

Nasal/ pharangeal PCR Test: Date:

Nasal/ pharangeal PCR Test: Date:

Nasal/ pharangeal PCR Test: Date:

Nasal/ pharangeal PCR Test: Date:

Nasal/ pharangeal PCR Test: Date:

3.9.3 Appendix 3: Informed consent form for donation of convalescent plasma by recovered

COVID-19 patient. Dear Participant

1. Information about the disease

As you know, you were recently diagnosed with SAR-Cov-2, the virus which causes Corona virus

disease 2019 disease (COVID-19). We are very grateful that you have recovered and have shown

some interest in participating in our research study.

As I’m sure you are aware, this disease is transmitted through close contact with the mucous

aerosols of infected people. Some of the symptoms of the disease include fever, coughing, sore

throat, headache and diarrhoea. We are thankful that you have recovered well but as you know the

disease can be quite severe in approximately 10% of people and of these only half will recover.

Currently, there is no medicine that has been proven in human beings to cure the disease, so we

don't have any medicines or vaccines to treat or prevent COVID-19. Only primary prevention

measures focusing on social distancing, quarantine and self-isolation to avoid direct contact with

people infected with the virus has been shown to reduce the transmission of the disease.

If a treatment for COVID-19 could be found, it would save many lives. People like you who recover

from COVID-19 do so because your blood contains substances known as antibodies that are

capable of fighting COVID-19. We think that patients with COVID-19 might improve faster if they

received the plasma (the liquid part of blood) from people like you who have recovered from COVID-

19, because your plasma contains the antibodies required to fight COVID-19.

2. What are we asking you?

We are asking you if you would consider donating plasma. Your plasma will have antibodies that

could improve a hospitalized patient with COVID-19 chances of recovery. We don't know if this

treatment will help them or not, and we don't know if it will have any harmful effects either, but this

is one of the few treatment options that we have at present. There have been a number of case

reports showing good recovery in patients who received this treatment. Because we don't have any

other proven treatment option at present, we would like to try it, and learn from the study.

3. What will you be asked to do if you accept to donate your blood?

You will be asked to complete a donor questionnaire that asks questions about risk factors that may

affect your health or the patients’ health. You will also have your blood pressure measured and a

test for your haemoglobin (iron levels) performed. If these are acceptable, you will be connected to

an instrument using a sterile needle into a vein in your arm that will remove some of your blood. The

instrument will centrifuge the blood and give you back your red cells (the iron storage part) while the

liquid straw colour plasma will be collected into a collection bag. About 650 mL of plasma separated

from the blood will be collected at each donation. If you tolerate the procedure well we would like to

perform this procedure every two weeks.

4. Can I change my mind after I say ‘Yes’:

Yes, you can change your mind at any time. If you wish to stop donating, just tell us. Any previous

donations will still be used for treatment of COVID-19 patients unless you specifically ask us not to

do so.

5. What is the benefit from donating this treatment?

You will not receive anything in return from the blood service but you will be contributing towards

science in fighting against this virus and potentially saving lives. We hope that the treatment is

successful as we believe that this treatment might be effective in improving the likelihood of many

people recovering from the disease.

6. What are the risks from donating this treatment?

Plasma donation have some minor risks. Some donors may feel a little light headed or even faint.

You could also have some bruising at the site where the needle went in.

7. Do you have other choices?

You can choose to donate or not. If you agree to this donation, you will also be helping us learn

whether the treatment works and how it works to help other patients, though you can withdraw at

any time.

8. What will it cost me?

You will not have to pay anything.

9. How will your privacy be protected?

Your medical records will only be reviewed by the blood service staff that are managing this project.

Additionally, all the information or data collected on you to help understand if the therapy is effective

will be kept confidential and only be used by specialists to better understand COVID-19 and its

potential treatment(s).

10. Who can I talk to?

If you have questions, concerns about the donation or medical problems, you can talk to any of our

staff at the clinic or with any of the investigators and doctors leading this project.

SIGNATURE PAGE

Your signature documents your permission to donate blood for this experimental treatment and for

NICD or your treating doctor to provide the diagnostic data collected from you while you were ill with

COVID-19. Your signature agrees that all the relevant information of this treatment and the process

of donation was explained to you telephonically with a research Nurse prior to you making an

appointment to donate blood

Full Name: Signature of Patient

ID number: Date of Signature:

I, the undersigned, have asked that the donor understands the study

Full name of Nurse: Signature of Nurse:

ID number: Date of Signature:

For office use only:

Donor ID

Full Name Date of Signature