Aggressive Antipyretics in CNS Malaria: A Randomized-Controlled Trial Assessing Antipyretic Efficacy and Parasite Clearance Effects
Phase: PHASE2
Conditions: Malaria, Seizures, Coma, Parasitemia, Hyperpyrexia, Fever
Sponsor: University of Rochester

 
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AGGRESSIVE ANTIPYRETICS IN CNS MALARIA: A RANDOMIZED-CONTROLLED TRIAL  
ASSESSING ANTIPYRETIC EFFICACY AND PARASITE CLEARANCE 
 
 
Principal Investigator 
Gretchen L. Birbeck, MD MPH DTMH  
Professor, University of Rochester, Departments of Neurology and Public Health, Center for Health & 
Technology 
Research Director, Epilepsy Division 
265 Crittenden Blvd 
CU 420694 
Rochester, NY 14642-0694, USA 
US Office +1-5172734265 
US Cell +1-5175050283 
SkypeIN +1-5176390272  
In Malawi +265-995008069 
In Zambia +260-978086957 
Fax +1-5175075440 
Email Gretchen_Birbeck@URMC.Rochester.edu  
SkypeID:  muyucottage 
Contents 
ADMINISTRATIVE INFORMATION ...................................................................................... 3 
1. TITLE ................................................................................................................................ 3 
2. TRIAL REGISTRATION ........................................................................................................ 3 
3. PROTOCOL VERSION .......................................................................................................... 3 
 
4. FUNDING ........................................................................................................................... 3 
5. ROLES AND RESPONSIBILITIES ........................................................................................... 3 
5(a). Protocol contributors .................................................................................................. 3 
5(b)Trial sponsor ................................................................................................................. 5 
5(c) Role of study sponsor and funders ............................................................................... 5 
5(d) Composition of Advisory Committee, Local Study Monitor and Data Safety Monitoring Board
 
5 
6. BACKGROUND AND RATIONALE ........................................................................................ 9 
6(a) Description of research question ................................................................................. 9 
7. OBJECTIVES .................................................................................................................... 13 
7.1 Hypothesis ................................................................................................................... 13 
7.2  Primary objectives ...................................................................................................... 13 
7.3 Secondary objectives ................................................................................................... 13 
8. TRIAL DESIGN ................................................................................................................. 14 
METHODS: PARTICIPANTS, INTERVENTIONS, AND OUTCOMES ............................ 14 
9. STUDY SETTING .............................................................................................................. 14 
10. ELIGIBILITY CRITERIA ................................................................................................... 14 
10.1 Inclusion Criteria ...................................................................................................... 14 
10.2 Exclusion Criteria...................................................................................................... 14 
11. INTERVENTIONS ............................................................................................................ 15 
11(a) Interventions ............................................................................................................ 15 
11(b) Criteria for discontinuing or altering interventions ................................................ 15 
11(c) Strategies to improve adherence .............................................................................. 16 
11(d) Relevant concomitant care ....................................................................................... 16 
12. OUTCOMES ................................................................................................................... 16 
12.1 Primary outcome measures ....................................................................................... 16 

 
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12.2 Secondary outcome measures .................................................................................... 16 
12.3 Additional demographic and clinical data to be collected ........................................ 17 
13. PARTICIPANT TIMELINE ................................................................................................. 18 
14. SAMPLE SIZE ................................................................................................................. 19 
15. RECRUITMENT .............................................................................................................. 20 
15.1 Blantyre. .................................................................................................................... 20 
15.2 Lusaka. ....................................................................................................................... 20 
METHODS: ASSIGNMENT OF INTERVENTIONS ............................................................ 20 
16. ALLOCATION ................................................................................................................ 21 
16(a) Sequence generation. ............................................................................................... 21 
16(b) Allocation concealment mechanism. ........................................................................ 21 
17. BLINDING...................................................................................................................... 21 
METHODS: DATA COLLECTION, MANAGEMENT, AND ANALYSIS ......................... 21 
18. DATA COLLECTION METHODS ....................................................................................... 21 
18.1 Collection of data ...................................................................................................... 21 
18.2 Retention of subjects .................................................................................................. 22 
19. DATA MANAGEMENT .................................................................................................... 22 
20. STATISTICAL METHODS ................................................................................................. 23 
METHODS: MONITORING ..................................................................................................... 24 
21. DATA MONITORING ....................................................................................................... 24 
23. AUDITING ..................................................................................................................... 27 
ETHICS AND DISSEMINATION ............................................................................................ 27 
24. RESEARCH ETHICS APPROVAL ....................................................................................... 27 
25. PROTOCOL AMENDMENTS ............................................................................................. 28 
26. CONSENT ...................................................................................................................... 28 
27. CONFIDENTIALITY ........................................................................................................ 28 
28. DECLARATION OF INTERESTS ........................................................................................ 29 
29. ACCESS TO DATA .......................................................................................................... 29 
30. ANCILLARY AND POST-TRIAL CARE .............................................................................. 29 
31. DISSEMINATION POLICY ................................................................................................ 29 
32. INFORMED CONSENT MATERIAL (FINAL ENGLISH VERSION WILL BE TRANSLATED INTO THE 
APPROPRIATE LOCAL LANGUAGES) ..................................................................................... 29 
 
 
 
 

 
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Administrative Information 
1. Title 
 
Aggressive Antipyretics in CNS Malaria: A Randomized-Controlled Trial Assessing Antipyretic Efficacy 
and Parasite Clearance Effects 
 
2. Trial registration 
 
This trial is registered with ClinicalTrial.gov (NCT03399318) and with the Pan African Clinical Trials 
Registry (PACTR201804003255157). 
 
3. Protocol version  
 
Issue date: 21 Oct 2020 
Authors: KBS, GLB, MM 
Version #: 5.2 
 
Revision Chronology: GLB revision to version 3.0 30Sep2016 
4. Funding 
 
Funded by the US NIH NIHR01NS102176 
 
5. Roles and responsibilities 
 
5(a) Protocol contributors 
Gretchen L. Birbeck, MD MPH DTMH  
Principal Investigator 
Professor, University of Rochester, Departments of Neurology and Public Health, Center for Health & 
Technology 
Research Director, Epilepsy Division 
265 Crittenden Blvd 
CU 420694 
Rochester, NY 14642-0694, USA 
US Office +1-5172734265 
US Cell +1-5175050283 
SkypeIN +1-5176390272  
In Malawi +265-995008069 
In Zambia +260-978-086-957 
Fax +1-5175075440 
Email Gretchen_Birbeck@URMC.Rochester.edu  
SkypeID:  muyucottage 
 
Karl Seydel, MD PhD 
Co-Investigator and local PI in Malawi 
Dept. of Osteopathic Medical Specialties 
College of Osteopathic Medicine 
909 Fee Road, West Feel Hall, Room B305-B  
East Lansing MI  48824-1315, USA 
US Office +1-5173533211 
In Malawi +265-999452989 
Fax +1-5174321062 

 
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Email seydel@msu.edu  
 
Manoj Mathews, MBChB, MMED Pediatrics and Child Health 
Co-Investigator 
National Paediatric Coordinator – Ministry of Health 
Consultant Paediatrician – UTHs Children’s Hospital 
Honorary Lecturer UNZA SOM 
University Teaching Hospital 
Nationalist Ave 
RW-1X 
Lusaka, Zambia 
Cell +260-977625727 
Email m_s_mathew@yahoo.com  
 
Musaku Mwenechanya, MBChB, MMED Pediatrics and Child Health 
Co-Investigator 
Head, Clinical Care 
UTH Lusaka Children’s Hospital 
Nationalist Ave 
RW-1X 
Lusaka, Zambia 
Tele +260-966722966 
Email mmusaku@gmail.com  
 
Suzanna Mwanza, MBChB, MMED Pediatrics and Child Health 
Co-Investigator 
Consultant Paeditrician and Head of Department for Paediatrics & Child Health 
Chipata Central Hospital 
P.O. Box 510119 
Chipata, Zambia 
Cell +260-977674471 
Work +260-961517604 
Email mwanzasue@yahoo.co.uk  
 
Michael McDermott, PhD 
Co-Investigator 
Professor of Biostatistics and Computational Biology 
265 Crittenden Blvd, CU 420630 
Rochester, NY  14642-0630, USA 
Tele +1-5852756685 
Fax +1-5852731031 
Email MikeM@bst.rochester,edu  
 
Archana Patel, MD, MPH  
Co-Investigator  
Instructor in Neurology  
300 Longwood Ave 
Boston, MA 02115-5724, USA  
Cell (+1) 617-355-7970 
Work (+1) 617-730-4850 
Email Archana.Patel@childrens.harvard.edu  
 
Phillip C. Thesing, DO DTMH 
Research Coordinator & Clinician 
Neurology Research Office 
UTH Lusaka Children’s Hospital 
Paediatric Annex 
Private Bag RW1X 

 
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Ridgeway 
Lusaka, Zambia 
Cell +260-962121455 
Email Phillip_Thesing@urmc.rochester.edu 
Skype: phillip.thesing  
 
University of Rochester Study Co-coordinator 
Ifunanya F. Dallah, BA 
University of Rochester 
Center for Health & Technology 
265 Crittenden Blvd 
CU 420694 
Rochester, NY 14642-0694, USA 
Office: +1-5852752791 
Cell: +1-3014123291 
Email: Ifunanya_Dallah@URMC.Rochester.edu 
SkypeID: Ifunanya.dallah 
 
Ivy Mulwani Makulu 
Site Administrator (Zambia) 
UTH Neurology Research Office 
Paediatric Annex 
Private Bag RW1X 
Ridgeway 
Lusaka, Zambia 
Cell +260-974795275/+260-950644493 
Email chase2uth@yahoo.com    
 
Authors’ contributions: 
GB conceived of the study. GB, KS, and MacM initiated the study design. IM and PT will help with study 
implementation. Mike M will complete the initial statistical analysis. All authors contributed to refinement 
of the study protocol. 
 
5(b) Trial sponsor  
 
 
University of Rochester,  
Departments of Neurology and Public Health,  
Center for Health & Technology 
265 Crittenden Blvd 
CU 420694 
Rochester, NY 14642-0694 
USA 
 
5(c) Role of study sponsor and funders 
 
The funding source had no role in the design of this study and will not have any role during its 
execution, analyses, interpretation of the data, or decision to submit the results. 
 
5(d) Composition of Advisory Committee1, Local Study Monitor and Data Safety Monitoring 
Board 
 
Terrie E. Taylor, DO 
 
1 Advisory Committee include DSMB, Pediatric Research Ward Directors, and Heads of Pediatrics Departments at both 
study sites. 

 
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Director-Blantyre Malaria Project 
Box 30096 
Blantyre 3, Malawi 
Cell +265-999969220 
Email ttmalawi@msu.edu  
 
Macpherson Mallewa, MBBS MRCP MRCPCh DTMH PhD  
Co-Investigator 
Consultant Paediatric Neurologist/ 
Senior Lecturer/Deputy Head-Department of Paediatrics 
Core Paediatrician-MLW 
College of Medicine Malawi-Liverpool-Wellcome Trust Clinical Research Programme 
P.O. Box 30096, Chichiri  
Blantyre 3, Malawi 
Tele +265-1876444 
Tele +265-9995835083 
Email mmallewa@mlw.medcol.mw  
 
Josephine Langton, MBChB, MRCPCH 
Academic Head of Department, Paediatrics and Child Health  
Queen Elizabeth Central Hospital 
Chipitala Ave., Chichiri 
Blantyre 3, Malawi 
Tele +265-993630543 
Email joelangton@doctors.org.uk  
 
Local Study Monitors 
 
Zambia: 
John Musuku, MBBS, MBChB 
Senior Medical Superintendent 
UTH Lusaka Children’s Hospital 
Nationalist Ave 
Lusaka, Zambia 
Tele +260-966766052 
Email jmusuku2001@yahoo.co.uk  
 
Dr. Mbinga Mbinga 
Senior Medical Superintendent 
Chipata Central Hospital 
P.O. Box 510119 
Chipata, Zambia 
Tele +260-216-221427/-223093/-223083 
Fax +260-216-222414 
Email dr.mbinga@gmail.com  
 
Dr. Nyakulira Elita Kandiwo (alternate/backup) 
EPHO 
P.O. Box 510023 
Chipata, Zambia 
Phone: (+260) 977-541-336 / 966-531-336 
Email: nyakukandiwo@gmail.com  
 
 
Malawi: 
Neema Mtunthama Toto, BSc Nursing, MSc Clinical Trials 
Cryptofaz Programme Manager 
Malawi Liverpool Wellcome Trust  

 
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P.O. Box 30096 
Blantyre 3 
Malawi 
Cell: +265-999981451 
Email: ntoto@mlw.mw 
Skype: Neema Toto 
 
 
George Chagaluka, B. Surgery & Medicine,  
Specialist in Pediatrics & Child Health, Oncology Fellow 
Department of Pediatrics & Child Health 
Pediatric Dept., College of Medicine 
Private Bag 360, Blantyre 3 
Malawi 
Cell: +265-998-108-968 
Email: gchagaluka@medcol.mw , gchagaluka@gmail.com  
Skype: georgechagaluka 
 
DSMB  
 
Professor Quique Bassat (Chair) 
Barcelona Institute for Global Health 
Rossello 132 
08036 Barcelona, Spain 
Cell +34609556300 
Email quique.bassat@isglobal.org 
 
 
Chandy C. John, MD 
Indiana University, Department of Microbiology & Immunology 
635 Barnhill Drive, MS 420 
 
Indianapolis, IN 46202 
Tele +1-3172789290 
Cell +1-6128399307 
Email chjohn@iu.edu  
 
Dr. Richard Idro 
Mulago Hospital, Makerere University School of Medicine 
PO Box 7072 
Kampala  
Uganda 
Cell +256-414531875 
Email ridro1@gmail.com 
 
Joseph C. Gardiner, PhD 
University Distinguished Professor 
Associate Chair, Department of Epidemiology and Biostatistics 
Professor, Biostatistics & Epidemiology 
909 Fee Road, West Fee Hall, Room B629  
East Lansing, MI 48824-1315 
USA 
Tele +1-517-884-3967 
Fax +1-517-432-1130 
East Lansing, MI 48824-1315 
USA 
Email jgardiner@epi.msu.edu  
 
Prof. Malcolm E. Molyneux 
Emeritus Professor  
Liverpool School of Tropical Medicine 

 
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5 Pembroke Place, Liverpool, UK 
Tel (+44) 151-9243184 
Mobile (+44) 7810-603669 
Email mmolyneux999@gmail.com  
 
 

 
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6. Background and rationale 
6(a) Description of research question 
 
Significance 
Neurologic Sequelae Following Severe Malaria in Childhood 
 
Despite eradication measures, ~200 million malaria cases occurred in 2013 with ~500,000 
malarial deaths, primarily in African children(1). Neurologic sequelae occur in 1/3rd of survivors of CNS 
malaria, meaning parasitemia and neurologic symptoms including impaired consciousness and/or 
seizures (2-5). Newer antimalarial medications rapidly clear peripheral parasitemia and improve 
survival, but mortality remains high at 12-25% with no associated decline in post-malaria neurologic 
injury (6). Past studies have identified neurologic deficits at discharge in 9-18% of CNS malaria 
survivors with additional sequelae, such as epilepsy, becoming evident with longer term follow-up (2, 7-
13). We conducted a prospective cohort study (BMPES) of children with the most severe form of CNS 
malaria—cerebral malaria (CM). CM is defined as unarousable coma (persisting for at least 30 
minutes after any seizure), parasitemia and no other coma etiology(14). When followed for an average 
of 77 weeks, 32% of BMPES children experienced neurologic sequelae including epilepsy (9%), 
behavioral problems (11%) and new neurodisabilities (23%)(2). Data from studies in other malaria-
endemic African countries indicate that neurologic sequelae are not unique to children with CM. Children 
with “CNS malaria”, meaning malaria-associated seizures or impaired consciousness without deep coma 
also experience high rates of sequelae. 
 
Table 1: A Review of Neurologic Outcomes after CNS Malaria 
COUNTRY 
INCLUSION CRITERIA 
ASSOCIATED NEUROLOGIC OUTCOME 
Uganda(15, 16) 
Children 5-12 years. Convulsions for > 15 minutes, 
repeated seizures in 24 hours based upon parental or 
healthcare staff report, abnormal level of consciousness 
(GCS≤14), or coma. Only 9/62 had cerebral malaria. 
Early problems with behavior and longer term 
follow-up identified poor academic 
performance and cognitive problems. 
Kenya(17), (18) 
Children with complicated seizures during malaria (not 
cerebral malaria) 
Long term problems with executive function 
compared to unexposed children  
Kenya(5) 
Children with malaria and seizures (M/S) compared to 
children with cerebral malaria(CM) 
Comparable rates of epilepsy during follow-
up and both exceeded the rates in 
unexposed  
Kenya(4) 
Children with malaria and seizures (M/S) compared to 
children with cerebral malaria(CM) 
24% of M/S and CM kids experienced 
neurologic sequelae during follow-up though 
CM kids were more likely to have multiple 
deficits.  
Kenya(17) 
Children with M/S (and not CM) 
Language and behavioral problems at follow-
up 
Zambia(19) 
Children 6 months to 6 years. Fever and seizures with 
81% of cohort having malarial fever but <1% meeting 
criteria for cerebral malaria. Complicated seizures (focal, 
recurrent in 24 hours and prolonged) were common. 
11.2% of children with complicated seizures 
developed epilepsy during follow-up and 15% 
had new neurodevelopmental problems at 
discharge or during follow-up 
 
Fever as a Risk Factor for Malaria-Associated Brain Injury (Scientific Premise) 
 
In BMPES, acute symptomatic seizures and a higher maximum temperature (Tmax) during the 
acute infection were associated with a greater risk of post-malaria neurologic sequelae. Children who 
developed epilepsy had a mean Tmax of 39.4°C vs. 38.5°C in those who did not develop epilepsy 
(absolute difference of 0.9°C; p=0.01). In addition, a higher Tmax predicted subsequent behavioral 
disorders (39.2°C vs. 38.7°C; absolute difference 0.5°C; p=0.04). These data are biologically consistent 
with the substantial body of evidence that fevers contribute to secondary neurologic injury in the setting 
of stroke, meningitis, anoxia, hypoxia, and trauma (20-24). In the U.S., induced hypothermia is now 
standard-of-care for post-anoxic(25) and neonatal hypoxic-ischemic encephalopathy(26-29) and fever-
reduction is an important aspect of neurocritical care(30-33). Malaria-induced fevers can be extremely 
high. Fifteen percent of the BMPES cohort experienced at least one temperature of ≥ 40.0°C (104.0°F). 
The age-related susceptibility to pediatric malaria substantially overlaps with the age-related 
phenomena of febrile seizures. Malarial seizures are often complex, multifocal, and prolonged with 
status epilepticus being common (2, 19, 34, 35).  See Table 2 for potential mechanisms of fever-
induced injury in CNS malaria. 
 

 
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Standard-of-Care for Malarial Fevers 
 
Despite substantial evidence for the deleterious effects of fever after brain injury, the World 
Health Organization’s (WHO) Malaria Care Guidelines recommend fever treatment only for rectal T ≥ 
38.5°C(36). Since malaria-associated fevers escalate rapidly, treatment based upon this threshold 
means many children develop significant hyperpyrexia prior to initiating fever-reduction therapy. In the 
BMPES cohort, among 52 children who were afebrile at the time of admission the mean Tmax during 
hospitalization was 39.0°C and 13/52 (25%) had a post-admission fever of ≥39.0°C based upon Q2 
hourly evaluations. In most malaria care settings, vital signs are only assessed every 6-12 hours, so 
adherence to WHO Guidelines inevitably result in children with CNS malaria developing and 
maintaining high fevers for some hours before antipyretics are initiated.  
While the neurologist accustomed to aggressive fever management in the neurocritical care unit 
may find this approach to fever management in pediatric malaria baffling, WHO guidelines and clinical 
practice patterns are likely predicated upon two factors—first, the well-described dearth of neurologic 
expertise in malaria-endemic regions(37) and secondly, some evidence suggesting that malarial fevers 
may be desirable. In vitro studies have shown that febrile temperatures inhibit parasite growth with the 
conclusion being that “long, high fevers during malaria may be beneficial for parasite clearance”(38) 
and a clinical trial of antipyretics for malarial fevers found that peripheral parasite clearance time was 
delayed in children who received acetaminophen(39). 
 
 
Table 2: Potential Mechanisms of Fever-Induced Brain Injury in CNS Malaria 
MECHANISM OF  
FEVER-INDUCED  
INJURY 
RELATIONSHIP TO CNS MALARIA PATHOPHYSIOLOGY 
↑ proinflammatory 
cytokine cascade 
(1) cerebral malaria cerebrospinal fluid (CSF) CSF exhibits high levels of inflammatory cytokines 
including interleukin (IL)-6, CXCL-8/IL-8, granulocyte- colony stimulating factor (G-CSF), tumor necrosis 
factor- alpha (TNF-alpha), and IL-1 receptor antagonists(40) 
(2) High TNF alpha levels are associated with later cognitive impairment(41) 
↑ excitoxicity 
including 
↑intracellular 
glutamate 
The high rates of age-dependent seizures in cerebral malaria are thought to be mediated by excitotoxic 
neurotransmitters especially glutamate (42, 43). Glutamate diffusion occurs with subsequent increase in 
glutamate-induced damage 
Acceleration of free 
radical 
production 
(1) Free radicals are also generated by the parasite. Excessive production can overwhelm glutathione 
metabolism(44) 
(2) Reactive oxygen intermediates may be important for parasite clearance in uncomplicated malaria(45) 
(3) Animal models indicate free radical production hastens tissue damage in cerebral malaria(46) 
Fever potentiates 
sensitivity of 
neurons to 
CSF in Malawian children with CM has elevated levels of the excitotoxin quinolinic acid. Higher levels of 
this excitotoxin are seen in CM children with acute seizures and higher levels are also associated with 
CM mortality(40),(43) 
↑cerebral metabolic 
rate 
(1) In CM focal, prolonged seizures +/- hypoglycemia +/- local ischemia from sequestration-induced 
sludging +/- systemic hypoxia +/- anemia makes brain tissue more susceptible to injury from primary 
energy failure associated with the increased metabolic rate from fevers(35) 
(2) Where auto-regulatory dysfunction occurs, an increased metabolic rates causes increased cerebral 
blood flow and increased intracranial pressure. Brain swelling has recently been shown to be the key 
structural predictor of mortality in pediatric CM based upon MRI(47) 
Increased 
sequestration(48) 
Increased rosette formation, a temperature dependent phenomena, results in enhanced CNS parasite 
sequestration, increased microvascular obstruction and increased ischemia and edema. 
 
New Insights into Parasite Behavior and Improved Methods for Measuring Parasite Burden 
 
In vitro, uninfected red blood cells (RBCs) stick to those infected with trophozoites and schizonts 
of P. falciparum forming rosettes which are thought to play an important role in sequestration and 
microvascular obstruction. Studies have shown that rosette formation increases from 37.0 to 40.0°C 
(48). This temperature-dependent, PfEMP-1 mediated effect doubles RBC cytoadherence and may 
explain the delayed peripheral parasite clearance time associated with antipyretic use (39). 
Essentially, since lowering temperatures may attenuate cytoadherence, peripheral parasite 
counts may transiently increase as sequestered parasites are liberated into the bloodstream. 
This may actually be a desirable effect if by doing so antipyretics improve cerebral blood flow at 
the capillary-level and reduce sequestration. Parasitized erythrocytes have also been shown to lose 
their flexibility at temperatures over 37.0°C especially in the late trophozoite and schizont phase, which 
likely further exacerbates sequestration (49). 
Histidine Rich Protein II (HRP2), a Plasmodium-specific protein in patient plasma, may facilitate 
quantification of whole-body parasite burden. Recent studies led by Dr. Seydel are supportive of the 

 
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supposition that sequestered parasites, not those circulating in the peripheral blood, are the primary 
contributors to severe malaria. They found that mean plasma HRP2 concentrations early in the malaria 
infection predict progression to CM, even among children receiving treatment(50). Higher plasma levels 
of HRP2 are also associated with CNS parasite sequestration based upon autopsy findings and 
bedside retinal assessments with quantitative HRP2 levels of ≥1700ng/ml providing 98% sensitivity and 
98% specificity for identifying CNS parasite sequestration (area under the ROC curve 0.98)(51). As 
such, HRP2 levels provide excellent proxy data for establishing CNS parasite sequestration even in 
conscious, acutely ill children in whom funduscopy is problematic. 
 
Study Rationale  
 
Studies of other pediatric infections have shown that combination therapy with standard 
antipyretics can result in reduced fevers, but whether this is true for malaria-associated fevers is unclear. 
Although antipyretic use with a single agent in one malaria study was associated with prolonged 
peripheral parasitemia, fever clearance time was not significantly different (32 hours in the antipyretic 
treated group vs. 43 hours in routine care; p=0.176)(39). Limited fever reduction benefits from single 
antipyretic agents in malaria have been shown in other studies(52). A randomized controlled trial of 
acetaminophen (without a loading dose) vs. ibuprofen found an ibuprofen advantage only at 4.5 hours 
post treatment(53). A controlled trial of acetaminophen vs. placebo for uncomplicated malaria found no 
differences in mean temperature, but 6/171 children receiving placebo required admission for febrile 
seizures compared to 2/167 on acetaminophen (54). Antipyretic efficacy has been shown in some 
studies--acetaminophen is more effective in malaria fever reduction than tepid sponging(55). No malaria 
studies to date have evaluated the impact of prophylactic treatment to prevent fevers or 
interventions using two antipyretics with different mechanisms of action.  
Acetaminophen’s mechanism of action is not fully understood, but it is a potent inhibitor of 
prostaglandin production in the CNS with minimal anti-inflammatory effects(56). Recent studies suggest 
that it inhibits the peroxidase functions of COX-1 and COX-2 with selectivity for the inhibition of 
prostaglandin synthesis (57). In children with non-malarial fevers and a rectal temperature of >39.0°C, 
15 mg/kg of acetaminophen resulted in a decrease of 1.07-1.98°C(58), which is greater than the 
temperature difference associated with better neurological outcomes in the BMPES study. The primary 
safety concern with acetaminophen use is the hepatotoxicity that can occur when the recommended 
dosage is exceeded. Ibuprofen is a non-selective COX inhibitor, inhibiting both COX-1 and COX-2. The 
analgesic, antipyretic, and anti-inflammatory activity of ibuprofen is achieved mainly through inhibition 
of COX-2, whereas inhibition of COX-1 impacts platelet aggregation and likely mediates gastrointestinal 
side effects (59). By 1991, some estimates indicated that over 250 million children had received 
ibuprofen with very few serious adverse events reported (60, 61). The most common ibuprofen side 
effects include gastritis, impaired platelet function and decreased urinary excretion of sodium. Among 
non-steroidal anti-inflammatories, ibuprofen is the least likely to cause gastrointestinal bleeding. Studies 
have shown both acetaminophen and ibuprofen to be safe in children when used individually(62, 63) 
and in combination(64). Both agents have been shown to be generally safe and effective for fever 
reduction in children (65-67). Studies in children with non-malarial fevers have found some additional 
fever-reduction benefit when the two drugs are used together(64). A Malawi-based study of children 
with uncomplicated malaria comparing acetaminophen and ibuprofen found no difference in fever 
resolution time and no serious adverse effects from either treatment were identified(68). 
Acetaminophen and ibuprofen are already approved for fever reduction in the dosage outlined 
for this planned intervention for use in children age 2-11 years by the appropriate regulatory 
agencies (the Pharmacy, Medicines and Poisons Board in Malawi and Zambia Medicines 
Regulatory Authority) as well as the US Food and Drug Administration. 
The rationale for this clinical trial is based upon (1) unmet clinical need in terms of the imperative 
to decrease the neurologic injury and sequelae that occur in ~250,000 malaria survivors each year, (2) 
previous epidemiologic data indicating that higher Tmax is associated with neurologic sequelae in CNS 
malaria, (3) the very plausible biological mechanisms of malarial fever-related secondary brain injury 
detailed in Table 2, (4) in vivo and in vitro data on temperature dependent parasite behavior and whole 
body parasite burden suggesting that findings from previous research linking fever reduction to slowed 
parasite clearance may be erroneous. 
 
Innovation 
 
Despite substantial evidence that hyperthermia in the setting of acute CNS injury generally 
worsens neurologic damage as well as observational data in pediatric CNS malaria showing the same 

 
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association, malaria care guidelines today recommend a single antipyretic agent and treatment 
initiation only after a significant fever (T ≥ 38.5ºC) occurs. The clinical trial proposed here seeks to 
challenge this practice paradigm by evaluating the fever-reduction efficacy of more aggressive 
antipyretic use while also taking advantage of a relatively new method for quantifying total parasite 
burden (HRP2) to further characterize malaria severity and elucidate the impact of antipyretics on 
parasite sequestration and clearance. This study will also assess the efficacy of aggressive antipyretic 
use in deterring acute symptomatic seizures during the malaria infection. The trial is novel in the 
provision of prophylactic treatment, the proposed use of combining two agents, and the select patient 
population—namely children with CNS malaria rather than uncomplicated malaria as were included in 
prior antipyretic malaria trials. Our “go” criterion will be met if we reject the null hypothesis of no 
treatment effect (i.e., no reduction in mean Tmax in the aggressive antipyretics group). If the true 
treatment effect is a reduction of at least -0.5ºC, we will have a 90% chance of detecting significance of 
the treatment effect. If the ‘go’ criterion is met, the phase III study to follow would be innovative in that it 
would entail a trial of aggressive antipyretics with the goal of normothermia rather than induced 
hypothermia as a neuroprotective intervention after CNS injury. 
 
Preliminary Data 
Capacity to Conduct Clinical Trials and Capture Delayed Outcomes  
Our prior outcome studies of severe malaria (2, 19) has provided us with the experience of 
(successfully) negotiating the regulatory requirements and compliance challenges of conducting an 
NIH-funded clinical trial in the African setting has provided us with the experience of (successfully) 
negotiating the regulatory requirements and compliance challenges of conducting an NIH-funded 
clinical trial in the African setting.  
 
Further Insights into the Role Fever Plays in the Pathophysiology of Neurologic Injury in CNS Malaria 
 
IS FEVER INDEPENDENTLY ASSOCIATED WITH ADVERSE NEUROLOGIC OUTCOMES? Children with CNS 
malaria are of an age to be susceptible to febrile seizures and acute malarial seizures are a well-
established risk factor for neurologic sequelae in malaria survivors. To evaluate whether temperature 
independently affects neurologic outcomes in CNS malaria, we used the BMPES data to examine the 
relationship between Tmax and adverse neurologic outcomes in a regression model that adjusted for 
the presence/absence of seizures during the acute admission. After controlling for acute seizures, a 
higher Tmax remained associated with adverse neurologic sequelae during follow-up (p=0.029).  
 
DOES THE RELATIONSHIP BETWEEN FEVER AND ADVERSE NEUROLOGIC OUTCOME HOLD TRUE FOR CHILDREN 
WITH CNS MALARIA MORE BROADLY DEFINED? The BMPES study, which identified a higher Tmax as being 
a risk factor for neurologic sequelae in CNS malaria, only included children with retinopathy positive 
CM(2). Although children with the more broadly defined CNS malaria experience similar rates of 
neurologic injury evident after recovery (detailed in Table 1 above), little is known or published about 
the impact of fever on outcomes in this broader population. To examine the effects of fever on a 
broader population of children with malaria, we compared Tmax in retinopathy negative children with 
and without neurologic sequelae who were enrolled during the BMPES study. The clinical 
characteristics(69), neurologic outcomes(70) and MRI findings(71) of these retinopathy negative 
children have been previously described. Among 35 retinopathy negative children, the mean Tmax 
in children with neurologic sequelae was 39.2ºC vs. 38.7ºC in those without sequelae—a finding 
very consistent with the difference in mean Tmax found in the retinopathy positive BMPES 
cohort suggesting that fever likely plays a role in neurologic injury across the broader spectrum 
of CNS malaria. 
 
WHAT IS THE PATHOPHYSIOLOGIC BASIS FOR FEVER-MEDIATED SECONDARY BRAIN INJURY? HOW CAN WE 
BEST CAPTURE THIS EXPOSURE? Based upon numerous epidemiological studies (20-24) (25-29)(30-
33)(30-33)￼(72) data from malaria experiments conducted by White et al. led them to conclude that 
keeping the temperature at 37.0°C will delay cytoadherence by 3 hours and allow up to 25% of the ring 
parasites to be removed before sequestration (48) other aspect of fever exposure. Fortunately, the 
0.5ºC difference in mean Tmax in children with vs. without sequelae in the BMPES study does offer 
some insights into what constitutes a clinically meaningful difference in Tmax. To further explore 
whether Tmax is the most sensitive measure for predicting fever-associated neurologic sequelae from 
malaria, we returned to the BMPES study data and examined the association between adverse 

 
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neurologic outcome and area under the fever-time curve based upon Q2 hourly assessments using a 
fever threshold of 37.0ºC and a threshold of 37.5ºC. Unlike Tmax, these alternate measures of 
temperature exposure were not associated with adverse neurologic outcomes, so our primary 
outcome remains Tmax. Unlike Tmax, these alternate measures of temperature exposure were 
not associated with adverse neurologic outcomes, so our primary outcome remains Tmax. 
 
HRP2 Studies 
 
 
7. Objectives  
 
7.1 Hypothesis 
We hypothesize that children who receive aggressive antipyretic therapy will have: 
(i) A lower mean Tmax using computer-based continuous temperature monitoring 
(ii) Decreased acute symptomatic seizures during the 72 hour treatment period 
(iii) A lower incidence of long term neurologic sequelae. This will be assessed in the more definitive 
study to follow if we meet our “go” criterion—meaning we reject the null hypothesis of no treatment 
effect with findings of a lower mean Tmax in the aggressive antipyretic treatment group compared to 
usual care. 
7.2 Primary objectives 
 
7.2.1 To conduct a randomized, double-blind, placebo controlled trial of aggressive antipyretic therapy 
to reduce Tmax in pediatric CNS malaria and evaluate the “proof-of-concept” for potential 
neuroprotective efficacy. Children admitted with CNS malaria, defined as malaria with impaired 
consciousness and/or seizures, will be randomized to usual care (15 mg/kg acetaminophen Q6 hours 
as needed for ≥ 38.5ºC) vs. aggressive antipyretic therapy with prophylactic acetaminophen (30 mg/kg 
load followed by 15 mg/kg Q6 hours) PLUS ibuprofen (10 mg/kg Q6 hours) from time 0 to hour 72, the 
timeframe in which most children with malaria will defervesce 
 
7.3 Secondary objectives 
 
7.3.1 To evaluate the safety of aggressive antipyretic therapy. After enrollment, serial assessments to 
identify incident hypoglycemia, bleeding/clotting problems, renal insufficiency, and/or hepatic 
dysfunction will be undertaken. Local Study Monitors will review adverse events for individual 
participants in real time. Interim analyses will be conducted annually with explicit stopping rules based 
upon mortality. 
  
7.3.2 To assess the effect of aggressive antipyretic therapy on parasite sequestration and parasite 
clearance, we will evaluate host parasite burden through Q6 hourly quantitative parasite counts as well 
as HRP2 quantitation. We hypothesize that fever treatment will reduce sequestration resulting in lower 
HRP2 levels based upon area under the curve during the 72 hour treatment period and that an 
associated transient paradoxical increase in peripheral parasitemia with a higher proportion of older 
parasites will be seen as centrally sequestered parasitized red blood cells are released. 
Our studies of HRP2 levels in Malawian children 
have supported the importance of quantifying the 
parasite burden through means other than a 
peripheral blood smear. HRP2 levels in the 
periphery are affected by multiple variables, 
including level of sequestration and rate of parasite 
clearance post-treatment. In a preliminary 
experiment we measured Q6 hour HRP2 levels 
post-treatment and found that marked differences 
occur despite identical treatment. We therefore will 
measure HRP2 levels every 6 hours in both arms 
of the trial with the hypothesis that in the 
aggressive antipyretic arm sequestration will be 
reversed and thus area under the concentration-
time curve of HRP2 levels will decrease. 

 
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8. Trial design 
 
The trial will be randomized, double-blind, placebo-controlled trial of aggressive antipyretic therapy with 
the primary outcome being the maximum temperature occurring in the 72 hours after presentation with 
acute malaria. Children with malaria and neurologic symptomatology (either cerebral malaria or CNS 
malaria) will be randomized to receive aggressive antipyretic therapy with scheduled acetaminophen 
starting with a 30mg/kg load following by 15mg/kg Q6 hourly PLUS ibuprofen 15mg/kg Q6 hourly vs. 
usual care. Usual care is 15mg/kg of acetaminophen Q6 hourly as needed for a temperature of 
≥38.5°C. A total of 284 children (142 in each study arm) will be enrolled. 
Methods: Participants, Interventions, and Outcomes 
9. Study setting 
 
The study will be carried out in three settings: the Pediatric Research Ward (PRW) at Queen Elizabeth 
Hospital in Blantyre, Malawi; the Pediatric Intensive Care Ward (PICU) at University Teaching Hospital 
in Lusaka, Zambia; the High Acuity Section within the Pediatric Ward at Chipata Central Hospital, 
Chipata, Zambia.  
 
10. Eligibility criteria 
 
Parents or guardians must provide written informed consent in their local language prior to any 
procedures or treatments taking place. 
 
10.1 Inclusion Criteria 
10.1.1 Age 2-11 years (24 to 132 months) 
10.1.2 Evidence of P. falciparum malaria infection by peripheral blood smear or rapid diagnostic test 
10.1.3 CNS symptoms associated with malaria. CEREBRAL MALARIA:  Impaired consciousness with a 
Blantyre Coma Score (BCS)(73) ≤2 in children under 5 years or a Glasgow Coma score (GCS) ≤10 in 
children ≥5 years OR CNS MALARIA: Complicated seizure(s), meaning prolonged (>15 minutes), focal or 
multiple; or impaired consciousness or other evidence of impaired consciousness (confusion, delirium) 
without frank coma (BCS>2, GCS =11-14)  
10.2 Exclusion Criteria 
10.2.1 Circulatory failure (cold extremities, capillary refill > 3 seconds, sunken eyes, ↓ skin turgor) 
10.2.2 Vomiting in the past 2 hours 
10.2.3 Serum Cr > 1.2 mg/dL 
10.2.4 A history of liver disease 
10.2.5 Jaundice or a total bilirubin of >3.0mg/dL 
10.2.6 A history of gastric ulcers or gastrointestinal bleeding 
10.2.7 A history of thrombocytopenia or other primary hematologic disorder 
10.2.8 Petechiae or other clinical indications of bleeding abnormalities  
10.2.9 A known allergy to ibuprofen, acetaminophen, aspirin or any non-steroidal medication 
*10.2.10 Any contraindication for nasogastric tube (NGT) placement and/or delivery of enteral 
medications  
 
10.3 Vulnerable Population 
Children with CNS malaria in Africa are a vulnerable population. They are targeted for inclusion in this 
study because they are the population who suffers from CNS malaria. Measures will be taken to 
safeguard their rights and welfare including a thorough informed consent process (Sec. 26 of protocol) 
and a detailed data and safety monitoring plan (Sec 21 of protocol). Staff who consent study subjects 
are local healthcare workers fluent in the local language. 
 

 
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11. Interventions 
11(a) Interventions 
 
Study Intervention 
 
11.a.1 Intervention arm-scheduled dosing every 6 hours with acetaminophen (30mg/kg p.o. load then 
15mg/kg Q6 hours) and ibuprofen (10mg/kg Q6 hourly), starting at enrollment (hour 00) and continuing 
through hour 72 including a final dose at hour 72.  
 
11.a.2 Usual care arm-acetaminophen 15mg/kg Q6 hourly as needed for temperature ≥ 38.5°C based 
upon axillary temperatures taken in the course of routine clinical care (starting at enrollment (hour 00) 
and continuing through hour 72 including a final dose at hour 72) 
.1   
 
 
 
11.a.3 Children who have received acetaminophen in the 24 hours prior to 
presentation,  based upon the available medical record or report from the parent or guardian, 
will not be given a loading dose of acetaminophen. Instead, they will be commenced on the 
maintenance dose of 15mg/kg Q6 hourly. 11(b) Criteria for discontinuing or altering 
interventions 
 
 
 
 Table 3. Plan for Monitoring and Discontinuation 
ADVERSE EVENT 
MONITORING 
PATIENT MANAGEMENT 
INTERIM ANALYSIS THAT MAY 
INFORM DISCONTINUATION 
Vomiting2 
Clinical monitoring  
Re-dose if within 30 minutes of  
Treatment. Stop aggressive  
antipyretics if grade 2 aspiration  
occurs 
Compare % vomiting 
NGT-related injury 
Clinical monitoring 
Withdraw from study if drug  
delivery requires NGT 
----------------------------------- 
Recurrent 
hypoglycemia 
Glucose checks Q6 hourly  
if BCS<5 or seizure 
Treat per ward protocols  
Compare proportion  
as well as # of events  
Lactic acidosis (above 
5.0 mmol/L) at or after 
24 hours of treatment  
Daily until intervention 
completed 
  Can be assessed more 
frequently at clincian’s discretion 
Compare hours with lactic 
acidosis and max. lactate  
Hepatic dysfunction 
with 
bilirubin increasing 
from 
baseline  
Clinical monitoring 
Daily total bilirubin  
Stop treatment if jaundice 
develops or bilirubin increases 
by >5mg/dL from baseline  
Compare max increase in  
bilirubin level from baseline  
Renal insufficiency 
with 
Increased Cr from  
baseline 
Clinical monitoring 
Daily serum creatinine  
 
Stop for clinical evidence of  
Renal insufficiency (poor urine 
output, peripheral edema) or  
>0.5mg/dL increase creatinine 
from baseline or a doubling of 
the baseline creatinine 
Compare max. creatinine & 
Proportion of subjects with  
Increase of ≥0.5 mg/dL 
Anemia and 
transfusion3 
 
6-hourly packed cell volume 
(Malawi: once two consecutive 
negative malaria smears, no 
further PCV will be done; 
Zambia: through hr-72) 
Transfuse, as needed.  
Compare % requiring 
transfusion  
Occult blood loss  
 
Daily urine dip for blood and  
Stool Hemoccult 
No action for occult blood loss.  
Compare % with occult  
blood loss detected 
Clinical evidence of 
Thrombocytopenia or 
Bleeding  
Daily check for purpura, 
Oozing from IV sites, 
petechiae, 
Or other bleeding 
Stop for any clinical evidence of  
Thrombocytopenia/bleeding 
Compare % with 
clinical evidence of 
thrombocytopenia/bleeding 
Prolonged parasitemia 
----------------------------------------- 
------------------------------------------- 
Mean hours for parasite  
clearance 
 
2 For grading purposes of vomiting as an AE: grade 1=no change in oxygen saturation and no evidence of aspiration, grade 2=suspected 
aspiration but no change in oxygen saturation, grade 3=oxygen saturation decrease that responds to immediate treatment and grade 
4=oxygen saturation decrease which does not respond to immediate treatment 
3 Expected with severe malaria so not AE per se but will compare rates in Interim analysis 

 
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Children will be withdrawn from the study if requested by a parent or clinician caring for the patient or 
recommended by the Local Study Monitor (LSM) or DSMB.  
 
11(c) Strategies to improve adherence 
 
All doses will be directly administered by a study-trained nurse. The administering ward nurse will 
directly observe the oral intake of the medication and document oral adherence. If vomiting occurs with 
30 minutes of oral administration, a repeat dose will be given and documentation of the event made. 
 
 
11(d) Relevant concomitant care 
 
Concomitant Treatment and Investigations 
All treatments routinely used in the acute care of children with severe malaria will be provided (75). 
These include antimalarials, anticonvulsants, and blood transfusions. The duration and characteristics 
of all clinical seizures are documented in a bedside “fitting chart”. Due to the significant risk of 
subclinical seizures in comatose children with malaria (2), a daily, routine, 30-minute EEG will be 
completed in any child with a BCS≤4 or GCS≤10. When necessary, nasogastric tube (NGT) placement 
will be undertaken by experienced ward/unit nurses. The NGT will be removed and oral administration 
resumed as soon as the child is able to swallow.  
 
12. Outcomes 
12.1 Primary outcome measures 
 
12.1.1 Maximum temperature (TMAX). TMAX will be defined as the highest temperature during the study 
duration (72 hours) in degrees Celsius recorded by a continuous temperature monitor. Regardless of 
treatment allocation, temperature will be continuously assessed for 72 hours using a non-invasive, 
accurate temperature monitoring system that continuously measures patient temperature using an 
external temperature sensor placed in the axilla. The continuous temperature display will be concealed 
from nursing staff responsible for measuring temperatures for clinical care and delivering rescue fever 
treatment based upon the protocol. Temperature data will be captured locally on a device and also 
transmitted via email to a dedicated study account. The continuous monitoring device is not MR 
compatible. If Tmax is a clinical temperature obtained when continuous monitoring data was not 
available, the clinical Tmax will be used as the primary outcome.  
12.2 Secondary outcome measures 
 
12.2.1 SEIZURES will be assessed for occurrence and severity, from t=0 to t=72 hours based upon 
“Fitting Charts” and a daily routine EEG in comatose (BCS≤4 and GCS≤10) children. The daily EEG will 
be reviewed by the neurologist covering the PRW or PICU Neurodiagnostic Service. Seizure outcome 
has three categories—no seizures, a single brief (<15 minute) seizure, and multiple or prolonged 
(>15 minutes) seizures. These seizure categories are clinically relevant and correspond to risk factors 
for subsequent neurologic sequelae in our previous Zambia-based prospective cohort study of fevers 
and seizures (19).  
 
12.2.2 HRP2 (i.e., total body parasite burden) is the quantitative level reported as ng/ml in plasma. 
Samples for HRP2 determination will be obtained Q6 hourly via finger prick. Levels will be determined 
by ELISA and will not be available in real time.  
 
 
12.2.3 QUANTITATIVE PARASITE COUNT (qPC, peripheral parasite burden) is the number of parasites per 
microliter of blood based upon standard laboratory measures and obtained Q6 hourly via finger prick. 
Samples will cease to be collected when no parasites are seen in two subsequent, consecutive 
samples at the Malawi site; since the Zambia site does not possess skilled malaria microscopists, 
malaria smears will be obtained Q6 hourly through each participant’s 72 hours of enrollment but then 
read at a later time by a Malawian microscopist. For enrollment and clinical care considerations at the 

 
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Zambia site, malaria rapid diagnostic tests (RDTs) will also be performed to guide anti-malarial 
treatment decision-making. Values will be obtained by counting the proportion of 500 RBCs that are 
parasitized under high-power microscopic evaluation of a thin blood smear. The PCV will also be 
obtained at each time point and will be used to estimate RBC count using the formula PCV/8 = RBC X 
10^6 per microliter of blood. Estimated RBC count will be multiplied by the percent RBCs parasitized to 
arrive at the number of parasites per microliter of blood. 
 
 
12.2.4 Parasite hemozoin will be assessed as the percentage of parasites with hemozoin deposition 
based upon 100 parasites viewed in a high powered field at each qPC. 
 
12.2.5 Fever exposure as measures by the area under the curve (AUC) for 72 hours for fever ≥ 38.5ºC   
 
 
12.3 Additional demographic and clinical data to be collected 
 
 
 
12.3.1 Gender 
 
12.3.2 Age 
12.3.3 Seizure history 
12.3.4 Admission temperature 
12.3.5 Difficult birth history 
12.3.6 Developmental status as assessed by Ten Question screen 
12.3.7 Family history of seizures 
12.2.8 Retinopathy status in comatose subjects 
 

 
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13. Participant timeline 
 
 
Table 4.  
STUDY PERIOD 
 
Enrolme
nt 
 
Allocation 
(Day 0) 
Day 0 
(hrs 0-24) 
Day 1 
(hr 24-48) 
Day 2 
(hr 48-72) 
Discharge 
(d/c) 
Enrolment 
 
 
 
 
 
 
Initiation of anti-malarial therapy 
X 
 
 
 
 
 
Physical Exam 
X 
 
 
 
 
 
Medical/Treatment History 
X 
 
 
 
 
 
Eligibility Screen 
X 
 
 
 
 
 
Informed consent 
X 
 
 
 
 
 
Allocation 
 
X 
 
 
 
 
Interventions 
 
 
 
 
 
 
Aggressive antipyretics 
 
 
      Acetaminophen 
 
* If the child has received 
acetaminophen in the past 24 hours, no 
loading dose will be given. 
 
30 mg/kg* 
15 mg/kg Q6 hours (starting at 
enrollment (hour 00) and continuing 
through hour 72 including a final 
dose at hour 72) 
 
      Ibuprofen 
 
10 mg/kg 
10 mg/kg Q6 hours (starting at 
enrollment (hour 00) and continuing 
through hour 72 including a final 
dose at hour 72) 
 
 
 
 
Cooling fan if T≥38.5 persists for 
more than 1 vitals assessment (6 
hours) after aggressive antipyretics 
 
Standard of care 
 
 
      Acetaminophen 
 
15 mg/kg 
if T≥38.5C 
15 mg/kg Q6 hours if T≥38.5C 
(starting at enrollment (hour 00) and 
continuing through hour 72 including 
a final dose at hour 72) 
 
 
 
 
Cooling fan if T≥38.5 persists for 
more than 1 vitals assessment (6 
hours) after acetaminophen 
 
Safety monitoring 
 
 
 
 
 
 
Vomiting assessment 
Twice daily on rounds  
Nasogastric tube (NGT)  
injury assessment 
Twice daily on rounds while NGT in place 
Hypoglycemia 
Q6 hourly until BCS=5 or GCS=14 or with any suspected seizure 
Lactic acidosis > 24 hours  
 
 
x 
x 
x 
x 
Clinical evaluation for jaundice 
 
 
Twice daily on rounds 
Bilirubin & creatinine check 
 
x 
x 
x 
x 
x 
Screen for occult blood loss 
 
 
x 
x 
x 
x 

 
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14. Sample size 
The primary analysis in this study will involve a comparison of the adjusted mean Tmax between the 
treatment groups. In the BMPES study, the difference in mean Tmax for children with vs. without 
behavioral disorders was 0.5ºC, and it was 0.9ºC between those with and without epilepsy (2). A 
receiver operating characteristic curve analysis suggests that a good balance between sensitivity and 
specificity for Tmax in predicting epilepsy is achieved for a Tmax of 38.9ºC and the mean Tmax for 
children who experienced epilepsy was 39.4ºC suggesting that a reduction in temperature of 0.5ºC is a 
clinically meaningful reduction. CM at the proposed study sites has a mortality rate of ~15% and most 
children who die will do so within 12-24 hours after admission and are unlikely to benefit from fever 
reduction measures. The effect of mortality on the sample size is manifested through attenuation of the 
group difference in mean Tmax of 0.5 ºC. Under the assumption that mortality is comparable in the two 
groups and that there is no treatment effect in those who die, the attenuated treatment effect will be 
(0.5 × 0.85) + (0.0 × 0.15) = 0.425 ºC. Assuming a standard deviation of the maximum temperature of 
1.1 ºC as was present in the BMPES study population, a sample size of 142 children per group will 
provide 90% power to detect a group difference in mean Tmax of 0.425ºC, using a two-sample t-
test and a 5% significance level (two-tailed).  The 0.5ºC threshold (before attenuation) is based on 
our observational data that adverse neurologic outcomes in cerebral malaria occur at mean Tmax 
differences of 0.5ºC (2). 
 
For the outcome of acute symptomatic seizures, data collected during past malaria studies (2, 19) 
suggest that the incidence of seizures after admission will be 40% in children with CM and 24% in CNS 
malaria. Assuming an overall seizure incidence after enrollment of 32% in the usual care group 
(68% with no seizures, 25% with a single brief seizure, and 7% with multiple or prolonged 
seizures), a sample size of 142 children per group will provide 80% power to detect a shift in the 
aggressive antipyretic treatment group to 82% with no seizures, 15% with a single brief seizure, 
and 5% with multiple or prolonged seizures, representing a common log-odds ratio of 0.7656. 
The method due to Whitehead(76) was used for this calculation. 
 
Since we are preferentially recruiting to ensure that approximately 50% of children enrolled have CM 
and past experience indicates that 70% of CM admissions during the rainy season (i.e., malaria 
season) are retinopathy positive, we anticipate that there will be 100 children included in the secondary 
analysis of Tmax differences between treatment groups among children with CM and CNS parasite 
sequestration compared to all others. Assuming a standard deviation of Tmax of 1.1 ºC(2), a sample 
size of 50 children per group will provide 80% power to detect a group difference in mean Tmax 
of 0.62ºC (after attenuation due to mortality), using a two-sample t-test and a 5% significance 
level (two-tailed). Sample size considerations cannot be provided for Hypothesis 2 due to the absence 
Structured screening evaluation 
for clotting or bleeding disorder 
 
 
Twice daily on rounds 
Assessments 
 
 
 
 
 
 
Vital signs (including temperature) 
 
X 
Q6 hours 
 
Continuous temperature monitor 
 
X 
X 
X 
X 
 
EEG 
 
 
Daily for BCS≤4, GCS≤10, suspect 
seizure 
 
Thick and thin smear 
 
X 
Q6 hours until two consecutive 
negative smears (until the 72-hr. 
point at the Zambia site) 
 
qPC 
 
X 
Q6 hours until two consecutive 
negative smears at the Malawi site 
(until the 72-hr. point at the Zambia 
site) 
 
HRP2 
X 
X 
Q6 hours 
 
Neurologic evaluation 
X 
 
 
 
 
X 

 
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of preliminary data on HRP2 levels, including the absence of any reasonable data on standard 
deviation for HRP2 levels or the percentage of mature parasites. 
15. Recruitment 
15.1 Blantyre.  
 
Recruitment will be directly from the Accident and Emergency Department where study nurses 
knowledgeable of the inclusion criteria will be based. Patients will be directly transferred to the Pediatric 
Research Ward (PRW). The PRW serves as the de facto intensive care unit for the hospital, hence 
many of the eligible patients will be transferred to the PRW independent of this trial  
 
15.2 Lusaka.  
 
 
Recruitment will be directly from the Emergency Department where a study nurse knowledgeable of the 
inclusion criteria will be based. Patients will be transferred to the Pediatric Intensive Care Unit (PICU) or 
the Admission Ward beds adjacent to the PICU depending upon medical need.   
 
15.3 Chipata.  
 
Recruitment will be directly from the Emergency Department where study staff knowledgeable of the 
inclusion criteria will be based. Patients will be transferred to the High Acuity section within the Pediatric 
Ward.   
 
16.0 Methods: Randomization and Assignment of Interventions 
 
16.1 Randomization 
Eligible children whose parent or guardian has provided written informed consent will receive treatment 
allocation as determined by randomization provided in sealed opaque envelopes maintained by the 
study pharmacist in the unlikely event that unblinding is needed. Patients will be assigned to treatment 
groups with 1:1 allocation using blocked randomization.  Randomization will be stratified by country and 
blocked randomization will be used due to the potential small sample size in Zambia. UR-Biostatistics 
will be responsible for generating the randomized list of subject assignments and providing sequentially 
numbered sealed opaque envelopes. Tmax and seizure outcomes will be determined in the 72 hours 
following enrollment. Safety assessments will occur during the 72-hour inpatient observation period. A 
30-day follow-up is standard of care for CM survivors at both study sites. Any child discharged with 
unresolved laboratory or clinical concerns will have a 30-day follow-up visit scheduled. 
 
Table 5: Overview of Treatment after Randomization 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
* If 
the child has received acetaminophen in the past 24 hours, no loading dose will be given.  
Aggressive Antipyretics 
Usual Care (WHO 2015 Guidelines) 
Initial Treatment 
30mg/kg acetaminophen* + 10mg/kg ibuprofen 
 
If temp ≥ 38.5, add acetaminophen placebo 
 
acetaminophen and ibuprofen placebos 
 
 If temp ≥ 38.5, add acetaminophen 
15mg/kg Q6 
Subsequent Management based upon Q6 hourly temperatures 
Continue acetaminophen 15mg/kg and ibuprofen 
10mg/kg Q6 hourly for 72 hours (from hr-00 through 
hr-72 including a final dose at hour 72) 
 
If temp ≥ 38.5, give acetaminophen placebo Q6 
hourly 
Continue acetaminophen and ibuprofen 
placebos Q6 hourly for 72 hours (from 
hr-00 through hr-72 including a final dose 
at hour 72) 
 
If temp ≥ 38.5, add acetaminophen 
15mg/kg Q6  
Management if continued temperature ≥ 38.5 
Cooling fan 
Cooling fan 

 
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16.2 Allocation 
 
 
16.2 (a) Sequence generation.  
 
The randomization process is designed to be blinded to data collectors. The randomization plan will be 
developed by the unmasked programmer at UR Biostatistics. It will be generated using a SAS program 
in accordance with Biostatistics standard operating procedures. Subjects will be randomly assigned 
with equal allocation to the two treatment groups. The randomization will be stratified by country, and 
will include blocking to ensure approximately equal allocation of the treatments within each stratum 
after a specified number of subjects have been enrolled in that stratum. The randomized allocation will 
be provided to the compounding and study site pharmacists preparing the intervention and placebos. 
Sealed envelopes indicating allocation will be provided at the study sites if unblinding is needed for 
patient care. 
16.2 (b) Allocation concealment mechanism.  
 
Patients will be assigned to treatment groups using blocked randomization with randomly selected 
block sizes. Randomization will delineate treatment allocation to sequential, previously delineated study 
IDs for each site. Details of random allocation will be provided to the local study pharmacist for 
preparation of treatment packages by the US-based compounding pharmacist as received from the 
unmasked UR Biostatistics programmer. In addition sealed opaque envelopes with treatment allocation 
by study ID will be provided to the study sites in case there is the need to break the code for an 
individual patient. At the completion of the study, all envelopes will be returned to UR Biostatistics.  
 
17. Blinding 
 
Allocation will be concealed from all staff. Continuous temperature readings will be captured 
electronically but the display will be concealed from nursing staff who provide treatment for interim 
fevers based upon treatment protocol and temperature measured clinically per usual care on the ward. 
The EEG interpreter will be blinded to allocation and temperature.  
 
Methods: Data collection, management, and analysis 
 
18. Data collection methods 
 
18.1 Collection of data 
 
18.1.1 Temperature and Tmax 
a. Temperature. Temperature for clinical care purposes will be acquired from the vital sign 
assessments performed by the study nurses.  
b. Tmax for primary study outcome will be acquired from the continuous temperature monitoring 
device. This data will not be visible to or made available to study nurses providing clinical care 
 
18.1.2 Fever Exposure. Fever exposure is the area under the curve (AUC) for 72 hours for fever ≥ 
38.5ºC and this will be uploaded into the REDCap database from the CRF. The raw data captured 
every 2 minutes will also be captured in an Excel spreadsheet to then be emailed to the biostatistician 
separately. 
 
18.1.3 Seizure activity. Seizure activity will be recorded by the study clinicians on a fitting chart 
attached to each subject file. This will capture the time, nature, and treatment of each episode of 
seizure activity. Subjects will also undergo a routine 30-minute 12-lead EEG every day while BCS≤ 4 or 
GCS≤10. Seizure activity on EEG adhere to ILAE guidelines for electrographic seizure 

 
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18.1.4 qPC. qPC will be determined by standard protocol as delineated in the SOP. Briefly the number 
of parasites in 500 RBCs will be determined by microscopy. This will be translated to parasites per 
microliter using the PCV divided by eight as an estimate of RBC X 10^6 per microliter (ul). 
 
18.1.5 HRP2. HRP2 concentration per ul will be determined by previously published methods (51). 
Briefly, plasma will be obtained from the microhematocrit tubes used for PCV determination. After 
determination of PCV (if clinically needed), tubes will be scored at the RBC/plasma interface with a 
triangular file and broken. A narrow pipette tip will be inserted in the plasma containing portion and the 
plasma removed. Plasma will be transferred to a bar code-labeled microcentrifuge tube and stored at -
20°C until analysis.  
 
At the time of analysis, plasma diluted at a ratio of 1:500 in phosphate buffered saline (PBS) as well as 
a titration of a stock of recombinant HRP2, will be plated onto a plate precoated with anti-HRP2 
antibody (Cellabs, Brookvale, Australia). The manufacturer’s protocol will then be followed, except for 
the modification of all incubations being carried out at 37°C in a humidified chamber. In brief, a 1-hour 
sample incubation step will be followed with extensive washing with PBS/0.1% Tween. One hundred 
microliters of the second conjugated antibody will be plated and allowed to incubate for 1 hour. The 
conjugate will subsequently be washed off and 100 μL of substrate added for 15 minutes, during which 
color change will be observed. This reaction will be stopped with 1N HCl and the plate analyzed at 
optical density (OD) 450. A standard curve will be generated from the recombinant protein and the 
readings from the diluted unknown samples will be compared to this curve to calculate HRP2 levels. If 
the initial dilution of the sample results in an OD reading that does not lie within the linear range of the 
recombinant protein, the sample will be rediluted at either 1:1000 or 1:100 to result in OD values within 
the dynamic range of the ELISA. Samples that remained off scale low, despite redilution, will be 
assigned a value equivalent to the lowest possible detection value of the ELISA. 
 
18.1.6 EEG.  
 
EEGs will be obtained on the day of admission and daily thereafter until recovery (i.e., if BCS≤4, 
GCS≤10). EEGs will be obtained using a modified 10-20 system, and meet the American 
Electroencephalography Society’s guidelines for EEG (77).  For clinical purposes EEGs will be 
systematically reviewed by the neurophysiologist providing clinical support for the respective site the 
day the EEG is obtained. 
 
18.1.7 Data collection Process  
Data will be collected on paper-based forms included in the subjects’ clinical files during the admission, 
and study-specific variables will be captured in these forms by study personnel. A paper-based data 
abstraction to a case-report form will then be completed by local study personnel before double data 
entry into REDCap. 
 
18.2 Retention of subjects 
 
 
 
The study period is limited to 72 hours and >90% of children admitted with CNS malaria are inpatient 
for 72 hours or longer. To encourage retention among those ready for discharge before the study 
completion, transportation home and a meal allowance will be provided for their parent(s). The informed 
consent process will also be very explicit and clear about the need for at least a 72-hour admission and 
children with parents unwilling to commit to this will not be enrolled. If clinical or safety concerns are 
present at discharge, a 30-day follow-up will be scheduled as per clinical care protocol for both study 
sites. 
19. Data management 
 
 
The REDCap system is a secure, web-based application that is flexible enough to be used for a variety 
of types of research. It provides an intuitive interface for users to enter data and real-time validation 
rules (with automated data type and range checks) at the time of data entry. REDCap offers easy data 
manipulation with audit trails and functionality for reporting, monitoring and querying patient records, as 

 
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well as an automated export mechanism to common statistical packages (SPSS, SAS, Stata, R/S-
Plus). The Double Data entry feature allows a project administrator to designate two users per study to 
perform double data entry. Other users are then able to compare the data entry results, using the data 
comparison tool. This requires that the Double Data Entry feature be activated for the study. 
 
Through the University of Rochester Medical Center’s Center for Health and Technology (CHeT), the 
Clinical Translational Science Institute (CTSI) Informatics Core will serve as a central facilitator for data 
processing and management. REDCap data collection projects rely on a thorough, study-specific data 
dictionary defined in an iterative self-documenting process by all members of the research team, with 
planning assistance from the CTSI Informatics Core. CHeT’s iterative development and testing 
processes results in a well-planned data collection strategy for individual studies. REDCap servers are 
housed in a local data center at the University of Rochester and all web-based information transmission 
is encrypted. REDCap was developed in a manner consistent with HIPAA security requirements and is 
recommended to University of Rochester researchers by the URMC Research Privacy Officer and 
Office for Human Subject Protection. Access to data in the REDCap application and database will be 
controlled by using user definitions and permissions. The PI will have access to all study data and will 
direct access for all users.  Audit logs are created automatically within the REDCap application to 
capture the complete user history of database activity.  
 
Data entry for the subject is expected to be complete within one week of randomization. Most data 
entry errors will be resolved by the Double Data Entry process operating on local machines at each 
site. Therefore, Data Management will be primarily responsible for ensuring CRFs are entered in a 
timely manner and are complete. Reports of delayed data entry and missing CRF elements will be 
generated weekly for the CHeT project manager to review with sites.  
 
20. Statistical methods 
 
The analyses presented below will be performed according to the intention-to-treat principle and will 
include all available data from all randomized subjects. The assumptions underlying all statistical 
models will be thoroughly checked using graphical and inferential methods and remedial measures will 
be taken (e.g., transformations, consideration of alternative models) if these assumptions are found to 
be seriously violated. A significance level of 5% will be used for hypothesis testing. 
 
Analytic Plan for Hypothesis 1 (i):  
Children who receive aggressive antipyretic therapy will have lower mean Tmax during the 72-hour 
treatment period based upon continual temperature assessments. 
The analysis of the Tmax will involve fitting an analysis of covariance model with treatment group as the 
factor of interest, site and disease severity (CM vs CNS malaria) as stratification factors, and admission 
temperature as a covariate. The estimated treatment effect (difference in adjusted group means 
between the aggressive antipyretic therapy and usual care groups) and its associated 95% confidence 
interval, as well as a t-test for significance of the treatment effect, will be derived from this model. 
 
For subjects who do not complete the 72-hour follow-up period, the maximum temperature observed 
during their abbreviated follow-up will be used for the primary analysis. A secondary analysis will be 
performed that is the same as the primary analysis except that the contribution of each subject’s data to 
the analysis will be weighted by the time that they are followed (percentage of the 72-hour follow-up 
period).  
 
To evaluate the effects in the study population most analogous to the BMPES population, a secondary 
analysis will include terms added to the above analysis of covariance model representing the main 
effect of subgroup (CM with CNS parasite sequestration vs. all others) and the interaction between 
treatment and subgroup. For purposes of this analysis, CM will be defined as having a BCS ≤2 or GCS 
≤10 and CNS parasite sequestration will be defined as having an initial HRP2 ≥1700 ng/dl. This model 
will permit estimation of the treatment effects within each subgroup (with associated 95% confidence 
intervals and p-values) and a test for significance of the treatment effects between the subgroups. 
Exploratory analyses will be performed using the above methods for the log-transformed fever 
exposure outcomes. For subjects who do not complete the 72-hour follow-up period, the AUC falling 

 
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above the fever cut-off during the subject’s abbreviated follow-up will be multiplied by the inverse of the 
percentage of time that the subject was followed for the primary analysis. Secondary analyses of these 
outcomes will be performed weighting each subject’s contribution by the time that they are followed, as 
described above for Tmax. 
 
Analytic Plan for Hypothesis 1(ii):  
Children who receive aggressive antipyretic therapy will be less affected by acute symptomatic seizures 
during the malaria infection based upon clinical assessments and daily routine EEGs for those with 
BCS≤4 and GCS≤10 
 
To compare seizure outcome between the treatment groups, outcome will be defined as a three-level 
ordinal variable: no seizures, a single brief (<15 minute) seizure, and multiple or prolonged (>15 
minutes) seizures. The analysis of this outcome variable will involve fitting an ordinal logistic regression 
model (proportional odds model)(78) with treatment group as the factor of interest, site and disease 
severity as stratification factors, and history of prior seizures and pre-existing developmental delay as 
covariates. The estimated treatment group odds ratio, along with its associated 95% confidence interval 
and p-value, will be derived from this model. If the proportional odds assumption appears to be 
seriously violated, a multinomial logistic regression model will be used instead (78).  
 
Analytic Plan for Hypothesis 2: 
We hypothesize that fever treatment will reduce sequestration resulting in lower HRP2 levels based 
upon area under the curve during the 72-hour treatment period and an associated transient paradoxical 
increase in peripheral parasitemia with a higher proportion of older parasites seen. 
AUC has been selected as the outcome due to substantial between-subject heterogeneity of the level-
time curves and because subjects will be at different time points in their illness in terms of treatment 
(some having received antimalarials as an outpatient prior to admission). As such, if a more rapid 
reduction in HRP2 occurs in general, it should be captured by this AUC. The analyses of the area under 
the HRP2 level-time curve (log-transformed) will involve fitting an analysis of covariance model with 
treatment group as the factor of interest, site and disease severity as stratification factors, and time 
since the initiation of antimalarial treatment and log-transformed HRP2 level at t=0 as covariates. The 
estimated treatment effect (difference in adjusted group means between the aggressive antipyretic 
therapy and usual care groups) and its associated 95% confidence interval, as well as a t-test for 
significance of the treatment effect, will be derived from this model. For subjects who do not complete 
the 72-hour follow-up period, the area under the HRP2 level-time curve (log-transformed) observed 
during the subject’s abbreviated follow-up will be multiplied by the inverse of the percentage of time that 
the subject was followed for the primary analysis. A secondary analysis of this outcome will be 
performed weighting each subject’s contribution by the time that they contribute HRP2 data. 
 
We expect aggressive fever reduction to facilitate release of mature sequestered parasites (evident by 
the hemozoin they contain) from the CNS. In an exploratory analysis, the mean percentage of mature 
parasites across all positive blood smears for each child taken Q6 hourly will be compared in the ‘usual 
care’ vs. ‘aggressive antipyretic treatment’ groups using a t-test. In ‘usual care’, less than 5% of 
parasites typically have evidence of hemozoin deposition but the natural history of parasite hemozoin 
clearance is unknown.  
 
Interim Analyses  
Interim analyses for efficacy will be performed at the end of the second and third recruiting malaria 
seasons. An upper boundary will be determined using the O’Brien-Fleming α-spending function to 
control the overall probability of a Type I error at 2.5% (since only an upper boundary will be considered 
for early stopping).  
Methods: Monitoring 
21. Data monitoring 
 
 
This study will be overseen by Local Study Monitors (LSM) at each study site and a Data and Safety 
Monitoring Board (DSMB). The LSMs will review adverse events and outcomes weekly. For Serious 
Adverse Events (SAEs, defined below) and any AEs of grade 3 or higher, the PI will be alerted 

 
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immediately and the LSMs will provide expedited 48-hour review which will be circulated to the DSMB 
and PI on completion. LSMs are individuals with substantial experience caring for children with severe 
malaria. Plans for detailed management for adverse events are outlined in Table 3. Weekly LSM 
reports will be provided to the DSMB at ~6 monthly intervals including those provided for the annual 
meeting and interim analysis. If the LSM develops concerns regarding the safe continuation of the 
study, he/she will inform the PI to suspend further study enrollment pending DSMB review and 
discussion. If the DSMB identifies a concern that may require halting of enrollment or modification of 
the protocol, they will contact the PI and have a meeting or teleconference with other members of the 
study team. NINDS will be involved as appropriate, in order to come to a final decision regarding course 
of action. 
 
SAEs include 
1. Death 
2. Neurologic sequelae evident at discharge 
3. Aspiration requiring discontinuation of the study drug 
4. The development of clinically evident bleeding or platelet dysfunction (not occult blood in urine or 
stool) 
5. Renal injury requiring management other than simple discontinuation of the intervention 
6. The development of clinically evident jaundice or an increase in bilirubin of > 5 mg/dL from baseline  
7. Prolonged hospitalization potentially related to the study intervention 
 
If study enrollment is suspended for safety reasons, the PI will notify the NIH, the supervising IRBs (the 
University of Rochester’s Research Subjects Review Board, The University of Malawi’s College of 
Medicine Research Ethics Committee, the University of Zambia’s Biomedical Research Ethics 
Committee) and the appropriate regulatory authorities including Malawi’s Pharmacy, Medicines and 
Poisons Board and Zambia’s Medicines Regulatory Authority.  
 
Enrollment occurs from January-June during the malaria seasons of years 1-4 of this award, except for 
the Chipata site which will enroll throughout each year given the high malaria admission rates at this 
setting year round. The DSMB consists of four clinician scientists with expertise in severe malaria in 
children who have worked in other African countries, plus a US-based biostatistician who has held this 
role on numerous DSMBs for other clinical trials. SAEs are reported to the DSMB within 48 hours, all 
other AEs reported to the DSMB Q 6-monthly and an interim safety analysis will be completed annually. 
As noted in Section 20 above, interim analyses for efficacy will also be conducted at the completion of 
Years 2 and 3 using an upper boundary determined by an O’Brien-Fleming α-spending function to 
control the overall probability of a Type I error at 2.5% (since only an upper boundary will be considered 
for early stopping). Interim analyses will also be performed for excess mortality in the aggressive 
antipyretic treatment group at the end of each of the first three recruiting malaria seasons. A lower 
boundary will again be determined using an O’Brien-Fleming α-spending function to control the overall 
probability of a Type I error. The DSMB will also carefully consider other adverse events in terms of 
treatment group imbalances, with particular attention paid to vomiting, recurrent hypoglycemia, elevated 
creatinine or bilirubin, blood transfusion requirements, identification of occult blood, and clinically 
evident thrombocytopenia or bleeding. Continuous variables that will be monitored include hours with 
lactic acidosis, maximum lactate, bilirubin, and creatinine levels, and parasite clearance time. Fisher’s 
exact tests (or chi-square tests) will be used to compare the treatment groups with respect to 
dichotomous outcomes, and t-tests (or Wilcoxon rank sum tests) will be used to compare the treatment 
groups with respect to continuous outcomes. A log-rank test will be used to compare the treatment 
groups with respect to parasite clearance time. If potential safety concerns are identified, the DSMB 
may consider recommending modification (or halting) of the trial. The DSMB will provide an annual 
review of the interim analysis through a combination of virtual and face-to-face meetings and provide a 
written summary report within 1 week of the annual review meeting.  
 
An initial meeting between the study leadership and the DSMB will take place prior to enrollment of the 
first study subject, to review study procedures and come to agreement on the DSMB Charter. The 
Charter will document the role and function of the DSMB including the frequency and format of DSMB 
meetings, the format of reports to be prepared for DSMB review, guidelines for interim analyses for 
safety and efficacy, extent of blinding of the DSMB, and rules for communication among the study 
leadership and the DSMB. 

 
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The Department of Biostatistics and Computational Biology (DBCB) at the University of Rochester will 
prepare formal reports for each interim analysis for the DSMB. These reports will include appropriate 
introductory material (study synopsis, current status of the trial, etc.), information on recruitment and 
retention, subject characteristics, subject disposition, treatment discontinuations, adverse events 
(including serious adverse events), laboratory test results, and other safety data. This information will 
be provided by treatment group, where applicable. 
 
Approximately one month before a scheduled DSMB meeting, the database will be transferred from 
CHeT to the DBCB using a long-established protocol, and a numbered version of the analytic database 
will be created by the DBCB.  All DSMB reports will refer to the specific version number of the database 
that is used in their preparation, as well as the date on which the database was created. The 
designated DBCB programmer who generated the randomization plan for the trial will prepare the 
DSMB reports. The treatment groups in the report will be coded as “A” and “B”, which can be linked to 
the identities of the actual treatment groups if requested by the DSMB. 
 
 
22. Harms 
 
CM is associated with high rates of morbidity and mortality. The expected outcomes related to the 
disease itself include severe anemia requiring blood transfusions, hyperlactatemia, acidosis, prolonged 
coma, hypoglycemia, severe thrombocytopenia, hyponatremia, extreme hyperpyrexia, seizures, and, 
neurologic sequelae including blindness, hemiparesis, hypotonia, and mutism. Death is also a common 
outcome, occurring in 16% of pediatric CM patients on the QECH Research Ward over the past 5 
years. All study subjects will receive treatment and management for these conditions consistent with 
the WHO’s guidelines for the management of severe malaria. 
 
Known potential harms from the Intervention are listed below 
 
22.1 Aspiration: Study subjects will be closely monitored clinically for signs of aspiration including Q4-
hourly assessments of oxygen saturation. The Q4-hourly assessments are intended to be done only if 
coma score is sub-normal, otherwise this metric need be done only per hospital ward protocol. If 
oxygen saturations are below 95%, the ward attending will be notified to make a physician-level 
assessment (auscultation, urgent PCV, etc.) and determine if aspiration is the potential underlying 
cause. If oxygen saturation declines and remains lower than the pre-aspiration baseline, the NGT will 
be placed to suction to remove any remaining gastric contents, the intervention will be discontinued and 
the NGT removed. Otherwise, the decision to discontinue the study drug intervention is at the discretion 
of the attending physician.  
 
22.2 Complications of NGT placement and maintenance: If placement/maintenance of the NGT by 
experienced staff is difficult and results in nasal trauma and/or significant epistaxis and the study 
subject is comatose and/or unable to swallow, the intervention will be discontinued and the NGT 
removed. Necessary measures to ameliorate any bleeding will be taken. 
 
22.3 Vomiting: Although common in the early stages of malaria, once comatose study participants with 
CM do not usually vomit. If vomiting occurs in a comatose study participant, the NGT will be placed to 
suction to remove the remaining gastric contents, oxygen saturations will be assessed, and once 
gastric contents have been removed the NGT will be removed and the intervention will be discontinued. 
 
22.4 Acidosis: Lactic acidosis is common on admission but generally resolves within 24 hours. 
 
22.5: Hyperbilirubinemia: Liver dysfunction is common in CNS malaria. Children with a bilirubin on 
admission of above 3 or those with frank jaundice are excluded. The study intervention will be halted if 
after enrollment the bilirubin escalates >5mg/dL or the child develops clinical jaundice. 
 
22.6 Renal insufficiency: If the creatinine increased by >0.5 mg/dL from baseline or a doubling of the 
baseline creatinine, the study intervention will be stopped.  
 

 
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22.7 Increased risk of bleeding: Thrombocytopenia is common during malaria infections. The use of 
ibuprofen may decrease platelet function and could therefore increase the risk of abnormal bleeding. 
Children with any history of thrombocytopenia prior to the acute malaria illness will be excluded. 
Structured clinical screening will also be conducted to assure anyone with evidence of abnormal 
bleeding is excluded from enrollment. During the study, children will be evaluated twice daily by an 
experienced clinician who will repeat the structured assessments to identify any clinical evidence of 
abnormal bleeding/poor clotting and the intervention will be halted in any child that develops 
signs/symptoms. 
23. Auditing 
 
Prior to the initiation of the study, harmonization training sessions will be conducted for clinician co-
investigators, the investigators and their study coordinators for each site.  This meeting will include a 
detailed discussion of the protocol, performance of study procedures, CRF completion, simulation of 
study procedures and specimen collection methods, as applicable.  Subsequent detailed local training 
sessions with ward nurses and clinicians will be held at each site. 
 
Prior to commencing enrolment, the University of Malawi Research Support Centre (RSC) will conduct 
an external audit of the study in Malawi and a certified RSC auditor will conduct a similar audit of the 
Zambian site to assure the clinical trial is in compliance with Good Clinical Practices. 
 
After completion of the data entry process, computer logic checks will be run to check for such items as 
inconsistent study dates and outlying laboratory values.  Any necessary correction will be made to the 
database and documented via addenda or audit trail.  A manual review of selected line listings will also 
be performed at the end of the study.    
 
The Project Coordinator will assist the PI in assuring protocol compliance, ethical standards, regulatory 
compliance and data quality at the clinical sites. The coordinator will provide real time daily review of all 
study files to assure protocol compliance and documentation completeness. The study sites may also 
be subject to quality assurance audits by the NINDS or its designees and appropriate regulatory 
agencies. Audits may include reviews of paper or electronic records. 
 
Ethics and dissemination 
24. Research ethics approval 
 
In addition to the oversight provided at each site by the local study monitors, the study has been 
approved by the following Institutional Review Boards: 
 
The University of Zambia’s Biomedical Research Ethics Committee FWA00000338 (UNZA BREC) 
The University of Malawi’s College of Medicine Research Ethics Committee FWA00011868 (COMREC) 
The University of Rochester’s Research Subjects Review Board FWA00009386 (RSRB) 
 
An intra-institutional agreement was generated between the University of Rochester’s RSRB and 
Michigan State University’s (MSU) Biomedical Institutional Review Board FWA00004556 (BIRB). 
Michigan State University’s BIRB and Boston Children’s Hospital (BCH) IRB have agreed to rely on 
University of Rochester’s RSRB.  
 
While in Malawi, the MSU PI is responsible for overseeing subject recruitment and data collection at 
Queen Elizabeth Central Hospital. As part of data cleaning process, he will also have access to data 
with patient identifiers.  
 
While in Zambia, the BCH PI will serve as a clinician. Her responsibilities also include data collection 
and conducting EEG’s on study patients.  As part of data cleaning, she will also have access to data 
with patient identifiers. 
 

 
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Our office takes responsibility for the required IRB reports (the University of Rochester’s Research 
Subjects Review Board, The University of Malawi’s College of Medicine Research Ethics Committee, 
and the University of Zambia’s Biomedical Research Ethics Committee) within Malawi and Zambia. 
Regular communications between the MSU PI and BCH PI, Local Safety Monitoring (LSM) and the 
Lead PI ensure that data collected and contact information is up-to-date. 
 
No human subjects contact will occur at any of the US-based sites. All data exported to the US is de-
identified prior to transfer. All RSRB determinations regarding this work will be shared with the non-
affiliated researchers in a timely fashion.  
 
All laboratory specimens, evaluation forms, reports, and other records that leave the participants 
enrollment sites will be identified only by the study ID number to maintain subject confidentiality. All 
paper records will be kept in a secure study offices, within locked file cabinet. All computer entry and 
networking programs will be done using IDs only. Clinical information will not be released without 
written permission of the subject or the subject’s parent or guardian, except as necessary for monitoring 
by the supervising IRBs (the University of Rochester’s Research Subjects Review Board, The 
University of Malawi’s College of Medicine Research Ethics Committee, the University of Zambia’s 
Biomedical Research Ethics Committee) and regulatory agencies, (Medicines and Poisons Board in 
Malawi and Zambia Medicines Regulatory Authority), the sponsor, and/or the sponsor’s designee.  Any 
presentation, abstract, or manuscript will be made available to the sponsor and IRBs as part of routine 
annual reports. 
 
25. Protocol amendments 
 
 
The protocol included in this submission, which was developed in accordance with the 2013 SPIRIT 
Guidelines, and any subsequent modifications will be reviewed and approved by the ethical review 
boards listed in Section 24, the local study monitors, and an Advisory Committee which will include 
leadership from the Department of Pediatrics in both African institutions. Any modifications to the 
protocol which may impact on the conduct of the study, potential benefit of the patient or may affect 
patient safety, including changes of study objectives, study design, patient population, sample sizes, 
study procedures, or significant administrative aspects will require a formal amendment to the protocol. 
Such an amendment will be agreed upon by the University of Rochester, NINDS, and the Advisory 
Committee, and approved by the IRB prior to implementation, and notified to the health authorities in 
accordance with local regulations. Administrative changes of the protocol are minor corrections and/or 
clarifications that have no effect on the way the study is to be conducted. These administrative changes 
will be agreed upon by the Advisory Committee and will be documented in a memorandum. The IRB 
may be notified of administrative changes at the discretion of The PI. 
26. Consent  
 
 
Written informed consent from the parent/guardian will be required for enrollment. The discussion 
regarding consent as well as the consent form itself will be provided in the preferred language of the 
parent/guardian. A signed consent form will be obtained from the parent/guardian of each subject. The 
consent form will describe the purpose of the study, the procedures to be followed, and the risks and 
benefits of participation. Alternatives to enrollment and the right to withdraw participation at any time will 
also be explicitly included within the consent form. A copy of the consent form will be given to the 
guardian, and this fact will be documented in the subject’s record. Since these are all children under 12 
years with active CNS malaria at the time of the enrollment, no assent will be sought. 
27. Confidentiality 
 
All laboratory specimens, evaluation forms, reports, EEGs, and other records that leave the site will be 
identified only by the study ID number to maintain subject confidentiality.  All records will be kept in 
locked study-dedicated offices.  All computer entry and networking programs will be done using SIDs 
only.  Clinical information will not be released without written permission of the subject, except as 
necessary for monitoring by the involved institutions ethics review boards (RSRB, COMREC, and 

 
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UNZA BREC), the Malawi Pharmacy Medicines and Poisons Board, the Zambia Medicines Regulatory 
Authority, the NINDS, the OHRP, the sponsor, or the sponsor’s designee. 
 
28. Declaration of interests 
 
 
None of the investigators on the trial declare any competing interests. 
 
 
29. Access to data 
 
The DBCB will oversee the intra-study data sharing process, with input from the Principal Investigator. 
 
All Investigators (both US and host country) will be given access to the cleaned data sets. Individual 
country investigators will have direct access to their own site’s data sets, and will have access to other 
site’s data by request. To ensure confidentiality, data dispersed to project team members will be 
blinded of any identifying participant information. 
 
30. Ancillary and post-trial care 
 
Patients that are enrolled into the study are covered by indemnity for negligent harm through an 
indemnity arrangement arranged at each study site. Insurance to cover for non-negligent harm 
associated with the protocol will be procured prior to enrollment. This will include cover for additional 
health care, compensation or damages whether awarded voluntarily by the Sponsor, or by claims 
pursued through the courts.  
 
31. Dissemination policy 
 
31(a) Plans for dissemination 
 
 
The primary outcome of this study will be submitted for publication no later than one year after study 
completion. This manuscript, as well as any other manuscripts, posters, or abstracts, must be approved 
by the publication committee for approval prior to submission. Financial support from the NINDS will be 
acknowledged in all publications.   
 
 
31(b) Authorship eligibility guidelines 
 
The guidelines defined by the International Committee of Medical Journal Editors will be used in 
determining authorship on all papers, abstracts, and posters emanating from this study.  
 
31(c) Public access of data 
 
No later than three years from the close of the study we will deliver a completely de-identified data set 
to an appropriate data archive for sharing purposes.  
 
32. Informed consent material 
The final English version will be translated into the appropriate local languages. 
 
 
 
 
 

 
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1. 
WHO. World Malaria Report 2013. Geneva: World Health Organization, 2013. 
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Birbeck GL, Molyneux ME, Kaplan PW, Seydel KB, Chimalizeni YF, Kawaza K, et al. Blantyre Malaria 
Project Epilepsy Study (BMPES) of neurological outcomes in retinopathy-positive paediatric cerebral malaria 
survivors: a prospective cohort study. Lancet Neurol. 2010;9(12):1173-81. 
3. 
Carter JA, Lees JA, Gona JK, Murira G, Rimba K, Neville BG, et al. Severe falciparum malaria and 
acquired childhood language disorder. Dev Med Child Neurol. 2006;48(1):51-7. 
4. 
Carter JA, Mung'ala-Odera V, Neville BG, Murira G, Mturi N, Musumba C, et al. Persistent 
neurocognitive impairments associated with severe falciparum malaria in Kenyan children. J Neurol Neurosurg 
Psychiatry. 2005;76(4):476-81. 
5. 
Carter JA, Neville BG, White S, Ross AJ, Otieno G, Mturi N, et al. Increased prevalence of epilepsy 
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