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Trial registered on ANZCTR


Registration number
ACTRN12618000517279
Ethics application status
Approved
Date submitted
5/10/2017
Date registered
9/04/2018
Date last updated
9/04/2018
Type of registration
Retrospectively registered

Titles & IDs
Public title
Efficacy and safety of Artesunate plus Amodiaquine , Artemether-Lumefantrine and Dihydroartemisinin+Piperaquine for the treatment of uncomplicated Plasmodium falciparum malaria among children 6 – 59 months in three sentinel sites; Sierra Leone.
Scientific title
Efficacy and safety of Artesunate plus Amodiaquine , Artemether-Lumefantrine and Dihydroartemisinin+Piperaquine for the treatment of uncomplicated Plasmodium falciparum malaria among children 6 – 59 months in three sentinel sites; Sierra Leone.
Secondary ID [1] 293059 0
None
Universal Trial Number (UTN)
None
Trial acronym
Nil
Linked study record

Health condition
Health condition(s) or problem(s) studied:
Malaria 304987 0
Condition category
Condition code
Infection 304309 304309 0 0
Studies of infection and infectious agents

Intervention/exposure
Study type
Interventional
Description of intervention(s) / exposure
The aim of the study was to evaluates the efficacy and safety of artesunate+amodiaquine, artemether+lumefantrine and dihydroartemisinin+piperaquine with the following dosages:
For testing the efficacy of artesunate+amodiaquine in Bo and Makeni sites, patients was administered a daily dose of artesunate 4 mg/kg bw + amodiaquine 10mg/kg once daily for 3 consecutive days.
For the evaluation of artemether-lumefantrine efficacy (each tablet contains artemether 20 mg+lumefantrine 120 mg) in Kenema site, patients was administered a 6-dose regimen of artemether-lumefantrine twice a day for 3 days according to the recommended weight bands as follows: 1 tablet to those weighing 5 to 14 kg; 2 tablets for 15 to 24 kg; 3 tablets for 25 to 34 kg and 4 tablets for equal or greater than 35 kg. Doses were calculated according to weight bands: Weight of patient has to be taken for dosage schedule.
For testing dihydroartemisinin+piperaquine in Bo and Makaeni sites, patients will be administered a daily dose of 4 mg/kg DHA and 18 mg/kg piperaquine once a day for 3 days.
All treatments will be taken orally under direct supervision by the health worker. When two drugs were tested in the same site, patients were enrolled sequentially. The patients in artesunate+amodiaquine or artemether+lumefantrine were followed up for 28 days and those in the dihydroartemisinin+piperaquinewere followed for 42 days.
Intervention code [1] 299301 0
Treatment: Drugs
Comparator / control treatment
No control group
Control group
Uncontrolled

Outcomes
Primary outcome [1] 303583 0
Percent of treatment failures (early treatment failure + late clinical failure +late parasitological failure). This is composite primary outcome.

Enrolled patients was assessed for parasitological and clinical responses during the 28 days or 42 days follow-up and treatment outcomes was classified according to the latest WHO protocol.
Timepoint [1] 303583 0
Time points for assessment are:
For artesunate+amodiaquine or artemether+lumefantrine: days 0, 1,2,3, 7, 14, 21 and 28 with day 28 as primary time point).
For dihydroartemisinin+piperaquine: days 0, 1,2,3, 7, 14, 21, 28, 35 and 42 with day 42 as primary timepoint.
Secondary outcome [1] 339463 0
Percent of adverse event following treatment of each drugs was assessed.
The known adverse events of the tested drugs are as follows:
Artesunate+amodiaquine: abdominal pain, asthenia, cough, diarrhoea, dizziness, insomnia, loss of appetite, nausea, vomiting.
Atemether+lumefantrine: abdominal pain, asthenia, cough, diarrhoea, dizziness, fever, headache, joint and muscle pain, loss of appetite, rush, nausea, vomiting.
Dihydroartemisinin-piperaquine: asthenia, cough, diarrhoea, fever, loss of appetite, nausea, vomiting.
Parents or guardians of all enrolled children was asked on each visit routinely about previous symptoms and about symptoms that have emerged since the previous follow-up visit. When clinically indicated, patients were evaluated and treated appropriately. All adverse events were recorded on the case report form.
Timepoint [1] 339463 0
Days 1, 2, 3, 7, 14, 21, 28 for artesunate+amodiaquine and artemether+lumefantrine and in addition days 35 and 42 were assessed for dihydroartemisinin+piperaquine
Secondary outcome [2] 342710 0
Prevalence of mutations K13 gene

DNA of day 0 (baseline) was extracted and were tested for the presence of mutations in the propeller domain in the pfK13 gene, which are associated with artemisinin resistance, whereby a portion of the pfK13 gene was amplified in a nested PCR assay (codons 440–680, 720 bp). DNA sequences were analysed to identify specific single nucleotide polymorphisms (SNPs) related to artemisinin resistance (Menard et al., 2016). Briefly, electrophoregrams were visualized and analysed with CEQ2000 genetic analysis system software (Beckman Coulter, Villepinte, France). The amino acid sequences were compared with the 3D7 wild-type amino acid sequences PF3D7_1343700. The presence of SNPs was confirmed by reading both the forward and the reverse strands. Parasites with mixed alleles were considered mutants.
Timepoint [2] 342710 0
Day 0
Secondary outcome [3] 342711 0
Prevalence of mutations in dhfr/dhps genes,
DNA extracts of day-0 samples were analysed for the presence of mutations in the pfdhfr and pfdhps genes, as described previously by Andriantsoanirina et al. (2009). DNA sequences were analysed with CEQ2000 genetic analysis system software (Beckman Coulter, Villepinte, France). The amino acid sequences were compared with the 3D7 wild-type amino acid sequences (PF3D7_0417200 for pfdhfr and PF3D7_0810800 for pfdhps). The presence of SNPs was confirmed by reading both the forward and the reverse strands. Parasites with mixed alleles were considered mutants.
Timepoint [3] 342711 0
Day 0
Secondary outcome [4] 342712 0
Prevalence of copy numbers of mdr1.

Copy number of Pfmdr1 gene (PF3D7_0523000) was assessed by qPCR using a CFX96 real-time PCR machine (Bio-Rad), as described previously by Witkowski et al. (2017). ß-tubulin (PF3D7_1008700) gene was used as housekeeping gene (single copy).
Timepoint [4] 342712 0
Day 0
Secondary outcome [5] 343311 0
Prevalence of copy numbers of plasmepsin2.

Copy number variation of pfplasmepsin2 gene (PF3D7_1408000) was determined in the day-0 samples of the DHA/PPQ-treated group, as described previously by Witkowski et al. (2017). The amplification signals of samples were compared with the signal of a standard control containing a known number of pfplasmepsin2 copies.
Timepoint [5] 343311 0
Day 0

Eligibility
Key inclusion criteria
1. age between 6 months to 59 months old ;
2. mono-infection with P. falciparum detected by microscopy;
3. parasitaemia of 1000 to 200 000 asexual forms per microliter ;
4. presence of axillary temperature greater or equal to 37.5 degrees centigrade or history of fever within the last 24 hours;
5. ability to swallow oral medication;
6. ability and willingness to comply with the study protocol for the duration of the study and to comply with the study visit schedule;
7. informed consent from the parent or guardian of children
Minimum age
6 Months
Maximum age
59 Months
Gender
Both males and females
Can healthy volunteers participate?
No
Key exclusion criteria
1. presence of general danger signs in children aged under 5 years or signs of severe falciparum malaria according to the definitions of WHO;
2. weight under 5 kg;
3. mixed or mono-infection with another Plasmodium species detected by microscopy;
4. Presence of severe malnutrition (who has a Mid Upper Arm Circumference [MUAC] below110 mm);
5. presence of febrile conditions due to diseases other than malaria (e.g. measles, acute lower respiratory tract infection, severe diarrhea with dehydration) or other known underlying chronic or severe diseases (e.g. cardiac, renal and hepatic diseases, HIV/AIDS);
6. regular medication, which may interfere with antimalarial pharmacokinetics;
7. history of hypersensitivity reactions or contraindications to any of the medicine(s) being tested or used as alternative treatment(s);

Study design
Purpose of the study
Treatment
Allocation to intervention
Non-randomised trial
Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
No concealment
Methods used to generate the sequence in which subjects will be randomised (sequence generation)
Not applicable
Masking / blinding
Open (masking not used)
Who is / are masked / blinded?



Intervention assignment
Other
Other design features
In the site (Kenema) where one drug (artemether+lumefantrine) was tested a single arm was used.
When two drugs were tested in one site (Bo and Makeni): patients were recruited sequentially to the two drugs: to the artesunate+amodiaquine until the target sample size is achieved and then to dihydroartemisinin+piperaquine.
Phase
Phase 4
Type of endpoint(s)
Safety/efficacy
Statistical methods / analysis
A minimum sample size of 50 was calculated assuming 5% treatment failure of the study medicines, a confidence level of 95% and a precision level of 5%. With a loss to follow-up of 10% by day D28, 55 patients per site and per drug was calculated.
All clinical and laboratory data were recorded in standardized case record forms for each patient. Data were validated. Demographic, clinical and laboratory data were double-entered independently and analysed with an Excel® database specifically designed by WHO for studies of anti-malarial drug efficacy (http://www.who.int/malaria/publications/atoz/9789241597531/en/). Baseline patient characteristics (age, temperature, parasitaemia) were compared across the study sites and antimalarial medicines using STATA. Patients were excluded from the per-protocol analysis of treatment outcomes if they were lost to follow-up, withdrawn, had reinfections or had unknown PCR. For the Kaplan-Meier analysis, all patients were included until the day of exclusion from the study. Chi-square test was used to compare categorical data. Fisher’s exact test was used where cell counts were less than 5. Differences in the mean were evaluated using the t-test. Confidence intervals were calculated for binomial proportions. Student’s t test was used to compare means

Recruitment
Recruitment status
Completed
Date of first participant enrolment
Anticipated
Actual
Date of last participant enrolment
Anticipated
Actual
Date of last data collection
Anticipated
Actual
Sample size
Target
Accrual to date
Final
Recruitment outside Australia
Country [1] 9265 0
Sierra Leone
State/province [1] 9265 0
Western, Northern, Southern and Eastern

Funding & Sponsors
Funding source category [1] 297683 0
Government body
Name [1] 297683 0
Ministry of Health and Sanitation
Address [1] 297683 0
4th Floor Youyi building
Brookfields
Freetown,
Sierra Leone
Country [1] 297683 0
Sierra Leone
Primary sponsor type
Government body
Name
Ministry of Health and Sanitation
Address
4th Floor Youyi building
Brookfields
Freetown,
Sierra Leone
Country
Sierra Leone
Secondary sponsor category [1] 296701 0
None
Name [1] 296701 0
Nil
Address [1] 296701 0
Nil
Country [1] 296701 0

Ethics approval
Ethics application status
Approved
Ethics committee name [1] 298755 0
Sierra Leone Ethics and Scientific Review Committee (SLESRC)
Ethics committee address [1] 298755 0
Youyi Building,
5t Floor, East Wing,
Free Town
Ethics committee country [1] 298755 0
Sierra Leone
Date submitted for ethics approval [1] 298755 0
Approval date [1] 298755 0
25/11/2015
Ethics approval number [1] 298755 0
SLESRC_2

Summary
Brief summary
A study was conducted in 2016 to assess the efficacy of three artemisinin based combinations (artesunate-amodiaquine, artemether-lumefantrine and dihydroartemisinin-piperaquine) for the treatment of uncomplicated falciparum malaria. We also investigated the prevalence of molecular markers for artemisinin, piperaquine and sulfadoxine/pyrimethamine resistance. The study was conducted in three sites (Bo, Kenema and Makeni Government hospitals). Artesunate-amodiaquine was evaluated in Bo and Makeni, artemether-lumefantrine in Kenema and dihydroartemisinin-piperaquine in Bo and Makeni sites. It was one-arm prospective assessment of clinical and parasitological outcomes to directly observed standard therapeutic regimens of the three medicines tested. Patients were followed up 28 days for artesunate-amodiaquine and artemether-lumefantrine and 42 days for dihydroartemisinin-piperaquine. In addition prevalence of K13 and dhfr/dhps mutations as well as copy numbers of mdr1 and plasmepsin2 were investigated using day 0 samples.
A total of 295 (128 for artesunate-amodiaquine, 64 for artemether-lumefantrine and 103 for dihydroartemisinin-piperaquine) eligible children were recruited from the three sites and 276 of them completed the follow-up. High cure rate (100%) was observed for the three treatments. All patients cleared their parasites on day 3. The proportion of parasites carrying of Pfmdr-1 multicopies was 10.9%. No pfk13 validated mutations nor Pfplasmepsin2 multiple copies were found while

Trial website
none
Trial related presentations / publications
none
Public notes

Contacts
Principal investigator
Name 78122 0
Prof Foday Sahr
Address 78122 0
College of Medicine and Allied Health Sciences
University of Sierra Leone
New England Ville,
Private Mail Bag, Freetown
Sierra Leone.




Country 78122 0
Sierra Leone
Phone 78122 0
+232-33-805221
Fax 78122 0
Email 78122 0
fsahr@yahoo.com
Contact person for public queries
Name 78123 0
Prof Foday Sahr
Address 78123 0
College of Medicine and Allied Health Sciences
University of Sierra Leone
New England Ville,
Private Mail Bag, Freetown
Sierra Leone.
Country 78123 0
Sierra Leone
Phone 78123 0
+232-33-805221
Fax 78123 0
Email 78123 0
fsahr@yahoo.com
Contact person for scientific queries
Name 78124 0
Prof Foday Sahr
Address 78124 0
College of Medicine and Allied Health Sciences
University of Sierra Leone
New England Ville,
Private Mail Bag, Freetown
Sierra Leone.
Country 78124 0
Sierra Leone
Phone 78124 0
+232-33-805221
Fax 78124 0
Email 78124 0
fsahr@yahoo.com

No data has been provided for results reporting
Summary results
Have study results been published in a peer-reviewed journal?
Other publications
Have study results been made publicly available in another format?
Results – basic reporting
Results – plain English summary