Prevention of Malaria in HIV-uninfected Pregnant Women and Infants
Phase: PHASE3
Conditions: Malaria
Sponsor: University of California, San Francisco

1 
“Novel Strategies to Prevent Malaria and Improve 
Maternal-Child Health in Africa” 
(PROMOTE II) 
A UCSF/ MAKERERE UNIVERSITY COLLABORATION 
Title: Prevention of Malaria in HIV-uninfected 
Pregnant Women and Infants 
Short Title: PROMOTE Birth Cohort 3 
NCT02793622
VERSION  5.0 
Sponsored by: 
The National Institute of Child Health and Human 
Development Bill and Melinda Gates Foundation 
Principal Investigators: 
Grant Dorsey, MD, PhD 
University California San Francisco 
Moses Kamya, MBChB, MMed, PhD 
Makerere University College of Health Sciences 
Protocol Version   5.0, 27 February 2018 

PROMOTE-II Birth Cohort 3 Protocol version 5.0, 27 Feb 2018 
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TABLE OF CONTENTS 
 
PROTOCOL TEAM ROSTER .............................................................................................................. 6 
GLOSSARY ........................................................................................................................................ 9 
SCHEMA ......................................................................................................................................... 10 
1. 
INTRODUCTION ................................................................................................................. 11 
1.1. 
Background ................................................................................................................ 11 
1.2. 
Preliminary studies .................................................................................................... 15 
1.3. 
Rationale ................................................................................................................... 18 
2. 
STUDY OBJECTIVES ............................................................................................................ 20 
2.1. 
Objective 1 ................................................................................................................. 20 
2.2. 
Objective 2 ................................................................................................................. 20 
2.3. 
Objective 3 ................................................................................................................. 21 
2.4 
Objective 4 ................................................................................................................. 21 
3. 
STUDY DESIGN ................................................................................................................... 21 
4. 
SELECTION AND ENROLLMENT OF SUBJECTS .................................................................. 22 
4.1. 
Inclusion Criteria ........................................................................................................ 22 
4.2. 
Exclusion Criteria ....................................................................................................... 22 
4.3. 
Initial Screening ......................................................................................................... 22 
4.4. 
Study Enrollment Procedures and Baseline Evaluation ............................................... 23 
5. 
STUDY TREATMENT ........................................................................................................... 24 
5.1. 
Treatment Group Assignments ................................................................................... 24 
5.2. 
Treatment Allocation ................................................................................................. 24 
5.3. 
Study Drug Dosing and Formulations ......................................................................... 24 
Table 1. Drug formulation and labeling ........................................................................... 25 
5.4. 
Blinding, Study Drug Administration, and Duration .................................................... 25 
5.5. 
Study Drug Accountability .......................................................................................... 26 
6. 
SUBJECT MANAGEMENT ................................................................................................... 26 
6.1. 
Subject Follow-up ...................................................................................................... 26 

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6.2. 
Diagnosis and Management of Malaria ...................................................................... 26 
6.3. 
Management of Non-Malaria Illnesses ....................................................................... 28 
6.4. 
After Hours Visits ....................................................................................................... 28 
6.5. 
Routine Assessments ................................................................................................. 28 
6.6. 
Delivery visit .............................................................................................................. 29 
6.7. 
Postpartum visits. ...................................................................................................... 30 
6.8. 
Medical Care Outside the Study Clinic ........................................................................ 30 
6.9. 
Duration of Follow-up and Criteria for Premature Study Withdrawal ......................... 31 
6.10. 
Diagnostic and Laboratory Testing ............................................................................. 31 
6.10.1. Microscopy ......................................................................................................... 32 
6.10.2. Clinical Laboratory Studies ................................................................................ 32 
6.10.3. Placental Studies ............................................................................................... 33 
6.10.4. Molecular and Parasitology Studies ................................................................. 33 
6.10.5. Immunology Studies .......................................................................................... 35 
6.10.6. Sample Storage for Future Use ......................................................................... 35 
6.11. 
Co-enrollment Guidelines .......................................................................................... 36 
6.12. MANAGEMENT OF ADVERSE EVENTS POTENTIALLY RELATED TO STUDY DRUGS ......... 36 
6.13. 
Grade 1 or 2 Adverse Events ...................................................................................... 36 
6.14. 
Grade 3 or 4 Adverse Events ...................................................................................... 36 
7. 
MONITORING OF ADVERSE EVENTS AND MANAGEMENT .............................................. 37 
7.1. 
Monitoring and Reporting of Adverse Events ............................................................. 37 
7.1.1. Definitions ............................................................................................................ 37 
7.1.2. Identification of Adverse Events ......................................................................... 38 
7.1.3. Reporting of Adverse Events ............................................................................... 38 
Table 2. Guidelines for reporting adverse events ........................................................... 39 
8. 
STATISTICAL CONSIDERATIONS ........................................................................................ 39 
8.1. 
Hypothesis 1 .............................................................................................................. 39 
8.1.1. Primary Outcome ................................................................................................ 40 
8.1.2. Secondary Outcomes ........................................................................................... 40 
8.1.3. Analyses ............................................................................................................... 40 
8.2. 
Hypothesis 2 .............................................................................................................. 41 
8.2.1. Primary Outcome ................................................................................................ 41 
8.2.2. Secondary Outcomes ........................................................................................... 42 
Table 4. Secondary outcomes .......................................................................................... 42 
8.2.3. Analyses ............................................................................................................... 42 

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8.3. 
Hypothesis 3 .............................................................................................................. 43 
8.3.1. Primary Outcomes ............................................................................................... 43 
8.3.2. Secondary Outcomes .............................................................................................. 43 
8.3.3. Analyses .................................................................................................................. 43 
8.4.    Sample size and power .................................................................................................. 44 
8.5. 
Data and Safety Monitoring Plan ............................................................................... 44 
8.5.1. Data and Safety Monitoring Board ..................................................................... 45 
8.5.2. Interim safety analysis ........................................................................................ 46 
Table 5. Schedule of interim safety analysis and boundaries to monitor study outcome
 ........................................................................................................................................... 47 
8.5.3. Stopping rules ...................................................................................................... 47 
9. 
DATA COLLECTION AND MONITORING ............................................................................ 47 
9.5. 
Record Keeping .......................................................................................................... 47 
9.6. 
Data Quality Assurance and Monitoring ..................................................................... 48 
10. 
HUMAN SUBJECTS ............................................................................................................. 48 
10.5. 
Subject Selection Criteria ........................................................................................... 48 
10.6. 
Risks and Discomforts ................................................................................................ 48 
10.6.1. Privacy ................................................................................................................ 48 
10.6.2. Finger Pricks, Heel Sticks, and Venipuncture ................................................... 48 
10.6.3. Risks of Study Medications ............................................................................... 48 
Table 6. Summary of adverse events following treatment with dihydroartemisinin-
piperaquine ....................................................................................................................... 50 
Table 7. Frequency, incidence, and risk of the 20 most frequently reported adverse 
events ................................................................................................................................ 51 
Table 8. Comparison of adverse events among children between 6-24 months of age 52 
Table 9. Measures of safety and tolerability from recent IPTp study conducted in 
Tororo, Uganda ................................................................................................................. 53 
10.7. 
Treatment and Compensation for Injury .................................................................... 53 
10.8. 
Costs to the Subjects .................................................................................................. 54 
10.9. 
Reimbursement of Subjects ....................................................................................... 54 
10.10 Institutional Review Board (IRB) Review and Informed Consent ................................. 54 
10.11 Definition of Parent/Guardianship. ............................................................................ 55 
12. 
PUBLICATION OF RESEARCH FINDINGS ............................................................................ 55 
13. 
BIOHAZARD CONTAINMENT ............................................................................................. 55 
14.  
REFERENCES ...................................................................................................................... 55 

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15.  
APPENDICES ...................................................................................................................... 61 
Appendix A. Information Sheet .............................................................................................. 61 
Appendix B. Determination of Gestational Age ...................................................................... 62 
Appendix C. Household survey ............................................................................................... 63 
Appendix D. Administration of study drugs and placebos ....................................................... 67 
Appendix E. WHO Criteria for Severe Malaria and Danger Signs ............................................. 68 
Appendix F. Uganda Ministry of Health Guidelines for Routine Care of Pregnant and 
Postpartum Women, and Newborns ...................................................................................... 69 
Appendix G. Schedule of routine assessments and procedures in pregnant women ............... 70 
Appendix H. Schedule of routine assessments and procedures in infants ............................... 72 
Appendix I.    Division of AIDS (DAIDS) Table for Grading the Severity of Adult and Pediatric 
Adverse Events Version 2.0 November 2014 ........................................................................... 73 
Appendix J. List of drugs associated with known risk of torsades de pointes .......................... 97 
Appendix K. List of drugs that potentially inhibit the metabolism of piperaquine ................. 100 

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PROTOCOL TEAM ROSTER   
 
Investigators   
 
 
 
 
Grant Dorsey, MD, PhD University of California, San Francisco 
 
Address:  San Francisco General Hospital, 995 Potrero Avenue, 
 
Building 30, Room 3240, UCSF Box 0811, San Francisco CA, 94110, U.S.A. 
Phone Number: 01-415-206-4680 
Fax Number:   01-415-648-8425 
 
Email: grant.dorsey@ucsf.edu  
 
Moses R. Kamya, MBChB, MMed, PhD, Makerere University College of Health Sciences 
 
Address:  Department of Medicine, P.O. Box 7072, Kampala, Uganda   
 
Phone Number:  +256-414-533200 
 
Fax Number:      +256-414-540524 
 
Email:  mkamya@infocom.co.ug 
 
Diane V. Havlir, MD, University of California, San Francisco 
Address: San Francisco General Hospital, 995 Potrero Avenue,  
Building 80, Ward 84, UCSF Box 0874, San Francisco, CA 94110, U.S.A.  
Phone Number:  01-415-476-4082, ext 400   
  
Fax Number:      01-415-502-2992 
 
Email:  dhavlir@php.ucsf.edu 
 
Miriam Nakalembe, MBChB, MMed Ob/Gyn, Makerere University College of Health Sciences 
 
Address: Department of Medicine,  
P.O. Box 7072, Kampala, Uganda   
 
Phone Number: +256 753 857 433 (Mobile), +256 414 534 361 (Office) 
Fax +256 414 533 451 (AOGU Office)  
Email: ivuds@yahoo.com 
 
 
Edwin Charlebois, MPH PhD, University of California, San Francisco 
Address:  550 16th St., 3rd Floor Box 0886, San Francisco, CA. 94158, U.S.A. 
Phone Number: 01-415-476-6241 
Email:  edwin.charlebois@ucsf.edu 
 
Abel Kakuru, MBChB, MSc, Infectious Diseases Research Collaboration 
Address: Infectious Diseases Research Collaboration,                                            
       
P.O. Box 7475, Kampala, Uganda 
 
 
 
 
 
      
Phone Number:  +256-414-530692  
 
 
                                
Fax Number:      +256-414-540524 
 
 
 
 
 
   
Email:  abelkakuru@gmail.com 
 
Maggie Feeney, MD, MSc, University of California, San Francisco 

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Address:  UCSF, Parnassus Avenue Box 1234, San Francisco, CA  94143, U.S.A. 
Phone Number: 415-206-8218 
 
Email: feeneym@medsfgh.ucsf.edu 
 
Tamara Clark, MPH, University of California, San Francisco 
             Address:  UCSF, Parnassus Avenue Box 0811, San Francisco, CA  94143, U.S.A. 
Phone Number: 01-415-206-8790 
Fax Number: 01-415-648-8425 
             Email:   tclark@medsfgh.ucsf.edu  
 
Theodore Ruel, MD, Assistant Professor, University of California, San Francisco, Dept Pediatrics 
Address: 550 16th Street, 4th Floor, San Francisco, CA 94158-0434 
Phone Number: 01-415 476 9197 
Fax Number: 01-415 476 1343 
Email:  ruelt@peds.ucsf.edu 
 
Prasanna Jagannathan, MD, Assistant Professor, University of California, San Francisco 
Address: 1001 Potrero Ave, Bldg 3, 525, San Francisco CA 94143 
Phone Number: 01-415-206-8366 
Email: jagannathanp@medsfgh.ucsf.edu 
 
Laura Jelliffe-Pawlowski, PhD, Associate Professor, University of California, San Francisco 
Address: 550 16th Street, 2nd Floor, San Francisco, CA 94158 
Phone Number: 01-415-476-6132 
Email: Laura.Jelliffe@ucsf.edu 
 
Elizabeth Rodgers, MD, Assistant Professor of Pediatrics, University of California, San Francisco 
Address: 550 16th Street, 5th Floor, San Francisco, CA 94158 
Phone Number: 01-415-353-1565 
Email: Elizabeth.Rogers@ucsf.edu 
 
 
 
 

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OTHER PERSONNEL  
Name 
Title 
Institution 
Dr. Mary Kakuru 
Study Coordinator 
IDRC, Uganda 
Dr. Paul Natureeba 
Study Coordinator 
IDRC, Uganda 
Dr. Patricia Awori 
Study Coordinator 
IDRC, Uganda 
Dr. Teddy Andra 
Study Coordinator 
IDRC, Uganda 
Dr. Julian Abeso 
Study Pediatrician 
MOH, Mbale Hospital 
Peter Olwoch 
Laboratory Manager 
IDRC, Uganda 
Bishop Opira 
Study Pharmacist  
IDRC, Uganda 
Jaffer Okiring 
Data Manager 
IDRC, Uganda 
Dr. Bridget Nzarubara 
Regulatory Affairs Manager 
IDRC, Uganda 
Katherine Snyman 
Quality Assurance Manager 
UCSF 
 
 
 
 
 
 
 
 
 

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GLOSSARY 
 
AE 
 
Adverse event 
ACT 
 
Artemisinin-based combination therapy 
AL 
 
Artemether-lumefantrine 
ALT 
 
Alanine transaminase (SGPT) 
CAB 
 
Community advisory board 
CBC 
 
Complete blood cell count 
CRF 
 
Case report form 
DP 
 
Dihydroartemisinin-piperaquine 
DSMB  
Data and Safety Monitoring Board 
IDRC 
 
Infectious Diseases Research Collaboration 
IPTp 
 
Intermittent preventive therapy in pregnancy 
IRB 
 
Institutional review board 
ITN 
 
Insecticide treated net 
MOH  
Ministry of Health 
MU 
 
Makerere University 
NICHD  
National Institute of Child Health and Human Development 
NIH 
 
National Institute of Health 
SAE 
 
Serious adverse event 
SP 
 
Sulfadoxine-pyrimethamine 
UCSF  
University California San Francisco 
WHO  
World Health Organization 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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SCHEMA  
Title 
Prevention of Malaria in HIV-uninfected Pregnant Women and Infants 
Description 
Double blinded randomized controlled trial 
Study Objectives 
1. 
To compare the risk of adverse birth outcomes among HIV-uninfected pregnant women randomized to receive IPTp with 
monthly SP vs. monthly DP.  
2. 
To compare the incidence of malaria among infants born to mothers randomized to receive IPTp with monthly SP vs. 
monthly DP. 
3. 
To validate and adapt a gestational dating by metabolic profile at birth algorithm and to evaluate the added benefits of using 
metabolic profile to identify newborns at increased risk for neonatal death or serious complications. 
Participants and 
Sample Size 
782 HIV-uninfected pregnant women and the children born to them 
Clinical Site 
The study will be conducted in Busia District, Uganda. A designated study clinic will be located within Masafu General Hospital. 
The study clinic will be open daily from 8:00 am to 5:00 pm and after-hours care will be available with the hospital complex.  
Selection Criteria 
Inclusion Criteria 
1. 
Pregnancy confirmed by positive urine pregnancy test or intrauterine pregnancy by ultrasound 
2. 
Estimated gestational age between 12-20 weeks  
3. 
Confirmed to be HIV- uninfected by rapid test 
4. 
16 years of age or older 
5. 
Residency within Busia District of Uganda 
6. 
Provision of informed consent  
7. 
Agreement  to come to the study clinic for any febrile episode or other illness and avoid medications given outside the 
study protocol 
8. 
Plan to deliver in the hospital 
Exclusion Criteria: 
1. 
History of serious adverse event to SP or DP 
2. 
Active medical problem requiring inpatient evaluation at the time of screening 
3. 
Intention of moving outside of Busia District Uganda 
4. 
Chronic medical condition requiring frequent medical attention 
5. 
Prior SP preventive therapy or any other antimalarial therapy during this pregnancy 
6. 
Early or active labor (documented by cervical change with uterine contractions) 
Treatment 
assignment 
HIV-uninfected pregnant women will be randomized at the time of enrollment 
Treatment arms 
1. 
Monthly SP 
2. 
Monthly DP 
Follow-up and 
Diagnosis of 
Malaria 
Study participants will be followed for all of their outpatient medical care in our study clinic. Women will be followed until 6 
weeks postpartum and children will be followed until 12 months of age. Routine assessments will be performed in the study clinic 
for all study participants every 4 weeks. Patients presenting with a new episode of fever will undergo standard evaluation for the 
diagnosis of malaria.  
Primary study 
outcome 
The risk of having an adverse birth outcome defined as the occurrence of any of the following: 
1) 
Low birth weight (< 2500 gm) 
2) 
Preterm delivery (< 37 weeks gestational age) 
3) 
Small for gestational age (< 10th percentile relative to an external growth reference) 

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1. INTRODUCTION 
 
1.1. Background  
 
Malaria in pregnancy: burden of disease and prevention. In sub-Saharan Africa over 30 million 
pregnant women are at risk of P. falciparum infection every year and 25% have evidence of 
placental infection.1 Among pregnant women living in areas of stable transmission few 
infections lead to symptomatic malaria, however, infection is associated with maternal 
morbidity, such as anemia, and adverse birth outcomes including abortions, stillbirth, preterm 
delivery, low birth weight (LBW), and infant mortality.2,3  
In Africa the only widely available tools for the prevention of malaria in pregnancy are 
insecticide treated bednets (ITNs) and intermittent preventive therapy (IPTp) with sulfadoxine-
pyrimethamine (SP). Older studies demonstrated the efficacy of IPTp with SP in reducing the 
risk of placental malaria and LBW.4-8 However, there are now concerns about the continued 
efficacy of IPTp with SP given the spread of antifolate resistance. A 2007 review suggested that 
IPTp with SP remained beneficial in areas with antifolate resistance, however, this conclusion 
was based on communities where SP treatment failure rates in children remained at moderate 
levels.9 More recently, reports from East Africa have documented SP failure rates over 65% in 
children when used for treatment10 or prevention11, and near saturation of common SP 
resistance alleles.12,13 In a recent study from Tanzania IPTp with SP was not associated with a 
decreased risk of placental malaria, maternal anemia, or LBW, and unexpectedly associated 
with an increased risk of fetal anemia.14 In a recent study from Uganda there was no significant 
difference in the risk of maternal infection, maternal anemia, and LBW for pregnant women 
receiving IPTp with SP plus ITNs vs. ITNs alone.15 In addition, most IPTp studies have defined 
placental malaria on the basis of placental blood smears, which dramatically underestimate the 
true prevalence of placental malaria. In summary, there are several lines of evidence suggesting 
that IPTp with SP is no longer effective in areas of East Africa with widespread antifolate 
resistance. New interventions to reduce the burden of malaria in pregnancy in this region are 
needed. 
 
The ACT class of drugs offers an attractive alternative to SP for use in pregnancy. In a 
recent systematic review of parasitological efficacy for the treatment and prevention of 
falciparum malaria in pregnancy, placenta-positive rates were unacceptably high in a majority 
of SP trial arms and ACTs provided the lowest parasitological failure rates.16 The authors 
recommended that SP should no longer be used for treatment or prevention of malaria in 
pregnancy and that ACTs provide the most efficacious and safe alternative therapy. Two studies 
of the ACT artesunate (AS) + SP from Africa concluded that this drug was safe for the treatment 
of malaria in pregnant women.17,18 More recent studies have focused on artemether-
lumefantrine (AL), considering efficacy, pharmacokinetics, and safety. In a prospective study 

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from Zambia, 495 pregnant women exposed to AL (including 156 in the 1st trimester) had 
similar risks of adverse maternal and infant outcomes compared to pregnant women exposed 
to SP.19  In a recent study from Uganda, pregnant women in their 2nd or 3rd trimester with 
peripheral parasitemia treated with AL had a cure rate of 99%.20 The ACT dihydroartemisinin-
piperaquine (DP) has also been safely used for the treatment of uncomplicated malaria in 
pregnancy in studies from Asia.21,22 In two studies on the treatment of uncomplicated malaria 
with DP in pregnant and non-pregnant women, one concluded that there were no clinically 
important differences in piperaquine pharmacokinetics in pregnancy 23 and another concluded 
that pregnancy was associated with an unaltered total exposure to piperaquine but a shorter 
terminal elimination half-life.24  
Two recent published studies have compared IPTp with DP versus SP. In a study from 
Kenya, HIV negative pregnant women were randomly assigned to receive intermittent 
screening and treatment with DP vs. standard dosing of IPTp with either SP or DP.25 
Intermittent screening and treatment with DP was not found to be a suitable alternative to IPTp 
with SP. However, compared to IPTp with SP, IPTp with DP was associated with a lower 
incidence of malaria infection and clinical malaria during pregnancy and a lower prevalence of 
malaria infection at delivery (3% vs. 10%, p<0.001). Serious adverse events were also lower in 
the IPTp with DP arm compared to the IPTp with SP arm. In a recent study from our group in 
Uganda, study participants were randomized to receive IPTp with 3 dose SP, 3 dose DP, or 
monthly DP.26 Compared to the 3 dose SP arm, monthly DP was associated with a significant 
reduction in the risk of symptomatic malaria, infection with malaria parasites, and maternal 
anemia during pregnancy, and the risk of placental malaria measured at delivery. In addition, 
compared to the 3 dose DP arm, monthly DP was associated with a significant reduction in the 
risk of symptomatic malaria and infection with malaria parasites during pregnancy, with a trend 
towards a lower risk of maternal anemia during pregnancy and placental malaria measured at 
delivery. All IPTp regimens were equally well tolerated with no differences in the risk of adverse 
events. 
In summary, most African countries continue to recommend IPTp with SP, however, 
there are serious concerns about the efficacy of SP given widespread resistance, especially in 
East Africa. Available data have shown that ACTs are effective and safe for the treatment of 
malaria in pregnancy and are now recommended by the WHO as 1st line therapy for pregnant 
women in their 2nd or 3rd trimester.27 More recently, two published studies have documented 
that IPTp with DP is superior to IPTp with SP for the prevention of malaria during pregnancy and 
the risk of placental malaria. In July 2015 the WHO sponsored an “Expert Review Group” 
meeting to review IPTp policy recommendations. Data from both recently published studies 
evaluating IPTp with DP were presented.  The WHO panel felt that based on these 2 new 
studies, DP is the most promising alternative to SP.  However, several limitations of these 

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studies were noted during the discussion, and knowledge gaps regarding evidence of clinical 
benefit in birth outcomes and safety need to be filled prior to a policy change.   These include:   
 
Lack of statistical power to detect a difference in birth outcomes known to be associated with 
placental malaria: Although a majority of RCTs evaluating IPTp have been powered to detect a 
difference in measures of malaria during pregnancy, the primary goal of IPTp is to reduce the 
risk of adverse birth outcomes, namely small for gestational age, low birth weight and 
premature delivery. Because these outcomes are relatively uncommon and can be caused by 
factors other than malaria in pregnancy, the sample size needed to detect differences in birth 
outcomes is larger than needed to detect differences in measures of malaria during pregnancy. 
To better justify a change in policy from IPTp with SP to IPTp with DP, one would ideally be able 
to show that this alternative regimen is associated with a significantly lower risk of adverse 
birth outcomes associated with malaria during pregnancy. 
 
Control arm did not reflect current Uganda/Global Guidelines: In the study from Kenya, both SP 
and DP were given a median of 3 times during pregnancy at intervals of 4-6 weeks.  In our study 
from Uganda, SP was given 3 times during pregnancy (at 20, 28, and 36 weeks of gestation) in 
line with Ugandan guidelines in place at the time the study was designed.  In contrast, in our 
monthly DP arm active study drugs were given every 4 weeks starting as early as 16 weeks of 
gestational age. Updated Ugandan and global guidelines now recommend that IPTp with SP be 
started as early as possible during the 2nd trimester and continued at each scheduled antenatal 
care visit at least 1 month apart up to the time of delivery in line with updated 
recommendations from the WHO.28 
 
Safety assessments: More data are needed on the safety of IPTp with DP, especially with 
regards to the risk of QTc prolongation. Our study is the only study of IPTp with DP conducted 
to date that included ECG evaluations, but we only included a subset of 42 women; 12 assigned 
to 3 dose SP, 17 assigned to 3 dose DP, and 13 assigned to monthly DP. QTc intervals were also 
only measured before and after study drug treatment at 28 weeks of gestational age. 
 
Impact of exposure to malaria during pregnancy on the development of immunity in the 
fetus. Increasing evidence suggests that maternal infection during pregnancy affects the 
developing immune system of the fetus independent of potential vertical transmission.29 
Several studies indicate that placental malaria is associated with altered parasite-specific 
immune responses in neonates that could affect response to malaria after birth.30-33 In addition, 
several clinical studies have reported that infants born to mothers with placental malaria have a 
higher risk of death 34 and malaria during infancy.35-38 However, all of these were observational 
studies in which it is very difficult to control for exposure, which is tightly linked between 

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pregnant women and their infants. It remains unclear whether, as we hypothesize in this 
proposal, prevention of malaria during pregnancy improves the development of antimalarial 
immunity and reduces the risk of malaria in the first year of life.  
 
Using metabolic profiles in the newborns for gestational age dating and evaluation of 
outcomes. A number of metabolites measured in newborn serum and bloodspots (i.e. 
acylcarnitines, amino acids, thyroid stimulating hormone) have been shown to be associated 
with intra-uterine growth restriction, mortality, and complications of prematurity including, for 
example, respiratory distress syndrome, patent ductus arteriosus, and necrotizing 
enterocolitis.39-44 Recently our group found that well-performing gestational dating algorithms 
could be built using newborn characteristics and metabolites measured within the first week of 
life (acylcarnitines, amino acids, thyroid stimulating hormone, 17-hydroxyprogesterone, and 
galactose-1-phosphate-uridyl-transferase ).45 Associations between these target markers, 
gestational age, and outcomes appears to be related to poor metabolic regulation – particularly 
with respect to glucose homeostasis46-51 and are also related to hepatic immaturity.52 
Evaluating these patterns in the context of the other aims of this study provides an opportunity 
to understand these patterns more fully in the population of study and also provides data that 
may prove critical for understanding the immune status of neonates over the course of the first 
year of life – particularly in those born preterm, with intra-uterine growth restriction, and in 
those with complications with close links to prematurity.  
 
Improved point-of-care testing for the detection of infection with malaria parasites during 
pregnancy. The detection of infection with malaria parasite during pregnancy could have 
important implications for screening and treating women with the goal of reducing the risk of 
complications due to malaria in pregnancy. Currently available rapid diagnostic tests (RDTs) lack 
the sensitivity to detect low level parasitemia common during pregnancy among women living 
in highly endemic areas.25 Malaria RDTs are lateral flow assays (LFA) that detect circulating 
malaria antigens. LFAs are uniquely applicable in a point-of-care setting because of their ease-
of-use and short time required for diagnosis. To date, most LFAs are limited by the requirement 
to accumulate a certain level of analyte-antibody-nanoparticle (dye) conjugate, commonly 
including a gold nanoparticle (GNP), sufficient to enable visual detection of a test line. This 
limits their potential in the clinical management, screening and surveillance of many infectious 
diseases. One result of this limitation is a failure to detect low-density (often asymptomatic) P. 
falciparum infections, which can lead to placental malaria. We plan to evaluate two new 
technologies aimed to improve the sensitivity of RDTs used to detect malaria parasites during 
pregnancy. The first is an LFA-enhancement technology based on photo-thermal spectroscopy 
(PTS) which can reduce the limit of detection (and thereby increase the sensitivity) of RDTs 
currently on the market by 4-5 fold. Photo-thermal spectroscopy involves the selective heating 

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of gold nanoparticles on the wick of a LFA, and detection of gold accumulation through an 
increase in temperature relative to its surrounding substrate. Heating is attained through 
excitation of gold nanoparticles with a laser of certain wavelength, and detection through use 
of a thermal camera or other device to detect temperature change. This device achieves lower 
thresholds of detection and thus enables the user of the LFA to detect target antigen or 
antibody at lower concentration, and/or at an earlier stage. The LFA-reader is approximately 
laptop sized and comprises the reader unit and disposable assay cartridges. The reader can be 
operated under battery power for 1 day and can be recharged using standard power sources. 
Both the cartridges and the readers can be operated under typical room conditions, not 
requiring air conditioning or refrigeration.  Approximately 5 µL of whole blood is placed on the 
cartridge, which is inserted into the reader, and the reader will take approximately 1-3 minutes 
to complete the testing. The graphical user interface (GUI) guides the user through the assay 
process. In addition to the Photo-Thermal Reader, we plan to evaluate an experimental RDT 
which has been designed to increase clinical sensitivity compared to commercially available 
RDTs. 
 
1.2. Preliminary studies  
 
Intermittent preventive therapy in pregnancy with sulfadoxine-pyrimethamine. We 
conducted a cross-sectional study of 565 HIV-uninfected women giving birth between February 
– July 2011 at Tororo District Hospital.53 The primary objective of the study was to measure 
associations between use of SP during pregnancy from antenatal records and the risk of 
adverse outcomes including placental malaria, low birth weight, maternal parasitemia and 
maternal anemia. The proportion of women who reported taking 0, 1, 2, and 3 doses of SP 
during pregnancy was 5.7%, 35.8%, 56.6% and 2.0% respectively. Overall, the prevalence of 
placental malaria was 17.5%, 28.1%, and 66.2% by placental smear, PCR, and histopathology, 
respectively. In multivariate analyses controlling for potential confounders, > 2 doses of SP was 
associated with non-significant trends towards lower odds of placental malaria by placental 
smear (OR=0.75, p=0.25), placental malaria by PCR (OR=0.93, p=0.71), placental malaria by 
histopathology (OR=0.75, p=0.16), low birth weight (OR=0.63, p=0.11), maternal parasitemia 
(OR=0.88, p=0.60) and maternal anemia (OR=0.88, p=0.48). Using a composite outcome, > 2 
doses of SP was associated with a significantly lower odds of placental malaria, low birth 
weight, maternal parasitemia, or maternal anemia (OR=0.52, p=0.01). In this area with intense 
malaria transmission, the prevalence of placental malaria by histopathology was high even 
among women who reported taking at least 2 doses of SP during pregnancy. The reported use 
of > 2 doses of SP was not associated with protection against individual birth and maternal 
outcome.  
 

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16 
Antifolate Resistance in Uganda. Surveillance of key mutations in P. falciparum dhfr and dhps 
genes, which encode the target enzymes of SP, has been proposed as a means of monitoring 
antifolate drug resistance in Africa. We have studied the association between the five key 
mutations commonly reported in Africa and clinical treatment failure in children treated with 
SP for uncomplicated malaria in Kampala 54,55. The prevalences of the dhfr 108N (98%) and 51I 
(95%) mutations were very high, and therefore these mutations were not useful independent 
predictors of treatment outcome. Considering combinations of mutations, there was generally 
a “dose response” relationship, with an increasing number of mutations resulting in stronger 
associations with treatment failure. Infections with parasites containing the quintuple mutant 
(dhfr 108N + 51I +59R; dhps 437G + 540E) was associated with over 10 times the odds of 
treatment failure compared to infections with parasites containing only the 108N and 51I 
mutations (OR = 10.7, 95%CI 1.8-64.4, p = 0.009).  
 
We have measured the prevalence of key antifolate resistance-conferring mutations 
from subjects living in Tororo (nearby the site of this proposal) over a 4 year period. From 2002-
2006 the prevalence of the dhfr triple mutant increased from 40% to almost 80% and the 
prevalence of the dhps triple mutant increased from 60% to almost 100%. This temporal 
increase in the prevalence of molecular markers of antifolate resistance corresponds to the 
2001 implementation of a national policy change from CQ to CQ+SP as the recommended first-
line treatment for malaria in Uganda 56. We have also measured the prevalence of key 
antifolate resistance-conferring mutations from the 9 children in a cohort of HIV-infected 
children who developed symptomatic malaria while taking TS prophylaxis 57. All of these 
samples contained the dhfr/dhps quintuple mutant and one sample contained an additional 
mutation (dhfr 164L) associated with high-level antifolate resistance (probably leading to 
complete loss of antimalarial activity of antifolates) that is rare in Africa 58 and was only very 
rarely detected in hundreds of prior samples from Uganda evaluated by our group. These data 
provided further evidence that SP, currently the regimen used for IPTp in Uganda, may be faced 
with diminishing protective efficacy. Thus, alternative regimens and strategies, such as DP as 
proposed in our protocol, should be considered.  
 
IPTp with DP vs. SP. As mentioned in the background section, we recently conducted a double-
blinded randomized controlled trial comparing 3 dose SP versus 3 dose DP versus monthly DP in 
300 HIV-uninfected pregnant women in Tororo, Uganda, where SP resistance is widespread and 
transmission intensity has historically been high. The primary outcome was the prevalence of 
placental malaria by histopathology. A total of 106, 94, and 100 women were randomized to 3 
dose SP, 3 dose DP and monthly DP, respectively. The prevalence of placental malaria by 
histopathology was significantly higher in the 3 dose SP arm (50.0%) compared with the 3 dose 
DP (34.1%, P=0.03) or monthly DP (27.1%, P=0.001) arms. The prevalence of a composite 
adverse birth outcome was lower in the monthly DP arm (9.2%) compared to the 3 dose SP 

PROMOTE-II Birth Cohort 3 Protocol version 5.0, 27 Feb 2018 
17 
(18.6%, P=0.05) and 3 dose DP (21.3%, P=0.02) arms. During pregnancy, the incidence of 
symptomatic malaria was significantly higher in the 3 dose SP arm (41 episodes over 43.0 
person years at risk) compared to the 3 dose DP (12 episodes over 38.2 person years at risk, 
P=0.001) or monthly DP (0 episodes over 42.3 person years at risk, P<0.001) arms, and parasite 
prevalence significantly higher in the 3 dose SP arm (40.5%) compared to the 3 dose DP (16.6%, 
P<0.001) or monthly DP (5.2%, P<0.001) arms. The risk of vomiting following the administration 
of study drugs was < 0.4% in all 3 treatment arms and there were no significant differences in 
the risk of adverse events.  
Currently, the children born to the pregnant women enrolled in this study are being 
randomized to receive monthly vs. 3 monthly DP from 2-24 months of age and then followed 
for an additional one year (to 36 months of age) after chemoprevention is stopped. One of the 
objectives of this study is to compare the incidence of malaria in children born to mothers who 
received different IPTp regimens. However, shortly after women started giving birth in this 
study, the district of Tororo implemented indoor residual spraying of insecticide (IRS) for the 
first time with the plan to conduct IRS every 6 months for 3 years (December 2014 through 
December 2017). Due to the combination of IRS and chemoprevention among the children, the 
incidence of malaria has been extremely low (< 0.1 episodes PPY) precluding our ability to test 
the hypothesis that the incidence of malaria will be different in children born to mothers 
randomized to IPTp with SP vs. DP. The study outlined in this proposal will address this 
development but recruiting study participants from an area of Eastern Uganda where IRS is not 
being conducted and chemoprevention will not be given to children, which remains the current 
standard of care in Uganda.  
 
Using metabolic profiles in the newborns for gestational age dating and evaluation of 
outcomes.  As is noted in the background section, our group is experienced in examining the 
relationship between metabolic profiles at birth, gestational age, and newborn outcomes. 
Specifically, we recently evaluated whether metabolic markers in newborns could be used to 
develop a population-level metabolic gestational dating algorithm that is robust despite 
intrauterine-growth restriction and could be used when fetal ultrasound dating is not available. 
We focused specifically on the ability of these markers to differentiate preterm births (<37 
weeks) from term births and to assign a specific gestational age in the preterm birth group. 
In a cohort of 729,503 singleton newborns we used multivariate backward stepwise regression 
to test for associations and linear discriminate analyses to create a linear function for preterm 
birth and to assign a specific week of gestation. These efforts resulted in a finding that when 
considered with birth weight and timing of test by hours after birth at blood draw, 35 of the 51 
metabolic markers evaluated were able to sort preterm and term births accurately with 
sensitivities and specificities of 95% or more in both the training and testing subsets. 
Assignment of a specific week of gestation in those identified as preterm births resulted in the 

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18 
correct assignment of week +/-2 weeks in 89.8% of all newborns in the training and 91.7% of 
those in the testing subsets.45  
Our group is also uniquely prepared to investigate the relationships between metabolic 
markers and newborn outcomes given extensive work with similar data and specimens. Of 
particular note is work from our group that has shown that preterm neonates are metabolically 
different than their term peers.42-44 Also important are our findings demonstrating differences 
in glucose-related markers in preterm birth neonates within the first few days of life that go on 
to develop complications of prematurity including respiratory distress syndrome and 
necrotizing enterocolitis. Recently we found that that acylcarnitine patterns within the first few 
days of life can help identify more than 80% of preterm neonates that develop necrotizing 
enterocolitis.  
 
1.3. Rationale 
 
Malaria remains one of the most important infectious diseases worldwide with an estimated 
3.3 billion people at risk leading to hundreds of millions of cases and 660,000 deaths each 
year.59,60 In 2010, 81% of cases and 91% of deaths were estimated to have occurred in Africa, 
with children under five years of age and pregnant women most severely affected.60 The 
primary tools currently available for malaria prevention in Africa include ITNs and IPTp. 
However, there are limitations with these interventions and the burden of malaria remains high 
in many parts of Africa despite recent increases in coverage levels. ITNs do not fully protect 
against malaria and there is concern for waning efficacy given the emergence of resistance to 
pyrethroid insecticides (the only class used in ITNs).61,62 The only drug widely used for IPTp is SP, 
and there are recent reports suggesting that IPTp with SP is no longer effective, especially in 
East Africa, where resistance to this drug is now widespread.14,63 Recent increases in funding for 
malaria control offer an unprecedented opportunity to expand preventative interventions; 
however, new strategies are urgently needed to reduce the burden of malaria for those at 
greatest risk.  
One of the most important malaria control interventions is the use of ACTs for the 
treatment of malaria. ACTs are highly efficacious, and now the recommended first-line 
treatment for uncomplicated falciparum malaria in all countries of sub-Saharan Africa , 
including the treatment of malaria in pregnant women during the 2nd and 3rd trimesters.27 ACTs 
also offer the opportunity to greatly reduce the burden of malaria in pregnant women and 
young children if their role is expanded to chemoprevention. IPT with the ACTs artesunate-
amodiaquine, artesunate-SP, and DP have been shown to be effective and safe for the 
prevention of malaria in African children.64-66 IPT with DP is especially attractive given its 
prolonged post-treatment prophylactic effect, due to the unusually long half-life of 
piperaquine.67  

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Two recent studies from East Africa have shown that IPTp with DP is more effective than 
SP at reducing the risk of malaria during pregnancy and the risk of placental malaria at 
delivery.25,26 However, there were limitations to these studies and WHO policy 
recommendations continue to recommend the use of IPTp with SP. This proposal will address 
some of these limitations by using a dosing strategy in-line with updated WHO 
recommendations, power the study to detect a difference in the risk of adverse birth outcomes, 
undertake a more thorough assessment of adverse events including repeated assessments of 
QTc prolongation in all study participant, and assess the impact of different IPTp regimens on 
the incidence of malaria during infancy. We will perform a randomized, double-blinded, 
controlled trial to compare IPTp with SP vs. DP delivered every 4 weeks starting as early in the 
2nd trimester as possible in an area of high transmission intensity and widespread antifolate 
resistance. Pregnant women will undergo frequent sampling using a highly sensitive molecular 
assay to better define the timing and frequency of malaria infection during pregnancy and the 
primary outcome will be based on a composite adverse birth outcome of low birth weight 
(LBW), preterm delivery, or small for gestational age (SGA). The overall theme of this proposal 
will be that in areas of high malaria transmission intensity where the burden of malaria remains 
high despite the use of currently available control interventions, aggressive and strategic use of 
highly effective drugs for IPTp may improve birth outcomes and reduce the risk of malaria 
during infancy.  
With respect to examining metabolites in newborns, given the established links 
between metabolic markers, gestational age, survival and morbidity, we suspect that this 
information may prove useful not only for determining gestational age when there is no 
ultrasound (a common occurrence in Uganda and in other developing countries), but we 
suspect that eventually, monitoring of these metabolites may provide useful information for 
tailoring care to an individual neonates’ metabolic profile. For example, carnitine levels might 
inform nutritional supplementation strategies given the link between total parenteral nutrition 
and carnitine deficiency which can impair fatty acid oxidation.68 In the context of the present 
study, we also suspect that these markers may prove useful for understanding immune 
patterns in some infants given that they may point to systems that are more or less mature. 
Such data may prove especially useful when evaluating drug efficacy. 
 
This metabolite assay is not validated for clinical use; therefore the results will not be routinely 
reported to clinicians or to participants and their families.  However, abnormal results from 
some chemicals in the assay can be associated with certain diseases.  Patterns of adult 
hemoglobins [HbA(A) and variants (S,C,D,E, B-thal)] as well as hemoglobin peak percentages 
(HGB-FAST, HGB-F1, HGB-F, HGB-F+F1, HGBFAST+ F1, HGB-Other, HGB-A] can suggest of Sickle 
Cell Disease (SCD) or other hemoglobinopathies like thalassemia.  The prevalence of sickle cell 
disease is ~ 1.5% in eastern Uganda, so it is quite likely that children with the disease will be in 
our study cohort of likely > 780 children69.  High levels of thyroid stimulating hormone (TSH) in 

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20 
the assay would be suggestive of hypothyroidism. The incidence of congenital hypothyroidism 
is generally considered to be ~ 1 in 2,000 to 4,000.70 There are no published precise estimates 
of the prevalence of congenital hypothyroidism in Uganda, but one small study of neonatal TSH 
levels suggests iodine deficiency is a persistent problem among neonates in Uganda.71  If this 
investigational assay yields values concerning for either SCD or hypothyroidism we will report 
the results to the parents and guardians and offer to perform additional testing using clinically 
validated assays to confirm or exclude the disease, free of charge. If the disease is confirmed, 
the study will offer care for these conditions during the study follow up free of charge, and 
referral to local providers at the end of the study.  The decision to act on the results of an 
investigational assay is based on the clinical and ethical rationale that early identification and 
treatment for these SCD and hypothyroidism has the potential to improve clinical outcomes for 
infants within the resources health care setting of Uganda.70  We believe that those potential 
benefits outweigh the risks, that include anxiety for families and phlebotomy for the cases 
shown to not actually have disease, risk from the additional phlebotomy for confirmatory 
testing, and risks of standard clinical treatment for the conditions if found to be present.   
Additional details about the management of test results and participant follow up are provided 
in Section 6.10.4. 
 
 
2. STUDY OBJECTIVES 
 
We will test the hypothesis that IPTp with DP will significantly reduce the burden of malaria in 
pregnancy and infancy compared to IPTp with SP. The specific study objectives are as follows: 
 
2.1. Objective 1 
 
To compare the risk of adverse birth outcomes among HIV-uninfected pregnant women 
randomized to receive IPTp with monthly SP vs. monthly DP. We will test the hypothesis that 
pregnant women who receive IPTp monthly DP will have a lower risk of a composite adverse 
birth outcome defined as LBW, preterm delivery or SGA compared to those who receive 
monthly SP. Secondary outcomes will include incidence of malaria and adverse events during 
pregnancy, risk of asymptomatic parasitemia and anemia during pregnancy, and measures of 
placental malaria at the time of delivery.  
 
2.2. Objective 2 
 
To compare the incidence of malaria among infants born to mothers randomized to receive 
IPTp with monthly SP vs. monthly DP. We will test the hypothesis that infants born to mothers 
randomized to IPTp with monthly DP will have a lower incidence of malaria in the 1st year of life 
compared to infants born to mothers randomized to IPTp with monthly SP. Secondary 
outcomes will include the incidence of complicated malaria, hospitalizations, infant mortality 
rate, and the prevalence of asymptomatic parasitemia and anemia. 
 

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2.3. Objective 3 
 
To validate and adapt a gestational dating by metabolic profile at birth algorithm and to 
evaluate the added benefits of using metabolic profile to identify newborns at increased risk 
for neonatal death or serious complications. We will test the hypotheses that a metabolic 
dating algorithm developed in a western setting can be applied to gestational dating in Uganda. 
We will also test the hypothesis that metabolic markers (especially those related to glucose 
metabolism) can be used to identify newborns at more or less risk for death and serious 
morbidities. 
 
2.4 Objective 4 
 
To evaluate experimental malaria diagnostic tests during pregnancy and infancy.  1) We will 
evaluate a Photo-Thermal Reader with the Ugandan public sector’s primarily used rapid 
diagnostic test (RDT), CareStart Pf HRP-2, and an experimental, highly-sensitive HRP2-based 
RDT to detect malaria parasites during pregnancy. We will estimate the sensitive and 
specificity of the Photo-Thermal Reader using a standard RDT and an experimental, highly-
sensitive RDT using quantitative PCR (qPCR) as the gold standard. RDT results will be used for 
research purposes only and not for clinical care.  2) We will evaluate the relative performance 
of a hemozoin-based rapid diagnostic test versus Ugandan public sector’s primarily used 
Rapid Diagnostic Test (RDT), CareStart Pf HRP-2, and an experimental, highly-sensitive HRP2-
based RDT to detect malaria parasites in infants. We will estimate the sensitivity and 
specificity of the Magneto-Optical Detection (MOD) test using standard RDT and microscopy 
test , using quantitative PCR (qPCR) as the gold standard. All results will be used for research 
purposes only and not for clinical care.  
 
 
3. STUDY DESIGN 
 
This will be a double-blinded randomized controlled phase III trial of 782 HIV uninfected 
pregnant women and the children born to them. HIV uninfected women at 12-20 weeks 
gestation will be randomized in equal proportions to one of two IPTp treatment arms: 1) 
monthly SP, or 2) monthly DP. Both interventions arms will have either SP or DP placebo to 
ensure adequate blinding is achieved in the study as outlined in appendix D. Follow-up for the 
pregnant women will end approximately 6 weeks after giving birth. All children born to mothers 
enrolled in the study will be followed from birth until they reach 12 months of age.  
 

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4. SELECTION AND ENROLLMENT OF SUBJECTS 
 
4.1. Inclusion Criteria 
 
1) Pregnancy confirmed by positive urine pregnancy test or intrauterine pregnancy by 
ultrasound 
2) Estimated gestational age between 12-20 weeks  
3) Confirmed to be HIV uninfected by rapid test 
4) 16 years of age or older 
5) Resident of Busia District, Uganda 
6) Provision of informed consent by the pregnant woman for herself and her unborn child 
7) Agreement to come to the study clinic for any febrile episode or other illness and avoid 
medications given outside the study protocol 
8) Plan to deliver in the hospital 
 
4.2. Exclusion Criteria 
 
1) History of serious adverse event to SP or DP 
2) Active medical problem requiring inpatient evaluation at the time of screening 
3) Intention of moving outside of Busia District, Uganda 
4) Chronic medical condition requiring frequent medical attention 
5) Prior SP preventive therapy or any other antimalarial therapy during this pregnancy 
6) Early or active labor (documented by cervical change with uterine contractions) 
 
4.3. Initial Screening 
 
 
We will recruit pregnant women presenting for routine care at the Masafu General Hospital 
antenatal clinic, at local health centers within Busia District, or referred by the Uganda 
government voluntary health teams. Pregnant women will be approached about participating 
in the study and will be provided an information sheet about the requirements of the study 
(Appendix A).  If women are initially agreeable to screening for participation in the study and 
are < 20 weeks gestation by LMP, 16 years of age or older, and not known to be HIV infected, 
they will either be escorted to the study clinic or made an appointment to return at a later date.  
At our study clinic study physicians will assess for initial eligibility criteria through conversation 
with the woman (confirming the age of the woman, location of residence, agreement to come 
to the study clinic for any febrile episode or other illness and avoid medications given outside 
the study protocol, plan to deliver in the hospital, no history of serious adverse event to SP or 
DP, no active medical problems requiring inpatient evaluation at the time of screening, no 
intention of moving outside the study district, no chronic medical condition requiring frequent 
medical attention, and no prior SP preventive therapy or any other antimalarial therapy during 

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23 
this pregnancy). Women who pass initial screening based on conversation with study physicians 
will undergo the following additional screening procedures: 1) rapid HIV testing to confirm HIV 
negative status, 2) ultrasound dating to confirm intrauterine pregnancy and gestational age of 
12-20 weeks in conjunction with LMP (Appendix B), and 3) a pelvic examination to exclude early 
or active labor if clinically indicated. Women who are not eligible for the study will be referred 
back to their local antenatal clinic. 
 
4.4. Study Enrollment Procedures and Baseline Evaluation 
 
Informed consent will be obtained from women who pass initial screening. Study physicians 
will conduct the informed consent discussion in the study clinic. Informed consent will include 
both participation of the pregnant woman and her unborn child (or children in the case of non-
singleton pregnancies). Informed consent will be conducted in the appropriate language and a 
translator will be used if necessary. The study will be described and consent obtained in one of 
4 languages (Samia, Swahili, Luganda, or English). The consent forms will be translated into 
each language and back-translated into English to check for any loss or change of meaning. 
Following the informed consent discussion, pregnant women will be asked by the study 
physicians to sign a written consent form approved by the UCSF Committee for Human 
Research (UCSF CHR), Makerere University School of Biomedical Sciences - Research and Ethics 
Committee (SBS-REC), and the Uganda National Council for Science and Technology (UNCST) for 
their own participation in the research study and a second approved consent form for the 
future use of biological specimens obtained during the course of the study.  If the pregnant 
woman is unable to read or write, her fingerprint will substitute for a signature, and a signature 
from an impartial witness to the informed consent procedures will be obtained. The father will 
also be asked to provide written consent or a fingerprint to allow participation of the unborn 
child. If a father is unknown or unavailable, the woman will document in accordance with 
UNCST guidance and participation will continue for both the woman and infant. If the biological 
father refuses consent for the child’s participation, the child will not be enrolled but the mother 
may still be enrolled.   
Women will be enrolled in study on the same day that they provide informed consent 
for participation in the research study.  On the day of enrollment, women will undergo a 
standardized history and physical examination, and have blood collected by venipuncture (15 
cc’s) for filter paper sample (for future molecular studies), routine baseline laboratory testing 
and storage.  Routine baseline laboratory testing will consist of a thick blood smear for malaria 
parasites (will be read later by laboratory technicians not involved in study participants care 
and will not used for clinical care), RDT testing including a standard RDT using a PTS reader and 
an experimental RDT (results will not be used for clinical care), qPCR for malaria parasites, CBC 
and ALT measurement. Women who have history of fever in the previous 24 hours or a 
temperature > 38.0ºC (tympanic) will have a thick blood smear read urgently in the study clinic.  
Women with history of fever in the previous 24 hours or a temperature > 38.0ºC (tympanic) 
and a positive blood smear will be diagnosed with malaria and treated as described in section 
6.2. At the end of the enrolment visit all study participants will be given a long lasting 
insecticide treated bed net (ITN) and a household survey appointment will be scheduled within 

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24 
2 weeks to collect household-level information on the use of bednets, house members, 
household characteristics, and GPS coordinates (Appendix C). 
 
 
5. STUDY TREATMENT 
 
5.1. Treatment Group Assignments 
There will be 2 treatment arms for the woman during pregnancy; monthly SP or monthly DP. 
We will use a 1:1 randomization scheme targeting 391 pregnant women in each treatment arm. 
A randomization list will be computer generated by a member of the project who will not be 
directly involved in the conduct of the study. The randomization list will include consecutive 
treatment numbers with corresponding random treatment assignments. Randomized codes will 
correspond to the 2 treatment arms using permuted variable sized blocks of 4 and 8. Sealed 
copies of the original randomization list and documentation of the procedure used to generate 
the lists will be stored in the project administrative offices in San Francisco and Kampala. Prior 
to the onset of the study, a set of sequentially numbered, opaque, sealed envelopes will be 
prepared.  Each envelope will be marked on the outside with the treatment allocation number. 
The inside of the envelope will contain a piece of paper with the treatment allocation number 
and treatment group assignment along with a piece of carbon paper.  
 
5.2. Treatment Allocation 
 
On the day of enrollment, pregnant women will be referred to a study pharmacist responsible 
for treatment allocation. The study pharmacist will assign treatment arms as follows: 
1. Select next available envelope 
2. Note treatment number on the outside of the envelope 
3. Write date, time, and study number on the outside of the envelope 
4. Open envelope 
5. Remove form containing code for treatment arm and date, time, and study number 
(transferred to form via carbon paper inside of envelope) 
6. Store form in lockable file box in study pharmacy 
7. Record onto the treatment allocation master list the study number, enrollment date, 
treatment assignment code, treatment arm, and study medications to be given during 
pregnancy 
8. Store treatment allocation Master list in a lockable cabinet in study pharmacy 
9. Record treatment number in the study participant’s file 
 
 
5.3. Study Drug Dosing and Formulations 

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25 
 
During pregnancy, women will be given 1 of 2 treatment regimens: 1) SP given every 4 weeks 
during pregnancy, or 2) DP given every 4 weeks during pregnancy. Each treatment with SP will 
be given as a single dose consisting of 3 full strength tablets. Each treatment with DP will 
consist of 3 full strength tablets given once a day for 3 consecutive days. In addition, placebos 
will be used to mimic the identical dosing strategy such that every 4 weeks women will receive 
two drugs on day 1 (SP and placebo or DP and placebo) followed by one drug on days 2 and 3 
(DP or placebo). Two placebos will be used, one that mimics the appearance of SP and one that 
mimics the appearance of DP. Dosing schedules for each treatment regimen according to 
gestational age are presented in Appendix D. The study drugs, DP (Duo-Cotecxin) and SP 
(Kamsidar) will be supplied by Holley-Cotec, Beijing and Kampala Pharmaceutical Industries 
(KPI), Uganda, respectively. Holley-Cotec will manufacture the DP placebo of exact 
specifications as that of the active DP. The DP placebo will be exactly the same in color, size, 
shape and packaging as the active DP.  KPI will manufacture the SP placebo of exact 
specifications as that of the active SP. The SP placebo will be exactly the same in color, size, 
shape and packaging as the active SP. Details of the study drug formulations are included in 
Table 1. 
 
Table 1. Drug formulation and labeling   
Drug 
Formulations 
Trade name (Manufacturer) 
Sulfadoxine-Pyrimethamine (SP) 
500mg/25mg tabs 
Kamsidar (KPI) 
Dihydroartemisinin-Piperaquine (DP) 
40mg/320mg tabs 
Duo-Cotexin (Holley-Cotec) 
 
5.4. Blinding, Study Drug Administration, and Duration 
 
Administration of all study drugs will be double blinded such that study participants and study 
staff will be blinded to study treatments with the exception of the study pharmacist and 
pharmacy technician, who will not be involved with patient care or assessment of study 
outcomes. All doses of study drugs will be prepackaged by a study pharmacist and administered 
by a study nurse blinded to the study participant’s treatment regimen. All doses of SP (or SP 
placebo) administered will be directly observed in the clinic. For DP (or DP placebo), the first of 
the 3 daily doses will be directly observed in the clinic and the 2nd and 3rd daily doses will be 
administered at home using pre-packaged study drugs in opaque envelopes with dosing 
instructions written on the outside. For doses of study drugs administered in the clinic, if a 
study participant vomits the study drug within 30 minutes of administration, the drug will be re-
administered. For doses of study drugs administered at home, if a study participant vomits the 
study drug within 30 minutes of administration or study drug is lost, the study participant will 
be instructed to come to the study clinic as soon as possible where the study drug will be re-

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26 
administered/replaced. For pregnant women all doses of study drugs will be given between 16 
and 40 weeks gestation as outlined in Appendix D.   
 
5.5. Study Drug Accountability 
 
The study pharmacist will maintain complete records of all study drugs received in the study 
pharmacy.  Lot number and number of pills given to each study participant will be recorded. A 
registry of all study medication, current product labels, and Certificates of Analysis, provided by 
suppliers will be maintained within the regulatory binder for the study.  The date received, lot 
number, expiration date, and date used will be recorded for each of the study medications.  
Monthly inventory of all study medications will be conducted and a record log of investigational 
medications will be kept at the study clinic.  
 
6. SUBJECT MANAGEMENT 
 
6.1. 
Subject Follow-up 
 
Pregnant women will be scheduled to be seen in the clinic every 4 weeks during their 
pregnancy and then 1 and 6 weeks following delivery. In addition, pregnant women will be 
instructed to come to the study clinic for all their medical care and avoid the use of any outside 
medications. Children will be scheduled to be seen in the clinic at 1, 4, 6, and 8 weeks of age 
and then every 4 weeks until they reach 52 weeks of age. Parents /guardians will be instructed 
to bring their children to the study clinic for all medical care and avoid the use of any outside 
medications. The study clinic will remain open 7 days a week from 8 a.m. to 5 p.m.  Pregnant 
women and children who are not seen on the day of their regularly scheduled visits will be 
visited at home and instructed to come to the clinic as soon as possible.  
 
Each time a study participant is seen in the clinic a standardized history and physical 
exam will be performed including temperature, pulse, and blood pressure measurement. 
Patients who are febrile (tympanic temperature > 3 8.0˚C) or report history of fever in the past 
24 hours will have blood obtained by finger prick for a thick blood smear (in very young 
children, heel sticks may be substituted for finger pricks). If the thick blood smear is positive, 
the patient will be diagnosed with malaria.  If the thick blood smear is negative, the patient will 
be managed by study physicians for a non-malarial febrile illness (Section 6.3).  If the patient is 
afebrile and does not report a recent fever, a thick blood smear will not be obtained, except 
when following routine testing schedules (Section 6.5).  
 
6.2. 
Diagnosis and Management of Malaria 
 

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Patients found to have malaria based on laboratory confirmation will have a second finger prick 
for a thin smear (to determine parasite species), hemoglobin measurement using a portable 
spectrophotometer (HemoCue), and collection of plasma, with residual blood used for testing 
of an experimental hemozoin-based rapid diagnostic test(MOD) or experimental magnetic 
levitation-based parasite detection (in children only).  All episodes of malaria will be classified 
as uncomplicated or complicated based on the following criteria:   
 
Uncomplicated malaria (all of the following) 
1) Fever (> 38.0ºC tympanic) or history of fever in the previous 24 hours 
  
2) Positive thick blood smear 
3) Absence of complicated malaria 
 
Complicated malaria (any of the following) 
1) Evidence of severe malaria (Appendix E) and parasitemia  
2) Danger signs present in children (Appendix E) and parasitemia 
 
Episodes of malaria will also be classified into the following categories according to the timing 
of previous malaria episodes for treatment purposes: 
1. New episodes of malaria will be defined as any first episode or any episode occurring > 
14 days after the diagnosis of a previous episode 
2. Treatment failures will be defined as any of the following: 
a. Complicated malaria occurring 1-14 days after the diagnosis of a previous 
episode 
b. Fever (> 38.0°C tympanic) or history of fever in the previous 24 hours with a 
parasite density > the parasite density of an episode of malaria diagnosed 2 days 
prior 
c. Fever (> 38.0°C tympanic) or history of fever in the previous 24 hours with a 
parasite density > 25% of the parasite density of an episode of malaria diagnosed 
3 days prior 
d. Fever (> 38.0°C tympanic) or history of fever in the previous 24 hours with a 
positive thick blood smear of any parasite density occurring 4-14 days after the 
diagnosis of a previous episode 
 
 
All patients diagnosed with new episodes of uncomplicated malaria will be prescribed 
AL, the recommended first-line treatment in Uganda for children and pregnant women in their 
2nd or 3rd trimester. Patients with complicated malaria will be prescribed quinine or artesunate 
according to national malaria treatment guidelines. Children who are less than 4 months of age 
or weigh <5kg, will be treated with quinine for uncomplicated malaria in accordance with the 

PROMOTE-II Birth Cohort 3 Protocol version 5.0, 27 Feb 2018 
28 
Uganda Ministry of Health Guidelines. Patients with treatment failure within 14 days following 
treatment with AL will be prescribed quinine according to national malaria treatment 
guidelines. Patients with treatment failure within 14 days following treatment with quinine or 
artesunate will be treated with quinine plus clindamycin or artesunate.  
 
6.3. 
Management of Non-Malaria Illnesses 
 
Patients who are found to have illnesses other than malaria will receive standard-of-care 
treatment in the study clinic, according to standardized algorithms, or will be referred to the 
local hospital.  We will avoid the routine use of non-study medications with antimalarial 
activity, including antifolates (with the exception of assigned chemopreventive regimens), and 
macrolide antibiotics, when acceptable alternatives are available. In addition, drugs with known 
risk of torsades de pointes or CYP3A inhibitors (Appendix J and K) will be avoided when 
prescribing treatment to pregnant women during the time they are taking study drugs. If the 
study clinician deems treatment with one of the drugs listed on Appendix J or K is required, the 
clinical management team will be consulted. During follow-up for non-malarial illnesses, blood 
smears will be done at the discretion of the study physician if the subjects are febrile (tympanic 
temperature > 38.0˚C) or report history of fever in the past 24 hours.  If the blood smear is 
positive, the patient will be diagnosed with a new episode of malaria and managed per study 
protocol.  
 
6.4. 
After Hours Visits 
 
Pregnant women will be encouraged to come to Masafu General Hospital maternity ward (open 
24 hours a day) and parents/guardians will be encouraged to bring their child to Masafu 
General Hospital pediatric inpatient ward (open 24 hours a day) when urgent care is needed 
outside of study clinic hours. Pregnant women or parents/guardians of children will be 
instructed to inform hospital personnel of their involvement in the study at the time of 
registration and to visit the study clinic on the following day. If a patient is diagnosed with 
uncomplicated malaria they will receive treatment from a hospital supply of AL and the doctors 
will be instructed to refer patients to our study clinic when it opens at 8 am the following day.  
If a patient is diagnosed with severe malaria, he/she will receive quinine or artesunate following 
standard treatment guidelines. Patients with non-malarial illnesses will be managed at the 
discretion of the hospital staff.  Upon discharge, patients will receive follow-up at the study 
clinic as outlined above.   
 
6.5. 
Routine Assessments 
 

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29 
Routine assessments will be done in the clinic every 4 weeks for both pregnant women and 
children. Study participants not seen in the clinic for their every 4 week routine visits will be 
visited at home and requested to come to the study clinic as soon as possible. Pregnant women 
and children will receive standards of care as designated in the Uganda MOH guidelines 
(Appendix F). Routine antenatal care will include screening and treatment for sexually 
transmitted Infections, blood pressure assessment, urine dipstick for proteinuria, prescription 
of iron, folate, multivitamins and mebendazole. Routine care in children will include 
immunizations, vitamin A supplementation, and management of anemia using Integrated 
Management of Childhood Illness (IMCI) guidelines. During routine assessments subjects will be 
asked about visits to outside health facilities and the use of any medications outside the study 
protocol.  The study protocol will be reinforced with discussion regarding the need to come to 
the study clinic promptly upon the onset of any illness and to avoid use of outside medications.  
Standardized assessment of adherence will also be done for study drugs administered at home 
and ITN use.  A routine history and physical exam will be performed using a standardized 
clinical assessment form.  Blood will be collected by finger prick (in very young children, heel 
sticks may be substituted for finger pricks) for thick smear; capillary plasma, RDT testing, qPCR 
(for routine visits where phlebotomy is not done); and filter paper samples. In a subset of visits, 
less than 10 µL of blood from finger prick or phlebotomy, if performed, will be used for 
magnetic levitation-based detection of malaria parasites. If a pregnant woman or 
parent/guardian of a child reports a fever in the last 24 hours or the patient has a documented 
temperature > 38.0˚C tympanic, the patient’s thick blood smear will be read immediately and if 
positive the patient will be diagnosed and treated for malaria (see section 6.2). In pregnant 
mothers, thick blood smears (other than those done when a mother has fever) and RDT testing 
will not be used for clinical care of study participants.  Phlebotomy for routine laboratory tests 
(CBC and ALT) to monitor for potential adverse events from study medications, storage of 
plasma, RDT testing using PTS reader and experimental RDT, qPCR, and for immunology studies 
will be performed every 8 weeks in pregnant women.  Phlebotomy for routine laboratory tests 
(hemoglobin measurement using a portable spectrophotometer (HemoCue Angholm, 
Sweden)), hemozoin based experimental rapid diagnostic test (experimentalMOD), standard 
RDT, microscopy, qPCR and immunology studies will be performed at 12, 28, and 52 weeks of 
age in children. For pregnant women, study drugs will be administered at the time of each 
routine visit as described in sections 5.3 and 5.4. ECGs will be performed to measure the QTc 
interval in all pregnant women just prior to the 1st dose of study drugs and 2-3 hours after their 
3rd dose of study drugs at 20, 28 and 36 weeks of gestation. In addition a finger prick capillary 
plasma sample will be collected just prior to performing the ECGs after the 3rd dose of study 
drugs at 20, 28, and 36 weeks of gestation in pregnant women. 
 
6.6. 
Delivery visit  

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30 
 
Addressing one of the study outcomes, placenta malaria, requires collection and processing of 
specimens at delivery. Systems will be in place to facilitate a birth plan which will encourage 
women to come to the hospital for delivery, including access to transportation 24 hours a day. 
However for women who are unable to travel to the hospital for delivery or choose to deliver at 
home, a study staff member will be driven to the home to follow study procedures.  Study staff 
will document details of the delivery, including date and time, type of delivery, estimated blood 
loss and any maternal, obstetrical or neonatal complications. Study staff will document the 
infant’s Apgar score and birth weight with calibrated scales. Biological samples collected at the 
time of delivery will include maternal venous blood (for thick blood smear, filter paper samples, 
CBC, ALT, and immunology studies), cord blood (for thick blood smear, filter paper samples, 
hemoglobin measurement, and immunology studies) and placental tissue.  Following delivery, 
neonatal care, as per national guidelines, will include polio and BCG immunization, ophthalmic 
tetracycline, and vitamin K. On the day of birth newborns will have a heel stick or finger prick 
done for collection of blood for metabolic testing.  
 
At the time of delivery, women will undergo repeat rapid HIV testing based on national 
guidelines. If women are found to have become HIV-infected during pregnancy, both the 
mother and their newborn will be withdrawn from the study and immediately referred for care 
following local prevention of mother-to-child transmission (PMTCT) guidelines.  
 
6.7. Postpartum visits.  
 
Women will be evaluated within 1 week following delivery and 6 weeks postpartum as part of 
routine care. Both visits will include an abdominal exam, syndromic management of STIs, and 
follow-up on any obstetrical complications that occurred including evaluation of the neonate 
for any congenital abnormalities. Pelvic and breast exam will be done if clinically indicated. 
Contraceptive counseling, nutritional assessment and infant feeding and support will be 
provided. Following the 6 weeks visit, women will no longer be considered study participants, 
although most will remain primary care givers for their children enrolled in the study. 
 
Summaries of all procedures done during routine visits in pregnant women and children are 
presented in Appendix G and H, respectively. 
 
6.8. Medical Care Outside the Study Clinic 
 
We will provide routine medical care in our clinic free of charge, including medications, to the 
extent possible given resources available. Study participants and their guardians will be 
reimbursed for costs of any transportation to and from our clinic.  In addition, we will 

PROMOTE-II Birth Cohort 3 Protocol version 5.0, 27 Feb 2018 
31 
reimburse the cost of tests and drugs for referrals of study participants made by study 
physicians to other clinics and services as well as after-hours hospital visits.  We anticipate 
reimbursing the cost of most diagnostic tests (including laboratory tests, X-rays, and 
ultrasounds) and medications resulting from these referrals, using available funds. However, 
reimbursement of all diagnostic tests and treatment recommended outside the study clinic 
cannot be guaranteed in all circumstances.  Decisions on reimbursement will be made by the 
study coordinator and the investigators, in conjunction with the funding agency if necessary.  
 
6.9. Duration of Follow-up and Criteria for Premature Study Withdrawal 
 
Pregnant women will be followed until their 6 week postpartum visit. Children will be followed 
until they reach 12 months of age. Study participants will be prematurely withdrawn from the 
study for: 1) movement out of study area, 2) inability to be located for > 60 consecutive days, 3) 
withdrawal of informed consent, 4) inability to comply with the study schedule and procedures, 
5) at the discretion of the site investigator if the study is not in the best interest of the 
participant, 6) subject or parent/guardian judged by the site investigator to be at significant risk 
of failing to comply with the study protocol as to cause them harm or seriously interfere with 
the validity of study results, 7) women found to have become HIV infected at the time of 
delivery (child withdrawal only). If a subject is withdrawn for reasons # 1-3, we will be unable to 
perform any additional study procedures.   If a subject is withdrawn for reasons # 4-6, plans to 
obtain appropriate follow-up tests outside of the study will be individualized for each subject 
depending on the health status of the subject at the time of withdrawal and the willingness of 
the participant and his or her parent/guardian to proceed with additional testing.  If a subject is 
withdrawn for #7, they will be referred for appropriate care following local PMTCT guidelines. 
 
6.10. 
Diagnostic and Laboratory Testing 
 
Diagnostic and laboratory testing shall take place using accredited local laboratories, as 
described below. In the event that local capacity is not available for specialized testing, 
reasonable efforts will be made to build local capacity. In the event that local capacity is not 
available, samples will be exported with all required permissions and permits to external testing 
laboratories. Table 2 lists examples of specialized testing, laboratories and rationale required to 
meet study aims.   

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32 
Table 2: Laboratory Evaluations Requiring Sample Export 
Evaluation 
Testing Laboratory 
Rationale 
Pharmacokinetic 
assessment of 
antimalarial drug levels 
UCSF Drug Research Unit  
Francesca Aweeka, PharmD 
University of California, San 
Francisco 
Department of Pharmacology 
Measure piperaquine concentrations 
in venous specimens using liquid 
chromatography/ tandem mass 
spectrometry (LC/MS-MS). Testing 
equipment and expertise not available 
in-country. 
Assessment of cord blood 
metabolites 
Iowa State Hygienic Laboratory 
Ankeny, Iowa 
Need for standardized mass 
spectrometry guidelines and referents 
Immunologic studies of 
infants 
Department of Pediatrics 
Margaret Feeney, MD 
University of California, San 
Francisco  
Division of Experimental 
Medicine 
Testing equipment and expertise not 
available in-country for high-
throughput immunologic assays, 
including RNA-sequencing  
 
 
6.10.1. 
Microscopy 
 
Thick and thin blood smears will be stained with 2% Giemsa and read by experienced laboratory 
technologists.  Parasite densities will be calculated by counting the number of asexual parasites 
per 200 leukocytes (or per 500 leukocytes, if the count is <10 asexual parasites/200 leukocytes), 
assuming a leukocyte count of 8,000/µl.  A blood smear will be considered negative when the 
examination of 100 high power fields does not reveal asexual parasites. Gametocytemia will 
also be determined from thick smears.  Thin smears will be used for parasite species 
identification.  For quality control, all slides will be read by a second microscopist and a third 
reviewer will settle any discrepant readings. 
 
6.10.2. 
Clinical Laboratory Studies 
 
At enrollment and every 8 weeks during follow-up for pregnant women venipuncture blood 
samples will be collected for routine clinical laboratory studies, including CBC and ALT 
measurements. In children venipuncture blood samples will be collected for a routine 
hemoglobin measurement using a portable spectrophotometer (HemoCue Angholm, Sweden)  
at 12, 28, and 52 weeks of age. Additional venipunctures will be performed, as appropriate, for 
laboratory testing to evaluate non-malarial medical illnesses at the discretion of study 
physicians. Results will be made available to study physicians in a timely manner for patient 
management decision-making. Additional hemoglobin measurements will be performed each 
time a patient is diagnosed with malaria using a portable spectrophotometer (HemoCue, 
Angholm, Sweden) and results will be immediately available.  

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33 
 
6.10.3. 
Placental Studies 
 
Cord blood will be collected for immunology studies described below. Placental blood collected 
for Giemsa-stained blood smears and future molecular studies will be obtained by making a 
small incision on the maternal surface of the placenta within 1 hour of delivery, collecting blood 
from the intervillous space via syringe, and then placing the blood in an EDTA tube. Placental 
tissue will be collected for histological assessment. Two 1 cm-wide full thickness biopsies from 
each placenta, obtained about 5 cm from the cord, will be obtained within 1 hour of delivery 
and placed in 10% neutral buffered formalin. Biopsy specimens will be embedded in paraffin 
wax, sectioned into 3 μM slices using a rotary microtome, fixed to glass slides, and dehydrated 
in sequential ethanol baths. Separate slides will then be stained in 0.1% hematoxylin and 1% 
eosin for 5 and 1 min, respectively, or in 2% Giemsa for 30 minutes. All necessary expertise and 
infrastructure for these studies is in place in Tororo. For assessment of histologic evidence of 
placental malaria, placentas will be graded into 5 categories using a standardized approach.72 
The presence of intervillous parasite-infected erythrocytes and of pigment in 
monocyte/macrophages or fibrin will be noted. Quantitative assessments of placental malaria 
will be as follows. First, 1000 intervillous blood cells will be counted under high power. 
Percentages of intervillous erythrocytes infected with parasites and of monocyte/macrophages 
containing malarial pigment will be counted. Placental specimens will be examined by two 
experts, and any discrepant readings will be resolved by a third reader. 
 
6.10.4. 
Molecular and Parasitology Studies 
 
Each time a thick blood smear is obtained; blood will also be collected onto filter paper. 
Samples will be collected by venipuncture or by finger prick sampling.  Blood will be placed onto 
filter paper in approximately 25 μl aliquots per blood spot (4 blood spots per sample).  The 
samples will be labeled with study numbers and dates, air-dried, and stored in small, sealed 
sample bags at ambient temperature or 4°C with desiccant.  Molecular studies will include the 
extraction of DNA from filter paper and followed by characterization of parasite genetics using 
standard molecular procedures including loop-mediated isothermal amplification (LAMP), DNA 
hybridization, and/or restriction enzyme digestion.  Additional molecular studies will include 
analyses of polymorphisms in parasite genes and measurement of piperaquine drug levels from 
plasma samples.  Molecular studies will be performed only for research purposes and will have 
no impact on the clinical management of study patients. Molecular studies will be formed in 
Uganda whenever possible and at UCSF when facilities/equipment are not available in Uganda. 
One exception will be for metabolic analyses of newborn bloodspots and cord blood for the 
purposes of gestational dating and examination of metabolite-outcomes relationships. Given 

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34 
the need to evaluate relationships using standardized mass spectrometry guidelines and 
referents, these tests will be done at the Iowa State Hygienic Laboratory in Ankeny, Iowa. 
Specimens will be collected using Gutherie card stock provided by the laboratory. Specifically, a 
5 millimeter spot of 1) blood collected by heel stick or finger prick and 2) cord blood at birth (< 
10 drops) will be deposited on card stock from the same lot that is provided by the Iowa lab. All 
specimens will be delivered to Iowa from Uganda by mail via freezer packs within one week of 
draw.  
Blood collected by venipuncture or finger prick on the day malaria in child is diagnosed 
will be used in selected subjects for parasite culture, experimental MOD, standard RDT, 
microscopy, qPCR, parasite detection by magnetic levitation, and/or immunology studies 
(below). For these studies the skin will be prepped with 3 washes with a betadine or equivalent 
sterilizing solution, and then approximately 3-5 mls of blood will be collected in an 
anticoagulated sterile tubes and transferred promptly (generally within 30 minutes) to our 
molecular laboratory. Parasites will be cultured following standard protocols. In brief, 
erythrocytes will be separated from plasma by centrifugation and removal of the supernatant 
and buffy coat, and the infected erythrocytes will then be cultured in RPMI medium 
supplemented with human serum or Albumax serum substitute. Cultured parasites will be 
evaluated for in vitro drug sensitivity, molecular characteristics, and other features to 
characterize antimalarial drug resistance and other aspects of malaria. Information from the 
parasitology studies will have no impact on patient care. 
CareStart Pf HRP-2 (Access Bio Inc USA) RDT testing using the PTS reader will be 
performed at enrollment and every 4 weeks at the time of routine visits during pregnancy. 
Approximately 5 µL of whole blood will be placed on the cartridge, which is inserted into the 
reader, and the reader will take approximately 1-3 minutes to complete the testing. The 
graphical user interface (GUI) guides the user through the assay process. Quantitative PCR will 
be performed at enrollment and at the time of routine visits using standardized procedures on 
~ 100ul of whole blood. A HRP2-based experimental RDT will be tested at enrollment and every 
8 weeks at the time of routine phlebotomy during pregnancy using ~ 100ul of whole blood. An 
RDT result will be considered positive if both the control line and the test line are visible after 
the development time.  A result will be considered negative if the control line is visible, but no 
test line appears.  The result will be considered invalid if no control line is visible, regardless of 
whether or not a test line appears. A hemozoin-based experimental rapid diagnostic test (MOD) 
will be performed at routine visits in a subset of children using ~ 50ul of whole blood collected 
by finger prick or phlebotomy. Approximately 50ul of whole blood will be placed in a special 
cuvette with a custom dilute, which is inserted into the sonicator and then the reader, and it 
will take approximately  2 minutes to complete the testing. For samples undergoing parasite 
detection by magnetic levitation, less than 10 µL of blood will be mixed with a paramagnetic 

PROMOTE-II Birth Cohort 3 Protocol version 5.0, 27 Feb 2018 
35 
agent such as gadolinium, placed in close proximity to the earth magnets, and visualized by 
microscopy and/or a magnified imaging system. 
 
Procedures for reporting and follow up of incidental concerning metabolite testing results 
Participants will be considered at elevated risk for Sickle Cell Disease (SCD) or Congenital 
Hypothyroidism (CH) according to the following criteria: 
• SCD: Patterns of adult hemoglobins [HbA(A) and variants (S,C,D,E, B-thal)] as well as 
hemoglobin peak percentages (HGB-FAST, HGB-F1, HGB-F, HGB-F+F1, HGBFAST+ F1, 
HGB-Other, HGB-A] based on the interpretation of the Iowa testing laboratory.  
• CH: thyroid stimulating hormone> levels >50 mIU/L from cord blood sample 
The metabolite laboratory will send results and IDs for all participants with concerning results. 
The Ugandan team will ask the participant and parents to come to clinic when the will explain 
that the metabolite testing results suggest the possibility of a disease, but do not constitute a 
true diagnosis.  The team will explain offer to perform confirmatory testing using standard 
clinical tests; if the participant is found to have the disease of concern, the study team will offer 
treatment free of charge. A blood specimen would then be obtained for confirmatory testing by 
a local commercial lab, including Hemoglobin Electrophoresis for concern of SCD and TSH and 
T4 testing for concern for hypothyroidism.   Patients will receive care for these conditions by 
the study team during study follow up and be referred to local providers for care at the 
conclusion of the study  
6.10.5. 
Immunology Studies 
 
Venipuncture blood samples collected at enrollment, during routine visits done every 8 weeks 
in pregnant women and at 12, 28, and 52 weeks of age in children, and in select subjects on the 
day malaria is diagnosed (above) will be made available for immunology studies. Approximately 
15mls of blood in pregnant women and 5mls of blood in children will be collected and 
separated into plasma and peripheral blood mononuclear cells (PBMC) using a Ficoll gradient, 
following standard protocols.  Plasma will be stored at -80°C for future immunology studies, 
which may include measurement of levels of cytokines, antibodies, and other features related 
to the host immune response.  PBMCs will be stored in liquid nitrogen to maintain viability, and 
will be evaluated using flow cytometry, ELISPOT, RT-PCR, gene expression microarrays and 
other assays to assess the host immune response.  Stool will be collected in in select children at 
4 and 52 weeks of age and stored for future studies analyzing the influence of parasitic and 
bacterial infections on immunity. Information from immunology studies will have no impact on 
patient care. Immunology studies will be done in Uganda whenever possible. However, due to 
technological limitations some immunology studies may be done at UCSF. 
 
6.10.6.   
Sample Storage for Future Use 
 

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Certain biologic specimens (placenta, filter paper, plasma, stool, and PBMC) will be stored in 
our laboratories for future molecular and immunology studies, pending participant consent for 
future use of biological specimens obtained during the course of the study. Samples will 
generally be stored in our laboratory in Tororo, Uganda.  Certain specimens requiring long term 
freezer storage (plasma, PBMC) may be transferred for long-term storage to our laboratory in 
Kampala, Uganda (IDRC Molecular laboratory) or a specialized specimen bank with our 
collaborators at UCSF (Department of Medicine, 1001 Potrero Avenue, Building 3, Room 511).   
With consent for future use, sample retention will generally be open ended. Samples that do 
not have consent for future use, as detailed above, will be destroyed upon completion of 
clinical studies. Samples will be destroyed following SOPs which comply with local regulations 
and guidance. 
 
6.11. 
Co-enrollment Guidelines  
 
The pregnant women and children from this study may be co-enrolled in observational studies.  
They may not be co-enrolled in protocols that utilize concomitant study medications. Co-
enrollment in other studies will be determined on a case-by-case basis by the protocol team. 
 
 
6.12. 
Management of Adverse Events Potentially Related to Study Drugs 
 
The following section outlines management of adverse events potentially related to study drugs 
(SP or DP) among pregnant women. Given the double blinded nature of the intervention, study 
clinicians and study participants will not be aware of what study drugs are being administered. 
Therefore all women will be considered potentially exposed to either study drug during the 
period study drugs are first given up to the completion of follow-up (6 weeks post-partum).  
 
6.13. 
Grade 1 or 2 Adverse Events 
 
Participants who develop grade 1 or 2 adverse events may continue study drugs.  The study 
clinicians will manage the grade 1 or 2 events according to standard practice.  
 
6.14. 
Grade 3 or 4 Adverse Events 
 
Management will be as follows: 
 
• Repeat observation or lab test within 72 hours of observation or of receiving lab results 
report. 

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37 
• Work-up to exclude other causes. 
• For grade 3 or non-life threatening grade 4 adverse events, subjects may continue taking 
study drugs pending clinic visit or repeat laboratory tests.  Clinician has the option of 
immediately stopping the study drugs if subject cannot be examined in clinic, if a repeat 
laboratory test cannot be performed within 72 hours, or if the clinician determines that the 
continuation of study drugs is unsafe while awaiting clinic exam or test results.  
• For grade 4 life-threatening adverse events, study clinicians should hold study drugs 
pending laboratory confirmation. 
• For all grade 3 or 4 adverse events supported by repeat clinical exam or laboratory test 
results, study drugs will be held, and laboratory tests will be repeated every 1-2 weeks, until 
the adverse event resolves to < grade 2 unless there is strong evidence that the adverse 
event is not related to either study drug.  
• If the adverse event persists at grade 3 or 4 for more than 28 days or recurs on re-challenge, 
and the adverse event is thought to be possibly related to one of the study drugs, the study 
drugs will be permanently discontinued.  
 
In the event that study drugs are permanently discontinued, study participants will remain in 
the study, following our intention-to-treat analysis approach. In the event that study drugs are 
permanently discontinued, study clinicians may become un-blinded to the study participant 
assigned treatment regimen if this knowledge may assist in the management of the grade 3 or 4 
adverse event(s) that lead to the permanent discontinuation of the study drugs. 
 
 
7. MONITORING OF ADVERSE EVENTS AND MANAGEMENT 
 
7.1. Monitoring and Reporting of Adverse Events 
 
7.1.1. Definitions 
 
An adverse event is defined as "any untoward medical occurrence in a patient or clinical 
investigation subject administered a pharmaceutical product that does not necessarily have a 
causal relationship with this treatment" (ICH Guidelines E2A).  An adverse event can further be 
broadly defined as any untoward deviation from baseline health, which includes:  
• Worsening of conditions present at the onset of the study 
• Deterioration due to the primary disease 
• Concurrent illness 
• Events related or possibly related to concomitant medications  

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38 
(International Centers for Tropical Disease Research Network Investigator Manual, Monitoring 
and Reporting Adverse Events, 2003).    
 
7.1.2. Identification of Adverse Events 
 
At each scheduled and unscheduled visit to the clinic, study clinicians will assess in all pregnant 
women who have started study drugs, according to a standardized case record form.  A severity 
grading scale, based on toxicity grading scales developed by the NIH Divisions of AIDS (DAIDS) 
and the Division of Microbiology and Infectious Diseases (DMID) Toxicity Tables, will be used to 
grade severity of all symptoms, physical exam findings, and laboratory results (Appendix I).  All 
pregnant women, regardless of treatment arm, will be assessed using the same standardized 
case record form.  Adverse event monitoring will occur during the period when study drugs are 
given and up to 6 weeks post-partum.  
 
Data will be captured on the incidence of all adverse events, regardless of severity. For each 
adverse event identified and graded as severe or life threatening and felt to be possibly, 
probably or definitely related to study drugs, an adverse event report form will be completed.  
In addition, an adverse event form will be completed for all serious adverse events and 
unexpected events, regardless of severity. An adverse event report form will not be completed 
for events classified as mild or moderate (unless they are serious or unexpected), as mild and 
moderate symptoms are common and difficult to distinguish from signs and symptoms due to 
malaria and other common illnesses.  The following information will be recorded for all adverse 
experiences that are reported:  
1) Description of event  
2) Date of event onset 
3) Date event reported 
4) Maximum severity of the event 
5) Maximum suspected relationship of the event to study drugs (either SP or DP)   
6) Whether the event is a serious adverse event 
7) Initials of the person reporting the event 
8) Outcome  
9) Date event resolved 
 
7.1.3. Reporting of Adverse Events 
 
Guidelines for reporting of adverse events provided by NICHD, UCSF Committee for Human 
Research (CHR), and the Food and Drug Administration (FDA) in the U.S. and the Makerere 

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39 
University IRB (SBSREC), and National Drug Authority (NDA) in Uganda will be followed as 
summarized in Table 2 below.  
 
Table 2. Guidelines for reporting adverse events 
Institution 
Type of Adverse Events 
When to Report 
UCSF-CHR 
External (off-site) Adverse Events are: 
• 
AEs that occur in study participants who 
are not enrolled at a UCSF or affiliated 
study site. These AEs occur at sites that 
are under the oversight of another IRB. 
• 
Not applicable 
MU-SBSREC 
• 
All Serious and Unexpected events 
irrespective of relationship 
• 
Fatal or life-threatening events 
within 3 working days of awareness  
• 
All other SAEs within 7 calendar days 
NDA 
• 
All Serious and Unexpected events 
irrespective of relationship 
• 
Within 7 calendar days of awareness 
FDA 
• 
Definitely, Probably or Possibly related 
AND BOTH Serious* AND Unexpected± 
• 
For fatal or life-threatening events, 
by telephone or fax within 7 
calendar days of first awareness 
• 
All other reportable events within 15 
calendar days of first awareness 
 
 
Serious Adverse Event (SAE) is any AE that results in any of the following outcomes:  
• Death,  
• Life-threatening adverse experience.  
• Inpatient hospitalization or prolongation of existing hospitalization,  
• Persistent or significant disability/incapacity,  
• Congenital anomaly/birth defect, or cancer, or  
• Any other experience that suggests a significant hazard, contraindication, side effect 
or precaution that may require medical or surgical intervention to prevent one of the 
outcomes listed above,  
• Event that changes the risk/benefit ratio of the study. 
 
Unexpected Adverse Event An adverse event is defined as being unexpected if the event 
exceeds the nature, severity, or frequency described in the protocol, consent form and 
investigator brochure (when applicable). An unexpected AE also includes any AE that meets any 
of the following criteria:  
• Results in subject withdrawal from study participation,  
• Due to an overdose of study medication, or  
• Due to a deviation from the study protocol  
 
8. STATISTICAL CONSIDERATIONS 
 
8.1. Hypothesis 1 
 

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40 
We will test the hypothesis that pregnant women who receive IPTp with monthly DP will have a 
lower risk of a composite adverse birth outcome defined as LBW, preterm delivery or SGA 
compared to those who receive monthly SP. Secondary outcomes will include incidence of 
malaria and adverse events during pregnancy, risk of asymptomatic parasitemia and anemia 
during pregnancy, and measures of placental malaria at the time of delivery. For women with 
non-singleton birth (i.e. twins), dichotomous delivery outcomes at the level of the individual 
child/placenta will be based on whether the outcome was present in either child/placenta. 
 
8.1.1. Primary Outcome 
 
The primary outcome will be the risk of having an adverse birth outcome defined as the 
occurrence of any of the following: 
4) Low birth weight (< 2500 gm) 
5) Preterm delivery (< 37 weeks gestational age) 
6) Small for gestational age (< 10th percentile relative to an external growth reference)73 
 
8.1.2. Secondary Outcomes 
 
Secondary outcomes are summarized in Table 3 below. 
 
Table 3. Secondary outcomes  
Secondary outcome 
Definition 
Placental malaria by histopathology 
Any evidence of placental infection (parasites or 
pigment) 
Placental parasitemia 
Proportion of placental blood samples positive for 
parasites by microscopy or LAMP 
Maternal malaria 
Any treatment for malaria during pregnancy 
Incidence of adverse events 
Adverse events stratified by type, severity score 
and relationship to study drugs 
Prevalence of anemia 
Proportion of routine hemoglobin measurements 
< 11 g/dL & < 8 g/dL 
Prevalence of asymptomatic 
parasitemia 
Proportion of routine monthly samples positive 
for parasites by microscopy and LAMP 
 
8.1.3. Analyses 
 
A modified intention-to-treat approach to all analyses will be used, including all study 
participants randomized to therapy and have the outcome of interest measured including all 

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41 
follow-up time until the study participants complete the study or early study termination 
regardless of whether the intervention was stopped due to an adverse event.  
 
Primary analysis. We will compare the risk of having any adverse birth outcome between the 
study arms using the Chi-Square or Fisher’s exact test. We will explore for any differences of 
potential confounders between the treatment arms and if necessary adjust our analysis using 
multivariate logistic regression. We will also perform sub-group analyses comparing the risks of 
having individual adverse birth outcome (LBW, preterm delivery, SGA) between the study arms 
using the Chi-Square or Fisher’s exact test. 
 
Secondary analyses. We will compare the prevalence of different definitions of placental 
malaria (placental parasitemia by microscopy, placental malaria by LAMP, placental malaria by 
histopathology) using the Chi-Square or Fisher’s exact test. We will compare the incidence of 
maternal malaria and adverse events using Poisson or negative binomial regression models. The 
Poisson models will include the logarithm of the follow-up time as an offset. We will translate 
the fitted coefficients and their confidence bounds into percentage effects with the formula 
100*[exp(coefficient)-1]. This approach is closely related to exponential survival models for 
analyzing events per follow-up time, but is better able to adjust for violated assumptions. 
Testing for overdispersion in the Poisson regression can detect violations of these assumptions, 
and variances can be adjusted accordingly to produce valid p-values and confidence interval.  If 
significant deviations from required distributions in study data are detected, we will employ 
negative-binomial or zero-inflated negative-binomial models to account for the observed 
pattern of data. We will compare the prevalence of maternal anemia and asymptomatic 
parasitemia using generalized estimating equations with adjustments for repeated measures in 
the same study participant. If necessary, multivariate analyses will be performed to adjust for 
potential confounders and effect modifiers.  
 
8.2. Hypothesis 2 
 
We will test the hypothesis that infants born to mothers randomized to IPTp with monthly DP 
will have a lower incidence of malaria in the 1st year of life compared to infants born to mothers 
randomized to IPTp with monthly SP. Secondary outcomes will include the incidence of 
complicated malaria, hospitalizations, infant mortality rate, and the prevalence of 
asymptomatic parasitemia and anemia. 
 
8.2.1. Primary Outcome 
 

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42 
The primary outcome will be the incidence of malaria, defined as the number of incident 
episodes per time at risk. Incident cases will include all treatments for malaria not proceeded by 
another treatment in the previous 14 days. Time at risk will begin at birth and will end when 
study participants reaches 12 months of age or early study termination (if prior to 12 months of 
age). 
 
8.2.2. Secondary Outcomes 
 
Secondary outcomes are summarized in Table 4 below. 
 
Table 4. Secondary outcomes  
Secondary outcome 
Definition 
Incidence of complicated malaria 
Any treatment for malaria meeting criteria for 
severe malaria or danger sings 
Incidence of hospital admissions 
Admission to the pediatric ward for any cause 
Infant mortality rate 
Any deaths occurring after birth 
Prevalence of anemia 
Proportion of routine hemoglobin measurements 
< 10 g/dL & < 8 g/dL 
Prevalence of asymptomatic 
parasitemia 
Proportion of routine samples (by microscopy or 
LAMP) positive for asexual parasites. 
 
8.2.3. Analyses 
 
A modified intention-to-treat approach to all analyses will be used, including all live infants 
born and including all follow-up time until the study participants reach 12 months of age or 
early study termination regardless of whether the infant’s mother received her assigned IPTp 
regimen.  
 
Primary analysis. We will compare the incidence of malaria using Poisson or negative binomial 
regression models as described in section 8.1.3. If necessary, multivariate analyses will be 
performed to adjust for potential confounders and effect modifiers.  
 
Secondary analyses. We will compare the incidence of complicated malaria and 
hospitalizations using Poisson or negative binomial regression models as described in section 
8.1.3. We will compare the prevalence of anemia and asymptomatic parasitemia using 
generalized estimating equations with adjustments for repeated measures in the same study 
participant. If necessary, multivariate analyses will be performed to adjust for potential 
confounders and effect modifiers. 

PROMOTE-II Birth Cohort 3 Protocol version 5.0, 27 Feb 2018 
43 
 
8.3. Hypothesis 3 
 
We will test the hypotheses that a metabolic dating algorithm developed in a western setting 
can also be used for gestational dating in Uganda. We will also test the hypothesis that 
metabolic markers – especially those related to glucose metabolism can be used to identify 
newborns at more or less risk for death and serious morbidities. 
 
8.3.1. Primary Outcomes 
 
The primary outcomes will be preterm birth (< 37 completed weeks gestation) as determined 
by ultrasound dating and an existing gestational dating by metabolic profile algorithm. With 
respect to newborn outcomes, primary outcomes will be survival to 24 hours, 48 hours, 7 days, 
30 days, and to the first year of life as well as diagnoses of any major morbidity including 
necrotizing enterocolitis, respiratory distress syndrome, and retinopathy of prematurity or 
blindness. 
 
8.3.2. Secondary Outcomes 
 
Secondary outcomes of interest include SGA birth outcome and the capacity of metabolic 
markers to correctly date a pregnancy in the context of intra-uterine growth restriction. Also, 
we will evaluate whether metabolic associations with survival and morbidity differ by SGA 
status. 
 
8.3.3. Analyses 
 
Analyses will focus on model validation for both the gestational dating and neonatal survival 
and morbidity using predictive models that have been or will be built using a population of 
more than 720,000 newborns in California using linear discriminate analyses.  
 
Primary analysis. We will compare categorization of a newborn as preterm or not and specific 
week of gestation using the metabolic algorithm versus ultrasound dating. We will also 
compare predicted survival and diagnoses based on metabolic prediction versus true events 
and diagnoses. Performance will be measured using sensitivity, specificity, positive predictive 
value, negative predictive value, positive likelihood ratio, and negative likelihood ratio. 
 

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Secondary analyses. We will compare performance statistics in newborns with and without 
SGA (sensitivity, specificity, positive predictive value, negative predictive value, positive 
likelihood ratio, and negative likelihood ratio). 
 
 
8.4.    Sample size and power  
 
The number of pregnant women enrolled and the number of study participants reaching the 
various endpoints will determine the samples sizes for each of the primary outcomes of our 
study aims. The primary determinant of our target sample size was based on testing hypotheses 
1. Based on our previous studies, we estimate that 95% of pregnant women enrolled will reach 
the primary study endpoint and we will lose 5% of follow-up time per year in the infants. The 
study will be powered to detect a significant difference in the risk of our composite adverse 
birth outcome between the 2 study arms. Considering pregnancies resulting in either low birth 
weight (< 2500 gm), small for gestational age, or premature delivery (< 37 weeks) in our 
previous study, the risk was 21.4% in the monthly DP arm compared to 30.4% in the 3 dose SP 
arm. Assuming the same risks, we would need to enroll 782 women (assuming 5% loss to 
follow-up during pregnancy) to have 80% power (2-side alpha = 0.05) to detect a 30% or greater 
reduction in the relative risk of our composite birth outcome. For hypothesis 2, we will have 
80% power (2-side alpha = 0.05) to detect an 18-23% relative difference in the incidence of 
malaria between 0-12 months of age among children born to mothers randomized to the 2 IPTp 
arms assuming an incidence of malaria ranging from 3-5 episodes PPY among children born to 
mothers randomized to receive IPTp with monthly SP. Hypothesis 3 relies on the collected study 
data and samples to validate existing gestational dating, survival, and morbidity algorithms and 
as such, no limitations in statistical power are anticipated. 
 
8.5. 
Data and Safety Monitoring Plan 
 
The proposed study will conform to rigorous standard monitoring procedures, standardized 
reporting of adverse events (Adverse Event Report Forms are completed by study coordinators 
and sent immediately to the investigators), and regular review of the study by a Data and Safety 
Monitoring Board (DSMB). The PI has primary responsibility for the overall conduct of the 
study, including the safety of human subjects. The PI will ensure appropriate (1) conduct of the 
informed consent process (e.g. that informed consent is obtained before proceeding with study 
procedures); (2) enrollment of study subjects; (3) collection and analysis of data; (4) 
implementation of study procedures to ensure consistent monitoring of subjects for possible 
adverse events; (5) review of adverse events and reporting to the DSMB and the IRBs; and (6) 
maintenance of the privacy and confidentiality of study subjects. The PI maintains ultimate 

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45 
responsibility for the project and for the safety of study participants.  The PI will be in contact 
with the research team on a regular basis to review the progress of the study and address any 
human subject issues that occur. These discussions may involve adverse event prevention 
measures, recruiting of appropriate study subjects, research staff training on protection of 
human subjects, as well as occurrence of adverse events, unexpected incidents, or protocol 
problems. 
 
8.5.1. Data and Safety Monitoring Board 
 
A DSMB will be established by the study team in cooperation with the sponsor to assess at 
intervals the progress of a clinical trial, safety data, and critical efficacy variables and 
recommend to the sponsor whether to continue, modify or terminate a trial. The DSMB will 
have written operating procedures and maintain records of all its meetings, including interim 
results; these will be available for review when the trial is complete. The DSMB will be a 
separate entity from the US and host-country Institutional Review Boards (IRBs). The 
independence of the DSMB is intended to control the sharing of important comparative 
information and to protect the integrity of the clinical trial from adverse impact resulting from 
access to trial information.  DSMB members will not participate in the study as investigators 
and will not have conflicts of interest regarding the study or the investigational product. The 
composition of the DSMB will include at minimum: 
 
DSMB Chair, having experience and expertise in clinical trials 
Scientist with expertise in malaria and malaria inpregnancy 
Biostatistician with expertise in clinical trials. 
 
A member of the sponsor, NICHD, will be invited to attend and thus have access to unblinded 
information, and control of dissemination of interim trial results within the sponsor 
organization. The DSMB will meet at least annually to review progress of the clinical trial and 
safety data.   
 
The DSMB will review the study for progress and safety. The PI will provide information that will 
allow the DSMB to review and assess the following: 
• The research protocol, informed consent documents and plans for data safety 
and monitoring;   
• Periodic assessments of data quality and timeliness, participant recruitment, 
accrual and retention, participant risk versus benefit, and other factors that can 
affect study outcome;  
• Factors external to the study when relevant information, such as scientific or 

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46 
therapeutic developments, may have an impact on the safety of the participants 
or the ethics of the trial;   
• Study performance to make recommendations and assist in the resolution of 
problems;    
• The safety of the study participants;   
• The safety and scientific progress of the trial;  
• The continuation, termination or other modifications of the trial based on the 
observed beneficial or adverse effects of the treatment under study;   
• The confidentiality of the data and the results of monitoring; and  
• Any problems with study conduct, enrollment, sample size and/or data collection. 
 
The first meeting of the DSMB will take place prior to the initiation of the study to discuss the 
protocol and the Data Safety Monitoring Plan.  Meetings of the DSMB shall be held according to 
the plan outlined above. Meetings shall be closed to the public because discussions may 
address confidential patient data. Meetings may be convened as conference calls as well as in 
person. An emergency meeting of the Board may be called at any time should questions of 
patient safety arise. The DSMB may request the presence of study investigators at such 
meetings.  
 
The study PI will distribute study information to the DSMB at least 10 days prior to a scheduled 
meeting. The DSMB may request additions and other modifications to this information on a 
one-time or continuing basis. This information will consist of two parts: (1) information on 
study progress such as accrual, baseline characteristics, and other general information on study 
status and (2) any confidential data on study outcomes, including safety data. A formal report 
from the DSMB should be supplied to the PI within 6 weeks of each meeting. Each report 
should conclude with a recommendation to continue or to terminate the study. This 
recommendation should be made by formal majority vote. A recommendation to terminate the 
study should be transmitted to the PI, IRBs and NIH as rapidly as possible, by immediate 
telephone and fax if sufficiently urgent. In the event of a split vote in favor of continuation, a 
minority report should be contained within the regular DSMB report. 
 
 
8.5.2. Interim safety analysis 
 
Over the course of the trial, we will perform one interim safety analysis in addition to a final 
safety analysis for a total of two sequential evaluations of study safety for the pregnant women.  
The interim safety analysis will be performed when ½ of the study subjects have given birth. A 
standardized test statistic will be calculated for the incident rate ratio of significant adverse 

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47 
events (grade 3/4 & SAEs). If this statistic exceeds the nominal critical value calculated using the 
error spending function (Table 5), then a statistically significant result will have been achieved 
at the time of that analysis.  In that event, the sponsor will be notified and a report submitted 
for review by the Data Safety Monitoring Board (DSMB). The study team will present the results 
of the interim safety analyses to the DSMB, which will review the data and recommend a 
course of action.  
 
Table 5. Schedule of interim safety analysis and boundaries to monitor study outcome  
Number of Evaluable Subjects Accrued  
or % of Total Accrual  
Test Statistic 
Alpha 
Cumulative  
Alpha 
Lower Bound Upper Bound 
N=391 or 50% of accrual 
-2.51 
2.51 
0.00601 
0.01210 
N=782 or 100% of accrual 
-1.99 
1.99 
0.02313 
0.05000 
This analysis assumes α=0.05 (two-sided test), O’Brien-Fleming boundaries (DeMets error-
spending function) and 782 trial participants. We will utilize Programs for Computing Group 
Sequential Boundaries Using the Lan-DeMets Method. 
 
8.5.3. Stopping rules 
 
The DSMB will determine whether to stop the study for early evidence of intervention safety 
problems after a thorough review of interim data. Interim reports will provide cumulative 
enrollment figures and cumulative adverse birth outcomes, serious adverse events (classified 
according to grade), sorted by study arm. Brief clinical descriptions of key events will also be 
provided. The PI will be responsible for immediately reporting to the funding agency any 
temporary or permanent suspension of the project and the reason for the suspension.  
 
9. DATA COLLECTION AND MONITORING 
 
9.5. 
Record Keeping  
 
All clinical data will be recorded onto standardized case record forms (CRFs) by study clinicians.  
Blood smear results will be recorded in a laboratory record book by the study laboratory 
technologists and then transferred to the case record forms by study coordinators, who will 
review the case record forms frequently for completeness and accuracy.  Other laboratory data 
(CBC, ALT measurements) will be entered into the CRFs and hard copies of the original results 
will be stored in a file. Data will be entered directly from CRFs into a computerized database or 
transferred from the CRFs onto standardized data extraction forms and then into a 
computerized database.  All computerized data will be double entered to verify accuracy of 
entry.  Electronic data including all study databases and supporting electronic documentation 

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will be archived to large-scale digital tape on a daily basis.  On a monthly basis, a complete 
backup tape will be transported off-site to the Kampala Data Management Center for rotating 
secure storage.  
 
9.6. 
Data Quality Assurance and Monitoring  
 
In order to insure data quality, the study Data Manager will perform a quarterly data quality 
audit.  For this audit a 1% random sample of study forms entered into the data management 
system from the previous 2 weeks will be selected and compared for accuracy with the original 
case-report forms and source documents.  In addition the study Data Manager will perform 
monthly reviews of the 100% double data entry data verification logs and the data 
management system audit trail log to identify potential data quality issues. The data will be 
owned by the Makerere University-University of California, San Francisco Research 
Collaboration. 
 
 
10. HUMAN SUBJECTS 
 
10.5. Subject Selection Criteria 
 
Study subjects will be HIV-uninfected pregnant women and the children born to them who 
meet our selection criteria and provide informed consent.  We plan to recruit only Ugandan 
residents and will recruit both pregnant women age 16 and above and male or female children.   
 
10.6. Risks and Discomforts 
 
10.6.1. Privacy 
 
Care will be taken to protect the privacy of subjects, as described in this protocol. However, 
there is a risk that others may inadvertently see patients’ medical information, and thus their 
privacy may be compromised.  
 
10.6.2. Finger Pricks, Heel Sticks, and Venipuncture 
 
Risks of these procedures include pain, transient bleeding and soft-tissue infection. 
 
Risks of Study Medications 
Risk of Sulfadoxine-Pyrimethamine 

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Although technically a combination regimen, SP is generally considered a single antimalarial 
agent, as its success depends on the synergistic action of its two component inhibitors of folate 
synthesis. SP is currently the standard of care of IPTp throughout sub-Saharan Africa. Adverse 
reactions listed on the SP package insert are blood dyscrasias (agranulocytosis, aplastic anemia, 
thrombocytopenia), allergic reactions (erythema multiforme and other dermatological 
conditions), gastrointestinal reactions (glossitis, stomatitis, nausea, emesis, abdominal pain, 
hepatitis, diarrhea), central nervous system reactions (headache, peripheral neuritis, 
convulsions, ataxia, hallucinations), respiratory reactions (pulmonary infiltrates), and 
miscellaneous reactions (fever, chills, nephrosis); based on widespread experience with the 
drug, all of these reactions appear to be uncommon or rare with short-term therapeutic use. 
The best-documented severe adverse effects with SP are cutaneous reactions, primarily noted 
when SP was used for long-term chemoprophylaxis in non-African populations. Reported rates 
of serious reactions to SP in the UK, with long-term use for chemoprophylaxis, were 1:2100, 
with 1:4900 serious dermatological reactions and 1:11,100 deaths.74 Estimated rates of toxicity 
in the US were 1:5000-8000 severe cutaneous reactions and 1:11,000-25,000 deaths.75 Clinical 
experience suggests that risks of severe toxicity are much lower with malaria treatment 
regimens in Africa.  
 
The WHO currently recommends IPTp with SP in areas with moderate-to-high malaria 
transmission.28 In a recent systematic review and meta-analysis of 7 trials from sub-Saharan 
Africa, IPTp with 3 or more doses of SP was associated with a higher birth weight and lower risk 
of low birth weight compared to 2 doses of SP. In addition there were no differences in the 
rates of serious adverse events between the two groups.76  
 
Risk of Dihydroartemisinin-piperaquine 
 
Risks associated with DP among adults and children. Minyt and colleagues conducted a 
systematic review of DP efficacy and safety for treatment of malaria using data from 14 clinical 
trials involving adults and children.77 There were 2636 study participants treated with DP in 13 
trials in which safety data were reported. Overall, DP was associated with fewer adverse events 
compared to comparator medications. The most common adverse events were dizziness, 
nausea and vomiting, though generally the medication was well-tolerated by both adults and 
children (Table 6). Of note, the only serious adverse events in these 14 studies included 5 
deaths (2 adults, 3 children) that were thought unrelated to DP.  
 

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Table 6. Summary of adverse events following treatment with dihydroartemisinin-piperaquine 
 
More recently Lwin et al conducted a randomized controlled trial of monthly vs. bimonthly DP 
IPT among 961 adults at high risk of malaria at the Northwest border of Thailand.78 Overall, 69% 
of the participants included in the final analysis reported at least one adverse event. There was 
no difference in the proportion of those reporting at least one adverse event among 
participants in the monthly vs. bimonthly vs. placebo arms. There was an increased risk of joint 
pain among participants randomized to the placebo arm, but otherwise there were no 
differences noted in adverse events by study arm. There was only one serious adverse event 
not related to the use of DP (Table 7).   
 

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Table 7. Frequency, incidence, and risk of the 20 most frequently reported adverse events  
 
 
Risks associated the use of DP for IPT in infants. Relevant to this protocol is the PROMOTE 
Chemoprevention study, an open label randomized clinical trial conducted by our group 
evaluating the protective efficacy of 3 different chemoprevention regimens against malaria 
compared to the current standard of care of no chemoprevention. This was the first study to 
evaluate the safety of DP when used for IPT in infants. DP was shown to be very well-tolerated 
and associated with a significantly lower rate of all grade 3-4 adverse events, elevated 
temperature, anemia, and thrombocytopenia compared to the control arm (Table 8).79 In 
addition, 145 ECGs performed 19 study participants randomized to DP documented all QTc 
intervals to be within normal limits. 
 
 

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52 
Table 8. Comparison of adverse events among children between 6-24 months of age 
Characteristic 
Number of events (incidence per PYAR) by treatment arm 
Control 
Monthly SP 
Daily TS 
Monthly DP 
All grade 3-4 adverse events 
169 (1·159) 
202 (1·415) 
135 (0·914) 
87 (0·611) ‡ 
All serious adverse events 
26 (0·178) 
52 (0·364) 
29 (0·196) 
13 (0·091) 
Grade 3-4 adverse events possibly related to study drugs 
N/A 
8 (0·056) 
8 (0·054) 
3 (0·021) 
Individual grade 3-4 adverse events* 
     Elevated temperature 
     Anaemia 
     Thrombocytopenia 
     Elevated aspartate aminotransferase 
     Elevated alanine aminotransferase 
     Neutropenia 
 
79 (0·542) 
56 (0·384) 
18 (0·123) 
7 (0·048) 
4 (0·027) 
3 (0·021) 
 
78 (0·546) 
86 (0·602) 
17 (0·119) 
8 (0·056) 
4 (0·028) 
6 (0·042) 
 
58 (0·393) 
47 (0·318) 
9 (0·061) 
6 (0·041) 
4 (0·027) 
2 (0·014) 
 
46 (0·323) † 
24 (0·168) † 
5 (0·035)α 
3 (0·021) 
3 (0·021) 
1 (0·007) 
PYAR = person-years at risk.  
SP = sulfadoxine-pyrimethamine. TS = trimethoprim-sulfamethoxazole. DP = dihydroartemisinin-piperaquine. 
* Only includes those with at least 5 total events.  
α p-value < 0.05 compared to control group; † p-value < 0.01 compared to control group; ‡ p-value < 0.001 compared to control 
group. 
 
Risks associated with DP during pregnancy. While data are limited, preclinical animal studies 80-
82 and clinical studies involving pregnant women 22,23 have not demonstrated significant safety 
concerns with the use of DP. In a recent study from Kenya, serious adverse events were less 
frequent in women randomized to IPTp with DP compared to women randomized to IPTp with 
SP.25 In a recent study from our group comparing IPTp with 3 dose SP vs. 3 dose DP vs. monthly 
DP in Tororo Uganda, study drugs were well tolerated and there were no significant differences 
in the risk of adverse events.26 Vomiting occurred < 0.2% of the time after administration of 
study drugs with no differences between study arms (Table 9). There were no significant 
differences in the incidence of any adverse events apart from dysphagia, which was higher in 
the monthly DP arm compared to the 3 dose DP arm. All episodes of dysphagia were mild in 
severity and we are not aware of any previous reports of DP being associated with dysphagia. 
Only one grade 3-4 adverse event was possibly related to study drugs; an episode of anemia 
which occurred both after the 1st and 2nd doses of monthly DP (study drug was subsequently 
withheld after the 2nd dose)(Table 9). Among 42 women who underwent ECG measurements at 
28 weeks gestational age, all pre- and post-dosing QTc intervals were within normal limits (< 
450 msec) and no clinical adverse events consistent with cardiotoxicity occurred during the 
course of the study. Median change in QTc intervals was greater in the 3 dose DP (20 msec) and 
monthly DP (30 msec) arms compared to the 3 dose SP arm (5 msec), but these differences 
were not statistically significant. 
 

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Table 9. Measures of safety and tolerability from recent IPTp study conducted in Tororo, Uganda 
Outcome 
Treatment arm 
3 dose SP 
3 dose DP 
Monthly DP 
Prevalence measures 
no./total no. (%) 
no./total no. (%) 
no./total no. (%) 
Vomiting following administration of study drugs 
 
 
 
   Observed after administration of 1st dose in clinic 
2/617 (0.32) 
0/542 (0) 
1/594 (0.17) 
   Reported after administration of 2nd or 3rd dose at home 
2/1222 (0.16) 
0/1067 (0) 
5/1180 (0.42) 
Incidence measures 
Events a 
Events a 
Events a 
Individual adverse events of any severity b 
 
 
 
   Abdominal pain 
172 (3.14) 
122 (2.52) 
132 (2.47) 
   Cough 
94 (1.72) 
71 (1.47) 
77 (1.44) 
   Headache 
90 (1.64) 
70 (1.45) 
78 (1.46) 
   Chills 
21 (0.38) 
14 (0.29) 
12 (0.22) 
   Diarrhea 
12 (0.22) 
10 (0.21) 
13 (0.24) 
   Malaise 
16 (0.29) 
9 (0.19) 
8 (0.15) 
   Dysphagia 
9 (0.16) 
2 (0.04) 
14 (0.26) c 
   Vomiting 
8 (0.15) 
8 (0.17) 
8 (0.15) 
   Nausea 
2 (0.04) 
4 (0.08) 
2 (0.04) 
   Urinary tract infection 
3 (0.05) 
2 (0.04) 
2 (0.04) 
   Anorexia 
2 (0.04) 
0 (0) 
4 (0.07) 
Individual grade 3-4 adverse events 
 
 
 
   Anemia 
12 (0.22) 
4 (0.08) 
6 (0.11) 
   Congenital anomaly 
2 (0.04) 
4 (0.08) 
0 (0) 
   Stillbirth 
1 (0.02) 
1 (0.02) 
1 (0.02) 
   Thrombocytopenia 
2 (0.04) 
0 (0) 
0 (0) 
   Threatened abortion 
1 (0.02) 
0 (0) 
0 (0) 
   Retained products of conception 
0 (0) 
1 (0.02) 
0 (0) 
   Preeclampsia 
0 (0) 
0 (0) 
1 (0.02) 
   Hypotension 
0 (0) 
0 (0) 
1 (0.02) 
   Pyelonephritis 
0 (0) 
1 (0.02) 
0 (0) 
   Respiratory distress 
0 (0) 
1 (0.02) 
0 (0) 
All grade 3-4 adverse events 
18 (0.33) 
12 (0.25) 
9 (0.17) 
Grade 3-4 adverse events possibly related to study drugs 
0 (0) 
0 (0) 
1 (0.02) 
All serious adverse events 
6 (0.11) 
9 (0.19) 
4 (0.07) 
a Number of events (incidence per person year at risk) 
b Includes only those categories with at least five total events 
c P=0.02 comparing monthly DP with 3 dose DP 
 
10.6.4 Risks of reporting and treatment of incidental findings 
Reporting the results of the experimental metabolite assay: Risks undue anxiety in families about diagnoses and 
child may not ultimately have. 
 
Treatment of hypothyroidism incidentally identified by study procedures: Risks of standard of care treatment 
include the side effects of treatment with thyroxine which include tachycardia, arrhythmias, and aspiration from avid 
suckling. 
 
Treatment of sickle cell disease incidentally identified by study procedures: Risks of standard of care treatment of 
sickle cell disease include the side effects of folate which include flushing and allergic reaction, and antibiotic 
prophylaxis, which include allergic reaction, serum sickness, and hemolytic anemia. 
 
10.7 Treatment and Compensation for Injury  
 

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If the participant is injured as a result of being in this study, treatment will be available through 
Masafu General Hospital.  The costs of the treatment may be covered by the study sponsor, 
NICHD, depending on a number of factors.  A clinical trial liability insurance policy has been 
provided to cover all trial participants for “Bodily injury” caused to the health of the person 
provided that causal-connection between harm, bodily injury or death resulting from 
participation in the trial is established.  
10.8 Costs to the Subjects  
 
There will be no cost to the participant or their parents/guardians for participation in this study. 
 
10.9 Reimbursement of Subjects 
 
Participants will not be paid for their participation in the study. The study will provide all 
routine medical care, including evaluations, medications available in our clinic, and cost of any 
transportation free of charge. In addition, we will reimburse the cost of consultation for 
referrals made by study physicians to other clinics and services and visits the cost of most 
diagnostic tests (including laboratory test, X-rays, and ultrasounds) and medications resulting 
from referrals by the study team, using available funds. However, reimbursement of all 
diagnostic tests and treatment recommended outside the study clinic cannot be guaranteed in 
all circumstances. 
10.10  Institutional Review Board (IRB) Review and Informed Consent  
 
This protocol, all procedures and consent forms, and any subsequent modifications must be 
reviewed and approved by the IRBs of all the participating institutions in both the U.S. and in 
Uganda. This includes the UCSF Committee on Human Research (CHR), the MU School of 
Medicine - Research and Ethics Committee (SOM-REC) or MU School of Biomedical Sciences – 
Research and Ethics Committee (SBS-REC), and the Uganda National Council of Science and 
Technology (UNCST). 
 
All consent forms will be translated into the local languages (Samia, Swahili, Luganda, and 
English) and back-translated into English to ensure correct use of language. Consent forms will 
be read aloud to parents by trained study interviewers. The informed consent will describe the 
purpose of the study, all the procedures involved, and the risks and benefits of participation. 
Study physicians will ask parents/guardians of study participants to summarize the study and 
explain the reasons why they want to participate. Either a signature or a thumbprint (for 
parents/guardians who cannot read) will be acceptable to confirm informed consent for 
participation in the study.  
 

PROMOTE-II Birth Cohort 3 Protocol version 5.0, 27 Feb 2018 
55 
Participant’s parents / guardians will be approached to have the "consent amendment" explained, 
and then either sign or decline participation at a routine visit.  If an urgent value in the metabolite 
assay has prompted follow up prior to the next scheduled visit, they will be contacted by phone 
and asked to come to the study clinic to review test results; the consent amendment will be 
reviewed and consent obtained/declined at that time. “ 
 
10.11 
Definition of Parent/Guardianship.   
 
For this study, we will define a parent/primary guardian of the child enrolled in the study as the 
women giving birth to the child. However to the extent possible, consent of the father will be 
also obtained.  
 
12. 
PUBLICATION OF RESEARCH FINDINGS  
 
The findings from this study may be published in a medical journal.  No individual identities will 
be used in any reports or publications resulting from the study. The researchers will publish 
results of the trial in accordance with NICHD, UNCST, UCSF, and Makerere University guidelines.  
 
 
13. 
BIOHAZARD CONTAINMENT 
 
As the transmission of HIV and other blood-borne pathogens can occur through contact with 
contaminated needles, blood, and blood products, appropriate blood and secretion precautions 
will be employed by all personnel involved in the drawing of blood, exposure to blood and 
secretions, and shipping and handling of all specimens for this study. We will follow the current 
guidelines set forth by the Centers for Disease Control and Prevention and the NIH.  All 
infectious specimens will be transported using packaging mandated in the Federal Code of 
Regulations, CDC 42 CFR Part 72. 
 
14.  
REFERENCES 
 
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37. 
Mutabingwa TK, Bolla MC, Li JL, et al. Maternal malaria and gravidity interact to 
modify infant susceptibility to malaria. PLoS medicine 2005; 2(12): e407. 
38. 
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in the first 30 months of life. Clinical infectious diseases : an official publication of the 
Infectious Diseases Society of America 2008; 47(8): 1017-25. 
39. 
De T, Kruthika-Vinod TP, Nagaraja D, Christopher R. Postnatal variations in blood free 
and acylcarnitines. J Clin Lab Anal 2011; 25(2): 126-9. 
40. 
Honzik T, Chrastina R, Hansikova H, et al. Carnitine concentrations in term and preterm 
newborns at birth and during the first days of life. Prague Med Rep 2005; 106(3): 297-306. 
41. 
Mandour I, El Gayar D, Amin M, Farid TM, Ali AA. Amino acid and acylcarnitine 
profiles in premature neonates: a pilot study. Indian J Pediatr 2013; 80(9): 736-44. 
42. 
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common complications of prematurity. Pediatr Res 2013; 73(6): 700-5. 
43. 
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JC. Metabolic heritability at birth: implications for chronic disease research. Hum Genet 2014; 
133(8): 1049-57. 
44. 
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of preterm birth associated with neonatal thyroid stimulating hormone. J Pediatr Endocrinol 
Metab 2014; 27(9-10): 929-38. 
45. 
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dateing by metabolic profile at birth: A California cohort study. Am J Obstet Gynecol 2015; In 
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46. 
Ambalavanan N, Baibergenova A, Carlo WA, et al. Early prediction of poor outcome in 
extremely low birth weight infants by classification tree analysis. J Pediatr 2006; 148(4): 438-
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47. 
Ambalavanan N, Carlo WA, Tyson JE, et al. Outcome trajectories in extremely preterm 
infants. Pediatrics 2012; 130(1): e115-25. 
48. 
Callaghan WM, MacDorman MF, Rasmussen SA, Qin C, Lackritz EM. The contribution 
of preterm birth to infant mortality rates in the United States. Pediatrics 2006; 118(4): 1566-73. 
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isoprostanes are elevated in newborns and inversely correlated to gestational age. Free Radic 
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50. 
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Assessment Collaborating G. Selected major risk factors and global and regional burden of 
disease. Lancet 2002; 360(9343): 1347-60. 
51. 
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Oxidative Stress in Preterm Infants with Symptomatic Patent Ductus Arteriosus. Am J Perinatol 
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52. 
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among extremely low birth weight infants. Pediatrics 2013; 132(1): e175-84. 
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pyrimethamine for malaria in pregnancy: a cross-sectional study from Tororo, Uganda. PLoS 
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54. 
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Principal role of dihydropteroate synthase mutations in mediating resistance to sulfadoxine-
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55. 
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7(12): 1031-41. 
57. 
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insecticide-treated bednets on malaria among HIV-infected Ugandan children. Aids 2007; 
21(15): 2059-66. 
58. 
Sibley CH, Hyde JE, Sims PF, et al. Pyrimethamine-sulfadoxine resistance in 
Plasmodium falciparum: what next? Trends Parasitol 2001; 17(12): 582-8. 
59. 
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2010: a systematic analysis. Lancet 2012; 379(9814): 413-31. 
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62. 
Trape JF, Tall A, Diagne N, et al. Malaria morbidity and pyrethroid resistance after the 
introduction of insecticide-treated bednets and artemisinin-based combination therapies: a 
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Cisse B, Cairns M, Faye E, et al. Randomized trial of piperaquine with sulfadoxine-
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Cisse B, Sokhna C, Boulanger D, et al. Seasonal intermittent preventive treatment with 
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Odhiambo FO, Hamel MJ, Williamson J, et al. Intermittent preventive treatment in 
infants for the prevention of malaria in rural Western kenya: a randomized, double-blind 
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67. 
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Uganda Sickle Surveillance Study (US3): a cross-sectional study. Lancet Glob Health 2016; 
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Schmiegelow C, Scheike T, Oesterholt M, et al. Development of a fetal weight chart 
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75. 
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Kayentao K, Garner P, van Eijk AM, et al. Intermittent preventive therapy for malaria 
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weight in Africa: systematic review and meta-analysis. JAMA 2013; 309(6): 594-604. 
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dihydroartemisinin-piperaquine. Trans R Soc Trop Med Hyg 2007; 101(9): 858-66. 
78. 
Lwin KM, Phyo AP, Tarning J, et al. Randomized, double-blind, placebo-controlled trial 
of monthly versus bimonthly dihydroartemisinin-piperaquine chemoprevention in adults at high 
risk of malaria. Antimicrob Agents Ch 2012; 56(3): 1571-7. 
79. 
Bigira V, Kapisi J, Clark TD, et al. Protective efficacy and safety of three antimalarial 
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80. 
Longo M, Zanoncelli S, Della Torre P, et al. Investigations of the effects of the 
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Longo M, Zanoncelli S, Manera D, et al. Effects of the antimalarial drug 
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Longo M, Zanoncelli S, Torre PD, et al. In vivo and in vitro investigations of the effects 
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797-810. 
 

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15.  
APPENDICES 
 
Appendix A. Information Sheet  
A STUDY ON PREVENTING MALARIA IN PREGNANT WOMEN AND 
YOUNG CHILDREN 
 
 
Makerere University in Uganda and the University of California, San Francisco in 
the United States are combining efforts in Busia district, Uganda to study new 
ways of using malaria drugs to prevent malaria in pregnant women and their 
babies.  
 
Malaria during pregnancy can have a harmful effect on you or your child. We 
want to study 2 different malaria drugs to see if they can be used to prevent 
malaria if taken during pregnancy. 
 
Our study clinic is located at Masafu General Hospital next to the antenatal clinic 
and is open every day from 8:00 am to 5:00 pm 
 
We want to enroll pregnant women who are at least 16 years old and follow them 
during pregnancy.  
 
We will then follow the child born up to 12 months of age.  
 
Women and children in this study will receive free medical care  
 
We shall also give reimbursement for transport to and from our study clinic 
 
For more information, please come to our study clinic where our doctors will be 
happy to talk to you and see if you and your baby can be in the study. 
UCSF

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Appendix B.  Determination of Gestational Age 
 
Gestational age will be based on the first day of the last menstrual period (LMP) and the earliest 
available ultrasound performed at > 6 weeks gestation.  The estimated due date (EDD) is 
calculated as 280 days following the LMP. 
 
If the first available ultrasound is consistent with a gestational age of 6 to 12 weeks, and the 
ultrasound gestational age is within 7 days of that given LMP, then the LMP will be used to 
determine gestational age.  However, if the ultrasound gestational age differs from the LMP 
gestational age by more than 7 days, then the ultrasound will be used to determine gestational 
age. 
 
If the first available ultrasound is consistent with a gestational age of 13-24 weeks, and the 
ultrasound gestational age is within 14 days of that given by the LMP, then the LMP will be used 
to determine gestational age.  However, if the ultrasound gestational age differs from the LMP 
by more than 14 days, then the ultrasound will be used to determine gestational age. 
 
If the first available ultrasound is consistent with a gestational age of 25 weeks or more, and the 
ultrasound gestational age is within 21 days of that given by the LMP, then the LMP will be used 
to determine gestational age.  However, if the ultrasound gestational age differs from the LMP 
by more than 21 days, then the ultrasound will be used to determine gestational age.  Care 
here should be taken to rule out intrauterine growth restriction (IUGR). 
 
If the LMP is not known, then the earliest ultrasound performed at > 6 weeks will be used to 
determine gestational age. 

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Appendix C. Household survey 
 
The household survey will be administered through a completely paperless QDS software 
system using hand-held tablet computers. A list of questions that will be used in the survey is 
provided below.  
 
Ques. No. 
Variable Name 
Question 
Section 1: Identification 
1 
VISDATE 
Date of final visit 
2 
STARTIME 
Start time of interview 
4 
BC 
Birth Cohort Number 
3 
PPTIDA 
Study Participant ID 
5 
PPTID 
To ensure data integrity, please re-enter the Participant ID. 
7 
INTNUM 
Interviewer number 
8 
AGREE 
Are you going to conduct the interview with this household? 
Section 2: Household Characteristics 
9 
SWATER 
What is the main source of drinking water for members of your household? 
10 
OTHERSCS 
Specify other source of water 
11 
TFACLTY 
What kind of toilet facility do members of your household usually use? 
12 
OTHERFCY 
Specify other kind of toilet facilities 
13 
ELECTRIC 
Does your household have... 
 
...Electricity? 
14 
RADIO 
...Radio? 
15 
CASSETTE 
…Cassette player? 
16 
TV 
…Television? 
17 
MOBILE 
…Mobile phone? 
18 
PHONE 
…Fixed phone? 
19 
FRIDGE 
…Refrigerator? 
20 
TABLE 
…Table? 
21 
CHAIR 
…Chairs? 
22 
SOFA 
…Sofa set? 
23 
BED 
…Bed? 
24 
CUPBOARD 
…Cupboard? 
25 
CLOCK 
…Clock? 
26 
FUELTYPE 
What type of fuel does your household mainly use for cooking? 
27 
OTHERFUE 
Specify other type of fuel used 
28 
SENERGY 
What is the main source of energy for lighting in the household? 
29 
OTHERENG 
Specify other source of energy for lighting 
30 
MMFLOOR 
MAIN MATERIAL OF THE FLOOR  
  
 RECORD OBSERVATION. 
  
 MARK ONLY ONE. 
31 
OTHERMMF 
Specify other material of the floor 
32 
MMROOF 
MAIN MATERIAL OF THE ROOF. 
   
 RECORD OBSERVATION. 
   
 MARK ONLY ONE.  

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33 
OTHERMMR 
Specify other material of the roof 
34 
MMEWALLS 
MAIN MATERIAL OF THE EXTERIOR WALLS. 
   
 RECORD OBSERVATION. 
 
 MARK ONLY ONE.  
35 
OTHERMME 
Specify other material of the exterior walls 
36 
HHROOMS 
How many rooms in your household  are used for sleeping? 
 
(INCLUDING ROOMS OUTSIDE THE MAIN DWELLING) 
 
If there are 15 or more rooms, enter 15 
37 
HHSPACES 
How many sleeping spaces like mats, mattresses,  or beds are available in your household? 
 
If there are 25 or more sleeping places, enter 25 
38 
WATCH 
Does any member of your household own or have… 
 
 …A watch? 
39 
BICYCLE 
….A bicycle? 
40 
SCOOTER 
…A motorcycle or motor scooter? 
41 
CART 
…An animal-drawn cart? 
42 
CAR 
…A car or truck? 
43 
MBOAT 
…A boat with a motor? 
44 
NOMBOAT 
…A boat without a  motor? 
45 
BANKACCO 
…A bank account? 
46 
NUMALAND 
How many acres of agricultural land do members of this household own? 
47 
DMARKT 
How far is it to the nearest market place? 
48 
HHMEALS 
Now I would like to ask you about the food your household eats. 
How many meals does your household usually have per day? 
49 
HHNUMT 
In the past week, on how many days did the household eat meat? 
50 
HHPSF 
How often in the last year did you have problems in satisfying the  food needs of the 
household? 
51 
DHFCTY 
How far is it to the nearest health facility? 
52 
MTHFCTY 
If you were to go this facility,how would you most likely go there? 
53 
OTHERMTH 
Specify other means of transport to the health facility 
54 
PSPRAY 
At any time in the past 12 months, has anyone asked permission to come into your dwelling to 
spray the interior walls against mosquitoes? 
55 
GPSPRAY 
Did you grant them permission to spray the interior walls of your dwelling? 
56 
RGSPRAY 
What was the primary reason that you did not grant permission to spray the interior walls of 
your dwelling against mosquitoes? 
57 
OTHERRGS 
Specify other reasons for not granting permission to spray the interior walls of your dwelling 
against mosquitoes 
58 
TSPRAY 
How many months ago was the dwelling last sprayed? 
59 
WSPRAY 
Who sprayed the dwelling? 
60 
OTHERWSP 
Specify other people who sprayed the dwelling 
61 
DSPRAY 
Did you pay for the dwelling to be sprayed? 
62 
PPWALLS 
Since the spraying, have the walls in your dwelling been plastered or painted? 
63 
TPPWALLS 
How many months ago were the walls plastered or painted?  
  
64 
MSPRAY 
In the past 12 months, have you seen or heard any messages about spraying the interior walls 
of your dwelling against mosquitoes? 
65 
MSGA 
Where did you hear or see message(s)? 
 
...Radio? 

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66 
MSGB 
...TV? 
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MSGC 
...Newspaper/Leaflet? 
68 
MSGD 
…Health worker/CMD? 
69 
MSGE 
…Neighbour/Relative/Friend 
70 
MSGF 
...Community Leader? 
71 
MSGG 
…Village public adress system 
72 
MSGH 
...Don't know 
73 
MSGI 
…Other 
74 
OTHERMSG 
Specify other 
75 
AHWKER 
Is there a community health worker (community medicine distributor/CMD, village health 
team/VHT, community own resource person/CORP) who distributes malaria medicines in your 
village or community? 
76 
AMCHWKER 
Does the community health worker currently have malaria medicines available? 
Section 3: Study Participants Sleeping Area Characteristics All questions in this section will be repeated with variable names entopen1, entcov1 
, etc. for each entryway and window in the study participants room  
77 
SRENTRY 
OBSERVATION: How many entryways into the room are there? 
78 
ENTOPN1 
OBSERVATION: Does it open to the outside? 
79 
ENTCOV1 
OBSERVATION: Is the entry way covered? 
80 
ETMM1 
OBSERVATION: Main material is the covering made of. 
81 
OTHCOV1 
Specify Other covering type 
82 
SRWINDOW 
OBSERVATION: How many windows are in the room? 
83 
WNDCOV1 
OBSERVATION: Is the window covered? 
84 
WNDOPN1 
OBSERVATION: Does the window open to the outside 
85 
SREAVES 
OBSERVATION: Does the room have eaves? 
86 
EAVESCOV 
OBSERVATION: If room has eaves, are the eaves covered? 
87 
EAVESOPN 
OBSERVATION: Do the eaves open to the outside? 
88 
AIRBRICK 
OBSERVATION: Does the room have airbricks? 
89 
AIRBRCOV 
OBSERVATION: If the room has airbricks, are the airbricks covered? 
90 
AIRBROPN 
OBSERVATION: Do the airbricks open to the outside? 
91 
AIRBRNUM 
OBSERVATION: How many airbricks are in the room? 
92 
SLEEP 
Where does the study participant usually sleep? 
93 
OTHERSL 
Specify other sleeping area 
94 
SRSLNUM 
Usually, how many people sleep in the same room as the study participant (excluding the study 
participant)? 
95 
SRSLNUM5 
How many of those people are under 5 years old (excluding the study participant)? 
96 
SLAREAS 
How many sleeping areas are in the room where the study participant sleeps? 
97 
SASLNUM 
How many people sleep in the same bed/sleeping area as the study participant under the 
mosquito net (excluding the study participant)? 
98 
SASLNUM5 
How many of those people are under 5 years old (excluding the study participant)? 
Section 4: Bednets All questions in this section will be repeated with variable names obs2,mnths2,where2, etc. for each mosquito net in the 
household (hhnumnet) 
99 
HHAMNETS 
IMMEDIATELY BEFORE Enrollment, did your household have any mosquito nets that can be 
used while sleeping? 
100 
HNUMNETS 
IMMEDIATELY BEFORE study enrollment, How many mosquito nets did your household have? 
101 
OBS1 
May I have a look at (all) the net(s) to establish the brand? 
102 
MNTHS1 
How many months ago did your household obtain the mosquito net? 
  
103 
WHERE1 
Where did you get the mosquito net from? 
104 
SPCFRO1 
Specify other sources of the mosquito net 
105 
BRAND1 
OBSERVE OR ASK THE BRAND OR TYPE OF MOSQUITO NET. 
106 
OTHERB1 
Specify other brands or types of mosquito net 

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107 
SMNET1 
Since you got the mosquito net, was it ever soaked or dipped in a liquid to repel mosquitoes or 
bugs? 
108 
TSMNET1 
How many months ago was the net last soaked or dipped? 
109 
SLPNET1 
Did anyone sleep under this mosquito net last night? 
110 
NUSED1A 
What are some of the reasons why this net was not used? 
 
...Too hot 
111 
NUSED1B 
...Don't like smell 
112 
NUSED1C 
...No mosquitoes 
113 
NUSED1D 
...Net too old/too many holes 
114 
NUSED1E 
...Net not  hung 
115 
NUSED1F 
...Net too dirty 
116 
NUSED1G 
...Net no longer kill insects 
117 
NUSED1H 
...Don’t know 
118 
NUSED1I 
...Other 
119 
NTHUNG1 
If not hung, why not? 
120 
OTHRNT1 
Specify other reason why the net was not hung. 
Section 5: Interviewer Details 
122 
STOPTIME 
End time of interview 
123 
VSTATUS 
Result of Visit 
124 
OVSTATUS 
Specify other result 
125 
TOTVISIT 
Total number of visits 
126 
COMMENTS 
Interviewer's Comments 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Appendix D. Administration of study drugs and placebos  
 
Timing of administration of study drugs during pregnancy 
Weeks of 
gestation 
Monthly SP  
(treatment arm A) 
Monthly DP  
(treatment arm B) 
16 
SP + DP placebo 
DP + SP placebo 
20 
SP + DP placebo 
DP + SP placebo 
24 
SP + DP placebo 
DP + SP placebo 
28 
SP + DP placebo 
DP + SP placebo 
32 
SP + DP placebo 
DP + SP placebo 
36 
SP + DP placebo 
DP + SP placebo 
40 
SP + DP placebo 
DP + SP placebo 
 

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Appendix E. WHO Criteria for Severe Malaria and Danger Signs 
 
Criteria for severe malaria 
 
Cerebral malaria - defined as unarousable coma not attributable to any other cause in a patient 
with falciparum malaria 
Generalized convulsions (> 3 convulsions over 24 hours period) 
Severe normocytic anemia (Hb < 5 gm/dL) 
Hypoglycemia 
Metabolic acidosis with respiratory distress 
Fluid and electrolyte disturbances 
Acute renal failure 
Acute pulmonary edema and adult respiratory distress syndrome (ARDS) 
Circulatory collapse, shock, septicemia ("algid malaria") 
Abnormal bleeding 
Jaundice 
 
Danger signs (in children only) 
 
Less than 3 convulsions over 24 hour period 
Inability to sit up or stand 
Vomiting everything 
Unable to breastfeed or drink 
Lethargy 
 

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Appendix F. Uganda Ministry of Health Guidelines for Routine Care of Pregnant and 
Postpartum Women, and Newborns 
 
In addition to receiving medical care as described above in the protocol, women and infants 
enrolled in the study will receive standard routine prenatal and postpartum care according to 
Uganda Ministry of Health guidelines. These standard procedures are subject to availability at 
the local health care facilities.  
 
Routine antenatal care. Women enrolled in the study will receive routine care as designated in 
the Uganda Ministry of Health Guidelines. Routine antenatal care includes screening and 
treating for syphilis and syndromic management of sexually transmitted infections (STIs).  
Pregnant women will receive iron and folic acid supplementation. In addition, women will be 
given multivitamins that will be given once daily. In addition, women receive mebendazole 
500mg as a single dose as early as possible after the 1st trimester. Each antenatal visit also 
includes blood pressure assessment and urine dip stick for proteinuria.  
 
Routine intrapartum/delivery care. Routine delivery care for in-hospital births will include 
labor management by the midwifery staff and management of obstetrical complications as per 
Ministry of Health guidelines. Immediate postpartum infant care will include polio and BCG 
immunization, ophthalmic tetracycline, and vitamin K. 
 
Routine postpartum care.  All postpartum women will receive vitamin A supplementation 
(200,000 IU) immediately following delivery. Depending on clinical circumstances and based on 
local standard of care, women may receive 2 weeks of multivitamins twice a day. Common 
indications for postpartum multivitamins include anemia, postpartum hemorrhage and 
prolonged labor. Women will be seen at 1 week after delivery as per Ugandan standards of 
care. Women also undergo a 6 weeks postpartum visit as part of routine care. These visits 
include an abdominal exam, syndromic management of STIs, and follow-up on any obstetrical 
complications that occurred. In addition, women receive vitamin A at this visit, if not given 
immediately postpartum, and are continued on iron and folic acid supplementation. Pelvic and 
breast exam will be done if clinically indicated. Contraceptive counseling is performed at this 
visit as is a nutritional assessment and infant feeding and support. Screening for cervical cancer 
will be performed postpartum by clinical staff if available at Masafu General Hospital. 
 
Routine infant care. Infants will be referred to Masafu General Hospital antenatal clinic for 
routine immunizations at 6 weeks, 10 weeks, 14 weeks, 6 and 9 months of life.  
  

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Appendix G. Schedule of routine assessments and procedures in pregnant women 
Evaluations  and Interventions 
Enrollmen
t 
Weeks of gestation 
Delivery 
1 and 6 weeks 
postpartum 
16* 
20 
24 
28 
32 
36 
40 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
HIV testing1 
X 
 
 
 
 
 
 
 
X 
 
Obstetrical ultrasound2 
X 
 
 
 
 
 
 
 
 
 
Blood collected by phlebotomy 
for CBC, ALT, and immunology 
studies 
X 
 
X 
 
X 
 
X 
 
X 
 
Blood collected by finger prick 
for blood smear and dried 
blood spot 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Blood collected by finger prick 
for standard RDT and qPCR 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Blood collected by phlebotomy 
for experimental RDT 
X 
 
X 
 
X 
 
X 
 
 
 
Routine assessment in the 
study clinic3 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
ECG (pre and post study drugs) 4 
 
 
X 
 
X 
 
X 
 
 
 
Administration of study drugs 
 
X 
X 
X 
X 
X 
X 
X 
 
 
Collection of cord blood and 
placental blood/tissue 
 
 
 
 
 
 
 
 
X 
 
Collection of heel stick blood in 
newborn 
 
 
 
 
 
 
 
 
X 
 
Labor and delivery 
documentation5 
 
 
 
 
 
 
 
 
X 
 
Standard Care 
Obstetrical exam6 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Syphilis screening 
X 
 
 
 
 
 
 
 
 
 
Iron and Folic Acid 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Prenatal vitamins 
X 
 
 
 
 
 
 
 
 
 
Mebendazole7 
 
X 
 
 
 
 
 
 
 
Screening for non-malarial 
parasitic infections8 
 
X 
 
 
 
 
 
 
 
Vitamin A9 
 
 
 
 
 
 
 
 
X 
 
Insecticide treated bednet 
X 
 
 
 
 
 
 
 
X 
 
* Only if study subject enrolled prior to 16 weeks gestation; If the woman is enrolled between 
18 or 20 weeks, then the week 20 phlebotomy will not be performed. 
 
Explanation of maternal schedule of events  
1. HIV test will be done at enrollment and documented. A repeat rapid HIV test will be done at 
delivery. HIV testing shall be done using standard rapid HIV-testing algorithm.   
2. Ultrasound will be done to confirm intrauterine pregnancy and estimate gestational age at 
enrollment. See Appendix B for dating criteria. 
3. Targeted physical exam will include anthropometric measurements (e.g. weight) and vital 
signs (i.e. temperature, pulse, and blood pressure). Measurement of height at the 
enrollment visit only. 
4. Also includes collection of finger prick capillary plasma sample just prior to performing the 
post study drug ECG 
5. Labor & Delivery documentation will include: Peripartum history, mode of delivery, Apgar 
scores (when available), weight, length, and head circumference of the child at birth, 
approximate gestational age, duration of labor, signs of fetal distress (presence of 

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meconium), summary of events in first days of life (including feeding, breathing patterns, 
jaundice, lethargy, or any additional abnormal findings), duration of admission if delivered in 
hospital. 
6. Obstetrical exam includes estimation of gestational age at study entry, fundal height 
measurement, fetal heart tones and urine dipstick for protein. A cervical exam will also be 
performed at screening and during antepartum study visits as clinically indicated. 
7. Mebendazole is typically given as 500mg as a single dose as early as possible after the 1st 
trimester (16 or 20 week visit). 
8. Screening for non-malarial parasitic infections will be done prior to administering 
Mebendazole and will include stool ova and parasite examination, circulating filarial 
antigens, and blood smear for microfilaremia.  
9. Vitamin A supplementation is dosed as 200,000 IU. 

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Appendix H. Schedule of routine assessments and procedures in infants 
Weeks 
of age 
Blood collected by finger 
prick 
Blood collected by 
phlebotomy for 
immunology studies 
and hemoglobin 
measurement 
Stool collected 
Routine 
assessment in 
the study clinic 
Blood 
smear 
Dried blood 
spots 
1 
 
 
 
 
X 
4 
X 
X 
 
X 
X 
6 
 
 
 
 
X 
8 
X 
X 
 
 
X 
12 
X 
X 
X 
 
X 
16 
X 
X 
 
 
X 
20 
X 
X 
 
 
X 
24 
X 
X 
 
 
X 
28 
X 
X 
X 
 
X 
32 
X 
X 
 
 
X 
36 
X 
X 
 
 
X 
40 
X 
X 
 
 
X 
44 
X 
X 
 
 
X 
48 
X 
X 
 
 
X 
52 
X 
X 
X 
X 
X 

73 
 
Appendix I.    Division of AIDS (DAIDS) Table for Grading the Severity of Adult and Pediatric 
Adverse Events Version 2.0 November 2014 
 
Citation:  
U.S. Department of Health and Human Services, National Institutes of Health, National Institute of 
Allergy and Infectious Diseases, Division of AIDS. Division of AIDS (DAIDS) Table for Grading the Severity 
of Adult and Pediatric Adverse Events, Version 2.0. [November 2014]. Available from: 
http://rsc.tech-
res.com/Document/safetyandpharmacovigilance/DAIDS_AE_GRADING_TABLE_v2_NOV2014.pdf 
 
 
Selected sections of the above document are listed here: 
 
 
Introduction 
The Division of AIDS (DAIDS) oversees clinical trials throughout the world which it sponsors and 
supports. The clinical trials evaluate the safety and efficacy of therapeutic products, vaccines, and other 
preventive modalities. Adverse event (AE) data collected during these clinical trials form the basis for 
subsequent safety and efficacy analyses of pharmaceutical products and medical devices. Incorrect and 
inconsistent AE severity grading can lead to inaccurate data analyses and interpretation, which in turn 
can impact the safety and well-being of clinical trial participants and future patients using 
pharmaceutical products. 
The DAIDS AE grading table is a shared tool for assessing the severity of AEs (including clinical 
and laboratory abnormalities) in participants enrolled in clinical trials. Over the years as scientific 
knowledge and experience have expanded, revisions to the DAIDS AE grading table have become 
necessary. 
The Division of AIDS (DAIDS) Table for Grading the Severity of Adult and Pediatric Adverse 
Events, Version 2.0 replaces the grading table published in 2004 and updated in 2009. In version 
2.0, AEs not previously included, but which now are deemed medically important events, are included 
while other AEs have been removed. Some AE severity grading descriptions have been revised to more 
appropriately reflect the presentation of these events in clinical settings and their impact on clinical 
trials. For example, DAIDS performed an extensive literature search and reviews of select DAIDS clinical 
trial data in revising certain hematology parameters (i.e., hemoglobin, white cell counts, and absolute 
neutrophil counts). DAIDS also took into consideration the U.S. Food and Drug Administration’s guidance 
regarding the use of local laboratory reference values and ethnic differences among certain healthy 
adolescent and adult populations in defining parameter limits. Finally, the revised DAIDS AE grading 
table also contains an updated glossary and acronyms section, an expanded instructions for use section, 
and an appendix that provides more age-specific information for an AE of concern to DAIDS. 
 
 
Instructions for Use 
General Considerations 
The Division of AIDS (DAIDS) Table for Grading the Severity of Adult and Pediatric Adverse 
Events, Version 2.0 consists of parameters, or AEs, with severity grading guidance that are to be used in 
DAIDS clinical trials for safety data reporting to maintain accuracy and consistency in the evaluation of 
AEs. The term “severe” is not the same as the term “serious” in classifying AEs. The severity of a specific 
event describes its intensity, and it is the intensity which is graded. Seriousness, which is not graded, 
relates to an outcome of an AE and is a regulatory definition. 

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Clinical sites are encouraged to report parameters in the DAIDS AE grading table as they are 
written to maintain data consistency across clinical trials. However, since some parameters can be 
reported with more specificity, clinical sites are encouraged to report parameters that convey additional 
clinical information. For example, diarrhea could be reported as neonatal diarrhea; seizures, as febrile 
seizures; and pain, as jaw pain. 
The DAIDS AE grading table provides an AE severity grading scale ranging from grades 1 to 5 
with descriptions for each AE based on the following general guidelines: 
• 
Grade 1 indicates a mild event 
• 
Grade 2 indicates a moderate event 
• 
Grade 3 indicates a severe event 
• 
Grade 4 indicates a potentially life-threatening event 
• 
Grade 5 indicates death (Note: This grade is not specifically listed on each page of the 
grading table). 
 
Other points to consider include: 
• 
Use parameters defined by age and sex values as applicable. 
• 
Male and female sex are defined as sex at birth. 
• 
Unless noted, laboratory values are for term neonates. Preterm neonates should be 
assessed using local laboratory normal ranges. 
• 
Where applicable, Standard International (SI) units are included in italics. 
 
Selecting and Reporting a Primary AE Term 
When selecting a primary AE term to report, sites should select the term that best describes 
what occurred to the participant. For example, a participant may present with itching, urticaria, flushing, 
angioedema of the face, and dyspnea. If the underlying diagnosis is determined to be an acute allergic 
reaction, sites should report “Acute Allergic Reaction” as the primary AE term. 
Primary AE terms should be reported using the DAIDS Adverse Experience Reporting System 
(DAERS) only if they meet expedited reporting criteria. However, all primary AE terms should be 
reported using protocol-specific case report forms (CRFs). Because the reported information is stored in 
different databases (i.e., safety and clinical), sites should report primary AE terms using the same 
terminology for data consistency. 
When reporting using DAERS, other clinically significant events associated with a primary AE 
term that more fully describe the nature, severity, or complications of the primary AE term should be 
entered in the “Other Events” section. However, the severity grade for these events must be lower than 
or equal to the severity grade of the primary AE term. In the example above, dyspnea and angioedema 
of the face may be entered in the “Other Events” section, because they are more descriptive and 
provide additional information on the severity of the acute allergic reaction. However, their severity 
grades must be lower than or equal to the severity grade of the primary AE term of “Acute Allergic 
Reaction”. 
Differences exist in the reporting and recording of information (e.g., signs and symptoms, 
clinically significant events) in DAERS and CRFs. Therefore, sites should refer to their protocols and CRF 
requirements for further instructions. 
 
Grading Adult and Pediatric AEs 
When a single parameter is not appropriate for grading an AE in both adult and pediatric 
populations, separate parameters with specified age ranges are provided. If no distinction between 
adult and pediatric populations has been made, the listed parameter should be used for grading an AE in 
both populations. 

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Reporting Pregnancy Outcomes 
In the Pregnancy, Puerperium, and Perinatal section, all parameters are pregnancy outcomes 
and should be reported using the mother's participant ID. If an infant is not enrolled in the same study 
as the mother, any identified birth defects should be reported using the mother's participant 
ID. However, if an infant is enrolled in the same study as the mother or in another study, any identified 
birth defects should be reported using the infant's participant ID. Sites should refer to the applicable 
network standards for reporting abnormal pregnancy outcomes on the CRFs. 
 
Determining Severity Grade for Parameters between Grades 
If the severity of an AE could fall in either one of two grades (i.e., the severity of an AE could be 
either grade 2 or grade 3), sites should select the higher of the two grades. 
 
Laboratory Values 
General. An asymptomatic, abnormal laboratory finding without an accompanying AE should not 
be reported to DAIDS in an expedited timeframe unless it meets protocol-specific reporting 
requirements. Sites should refer to the applicable network standards for reporting abnormal laboratory 
findings on the CRFs. 
  
Values below Grade 1. Any laboratory value that is between the ULN and grade 1 (for high 
values) or the LLN and grade 1 (for low values) should not be graded or reported as an AE. Sites should 
consult the Manual for Expedited Reporting of Adverse Events to DAIDS, Version 2.0 and their protocol 
when making an assessment of the need to report an AE. 
Overlap of Local Laboratory Normal Values with Grading Table Ranges. When local laboratory 
normal values fall within grading table laboratory ranges, the severity grading is based on the ranges in 
the grading table unless there is a protocol-specific grading criterion for the laboratory value. For 
example, “Magnesium, Low" has a grade 1 range of 1.2 to < 1.4 mEq/L, while a particular laboratory’s 
normal range for magnesium may be 1.3 to 2.8 mEq/L. If a study participant’s magnesium laboratory 
value is 1.3 mEq/L, the laboratory value should be graded as grade 1. 
 
Estimating Severity Grade for Parameters Not Identified in the Grading Table. The functional table below 
should be used to grade the severity of an AE that is not specifically identified in the grading table. In 
addition, all deaths related to an AE are to be classified as grade 5. 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
GRADE 4 
POTENTIALLY 
LIFE-THREATENING 
Clinical adverse 
event NOT identified 
elsewhere in the 
grading table 
Mild symptoms 
causing no or 
minimal 
interference with 
usual social & 
functional activities 
with intervention not 
indicated 
Moderate symptoms 
causing greater than 
minimal interference 
with usual social & 
functional activities 
with intervention 
indicated 
Severe symptoms 
causing inability to 
perform usual social 
& functional activities 
with intervention or 
hospitalization 
indicated 
Potentially life-
threatening symptoms 
causing inability to 
perform basic self-
care functions with 
intervention indicated 
to prevent permanent 
impairment, persistent 
disability, or death 

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Appendix J. List of drugs associated with known risk of torsades de pointes 
 
Substantial evidence supports the conclusion that these drugs prolong the QT interval AND are clearly associated 
with a risk of TdP, even when taken as directed in official labeling.  
Reference: https://www.crediblemeds.org/  
    

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Appendix K. List of drugs that potentially inhibit the metabolism of piperaquine 
 
 
Chloramphenicol 
Clarithromycin 
Diltiazem 
Erythromycin 
Fluconazole 
Itraconazole  
Ketoconazole   
Verapamil