Convenience and Cost-aspects of a New 1-step Reconstitution Injectable Artesunate Compared to Conventional 2-step Injectable Artesunate for the Treatment of Severe Falciparum Malaria: a Multi-centre Study
Phase: PHASE2
Conditions: Severe Malaria
Sponsor: University of Oxford

 
 
 
 
 
 
 
 
 
Convenience and cost-aspects of a new 1-step reconstitution injectable artesunate        
compared to conventional 2-step injectable artesunate for the treatment of                                  
severe falciparum malaria: a multi-centre study 
 
Short title: Study to compare feasibility of new artesunate antimalarial injection versus conven-
tional artesunate antimalarial injection 
Protocol version:  version 2.0 dated 18 August 2021 
Trial registration number: NCT05140278 
 
 
 

 
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1STEP-AS Protocol Version 2.0, dated 18 August 2021 
 
 
 
Convenience and cost-aspects of a new 1-step reconstitution injectable artesunate        
compared to conventional 2-step injectable artesunate for the treatment of                                  
severe falciparum malaria: a multi-centre study 
 
Short title: Study to compare feasibility of new artesunate antimalarial injection versus                             
conventional artesunate antimalarial injection 
ACRONYM: 1STEP-AS 
Protocol no.: MAL21006 
OxTREC ref: 21-21 
Protocol version:  2.0 dated 18 August 2021 
Trial registration number: TBC 
 
Principal Investigator:  
 
Prof. A.M. Dondorp 
Mahidol Oxford Tropical Medicine Research Unit 
Bangkok, Thailand 
Co-Principal Investigator: 
Assoc. Prof. Lorenz von Seidlein 
Mahidol Oxford Tropical Medicine Research Unit 
Bangkok, Thailand 
Site Principal investigator 
Prof M. Onyamboko (DRC) 
Kinshasa School of Public Health,  
University of Kinshasa, DRC 
Site Co-Principal investigator 
Dr. Caterina Fanello (DRC) 
Kinshasa School of Public Health,  
University of Kinshasa, DRC 
Site Principal investigator 
Dr. S. Gesase (Tanzania) 
Magunga District Hospital,  
NIMR Korogwe Research Laboratory,  
Korogwe, Tanga Region 
Project coordinator: 
Dr. T. Peto   
Mahidol Oxford Tropical Medicine Research Unit 

 
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1STEP-AS Protocol Version 2.0, dated 18 August 2021 
 
 
 
Corresponding to the SPIRIT checklist https://www.bmj.com/content/bmj/346/bmj.e7586.full.pdf, the 
roles and responsibilities of the funder are as follows. Consultation during study design, no role in 
the conduct, data analysis and interpretation, manuscript writing, and dissemination of results. The 
funder does not control the final decision regarding any of these aspects of the trial. 
 
Investigators and protocol development team:  
AM Dondorp, L von Seidlein and TJ Peto conceived of the study. S Gesase, M Onyamboko, T Cope, 
C Fanello, LvS, and TJP designed and will conduct the study. Y Lubell designed and will conduct 
the costing analysis. M Mukaka designed and will conduct the primary statistical analysis. B Adhikari 
designed and will conduct the social science data analysis. N Waithira designed and will conduct 
the data management. All authors contributed to refinement of the study protocol and approved the 
final version. 
 
Confidentiality Statement 
This document contains confidential information that must not be disclosed to anyone other than the 
Sponsor, the Investigator Team, host institution, relevant ethics committees and regulatory authori-
ties. 
 
 
 
Bangkok, Thailand 
 
Sponsor 
 
University of Oxford 
University Offices, Wellington Square, Oxford,  
OX1 2JD, United Kingdom   
Funder 
Shanghai Fosun Pharmaceutical Industrial Devel-
opment Co., Ltd 
No. 1289 Yishan Road,  Shanghai 200233, China 

 
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Investigator Agreement and Conflict of Interest 
 
“I have read this protocol and: 
- 
agree to abide by all provisions set forth therein. 
- 
agree to comply with the principles of the International Conference on Harmonisation Tripar-
tite Guideline on Good Clinical Practice. 
- 
and declare no conflict of interest, according to the current version of the Declaration of 
Helsinki”  
 
 
 
 
 
 
  Prof. Arjen M.  Dondorp            
 
    Principal Investigator           Principal Investigator’s signature 
                Date: 
 
 
 
 
 
 
 
 
Prof. M. Onyamboko (DRC) 
 
Site Principal Investigator      Site Principal Investigator’s signature     
     Date: 
 
   
 
 
 
 
 
 
 Dr. S. Gesase (Tanzania) 
 
Site Principal Investigator       Site Principal Investigator’s signature                    Date: 
 
 

 
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TABLE OF CONTENTS 
1. 
LIST OF ABBREVIATIONS 
 
 
 
 
 
 
7 
2. 
SYNOPSIS  
 
 
 
 
 
 
 
 
8 
3. 
BACKGROUND AND RATIONALE 
 
 
 
 
 
11 
3.1 
Background 
 
 
 
 
 
 
 
 
11 
3.2 
Study Rationale 
 
 
 
 
 
 
 
 
12 
3.3 
Proposed activities and outcome 
 
 
 
 
 
13 
4. 
OBJECTIVES 
 
 
 
 
 
 
 
 
15 
4.1. 
Co-primary Objectives 
 
 
 
 
 
 
 
15 
4.2. 
Secondary Objective 
 
 
 
 
 
 
 
15 
4.3. 
Exploratory Objectives 
 
 
 
 
 
 
 
15 
5. 
TRIAL DESIGN 
 
 
 
 
 
 
 
 
16 
5.1 
Study sites  
 
 
 
 
 
 
 
 
16 
5.2 
Summary of trial design  
 
 
 
 
 
 
16 
5.3 
Study duration 
 
 
 
 
 
 
 
 
16 
5.4 
Primary and secondary endpoints 
 
 
 
 
 
17 
5.4.1. 
Primary Endpoint  
 
 
 
 
 
 
 
17 
5.4.2. 
Secondary Endpoints 
 
 
 
 
 
 
 
17 
5.4.3. 
Exploratory endpoints 
 
 
 
 
 
 
 
17 
5.5 
Trial Participants  
 
 
 
 
 
 
 
17 
5.5.1. 
Overall Description of Trial Participants  
 
 
 
 
17 
5.5.2. 
Inclusion criteria 
 
 
 
 
 
 
 
 
17 
5.5.3. 
Exclusion criteria  
 
 
 
 
 
 
 
18 
6. 
PROCEDURES 
 
 
 
 
 
 
 
 
19 
6.1. 
Informed Consent  
 
 
 
 
 
 
 
20 
6.2. 
Screening, Eligibility and Baseline Assessments 
 
 
 
21 
6.2.1. 
Screening tests 
 
 
 
 
 
 
 
 
21 
6.2.2. 
Demographics and Medical History 
 
 
 
 
 
21 
6.2.3. 
Physical Examination and Vital Signs 
 
 
 
 
 
21 
6.2.4. 
Drug history  
 
 
 
 
 
 
 
 
21 
6.3. 
Randomisation and blinding 
 
 
 
 
 
 
21 
6.4. 
Procedures during hospitalisation 
 
 
 
 
 
22 
6.5. 
Follow-up visits 
 
 
 
 
 
 
 
 
22 
6.6. 
Blood sampling 
 
 
 
 
 
 
 
 
22 
6.6.1. 
On admission (time 0)  
 
 
 
 
 
 
 
22 
6.6.2. 
During hospitalisation 
 
 
 
 
 
 
 
23 
6.6.3. 
Blood volumes 
 
 
 
 
 
 
 
 
23 
6.7. 
Study drug regimens 
 
 
 
 
 
 
 
25 
6.8. 
Discontinuation/ Withdrawal of Participants from the Study  
 
25 

 
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6.9. 
Source Data 
 
 
 
 
 
 
 
 
25 
6.10. 
Definition of end of the trial 
 
 
 
 
 
 
26 
7. 
STUDY DRUGS 
 
 
 
 
 
 
 
 
27 
7.1 
Storage of Study Drugs 
 
 
 
 
 
 
 
27 
7.2 
Compliance with Study Drugs 
 
 
 
 
 
 
27 
7.3 
Accountability of the Study Treatment  
 
 
 
 
27 
7.4 
Concomitant Medication  
 
 
 
 
 
 
27 
8. 
SAFETY REPORTING 
 
 
 
 
 
 
 
28 
8.1 
Definitions  
 
 
 
 
 
 
 
 
28 
8.1.1. 
Adverse Event (AE) 
 
 
 
 
 
 
 
28 
8.1.2. 
Serious Adverse Event 
 
 
 
 
 
 
 
29 
8.2 
Reporting Procedures for Serious Adverse Events (SAEs)/ SUSARs 
29 
8.3 
Evaluating Adverse Events and Serious Adverse Events 
 
 
30 
8.3.1. 
Assessment of Intensity AE or SAE 
 
 
 
 
 
30 
8.3.2. 
Clarification of the difference in meaning between ‘SEVERE’ and ‘SERIOUS’  30 
8.3.3. 
Assessment OF RELATEDNESS OF AE OR SAE TO STUDY DRUGS  
30 
8.3.4. 
Outcome 
 
 
 
 
 
 
 
 
 
31 
9. 
STATISTICAL CONSIDERATIONS 
 
 
 
 
 
32 
9.1. 
Sample size justification  
 
 
 
 
 
 
32 
9.2. 
Analysis approach  
 
 
 
 
 
 
 
32 
9.2.1 
General Analysis Strategy  
 
 
 
 
 
 
32 
9.2.2 
Proportions  
 
 
 
 
 
 
 
 
33 
9.2.3 
Continuous data 
 
 
 
 
 
 
 
 
33 
9.2.4 
Safety analysis 
 
 
 
 
 
 
 
 
33 
10. 
DIRECT ACCESS TO SOURCE DATA/DOCUMENTS 
 
 
 
35 
11. 
QUALITY CONTROL AND QUALITY ASSURANCE PROCEDURES 
 
36 
11.1. 
Monitoring  
 
 
 
 
 
 
 
 
36 
11.2. 
DSMB 
 
 
 
 
 
 
 
 
 
36 
12. 
ETHICS 
 
 
 
 
 
 
 
 
 
37 
12.1. 
Declaration of Helsinki 
 
 
 
 
 
 
 
37 
12.2. 
ICH Guidelines for Good Clinical Practice 
 
 
 
 
37 
12.3. 
Approvals  
 
 
 
 
 
 
 
 
37 
12.4. 
Risks 
 
 
 
 
 
 
 
 
 
37 
12.4.1. Risks of parenteral artesunate 
 
 
 
 
 
 
37 
12.4.2. Risk of phlebotomy, venepuncture, finger stick  
 
 
 
38 
12.4.3. Risks to participation in social science studies  
 
 
 
38 
12.5. 
Benefits 
 
 
 
 
 
 
 
 
 
38 
12.6. 
Alternatives to Study Participation 
 
 
 
 
 
38 
12.7. 
Incentives & Compensation 
 
 
 
 
 
 
38 

 
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12.8. 
Confidentiality 
 
 
 
 
 
 
 
 
39 
13. 
SAMPLE MANAGEMENT  
 
 
 
 
 
 
40 
14. 
DATA HANDLING AND RECORD KEEPING 
 
 
 
 
41 
15. 
SPONSORSHIP AND INSURANCE 
 
 
 
 
 
42 
16. 
FUNDER 
 
 
 
 
 
 
 
 
 
43 
17. 
PUBLICATION POLICY 
 
 
 
 
 
 
 
44 
18. 
REFERENCES 
 
 
 
 
 
 
 
 
45 
APPENDIX 1. DOSING SCHEDULES 
 
 
 
 
 
 
47 
APPENDIX 2. LIST OF STUDY SITES & PRINCIPAL INVESTIGATORS  
 
49 
APPENDIX 3. TIME AND EVENT SCHEDULE 
 
 
 
 
 
50 
APPENDIX 4. TREATMENT GUIDELINES FOR SEVERE MALARIA 
 
 
51 
APPENDIX 5: PHARMACOKINETIC REPORT 
 
 
 
 
 
58 
APPENDIX 6: AMENDMENT HISTORY 
 
 
 
 
 
 
70 
 

 
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1. 
LIST OF ABBREVIATIONS 
ACT 
 
Artemisinin-based combination therapy 
AE 
 
Adverse event 
A/L 
 
Artemether-Lumefantrine 
ALT 
 
Alanine Aminotransferase 
AS 
 
Artesunate 
AST 
 
Aspartate aminotransferase 
CRF 
 
Case Report Forms  
CTCAE 
Common terminology criteria for adverse events 
CTSG  
Clinical trials support group (MORU) 
DHA 
 
Dihydroartemisinin 
DNA                Deoxyribonucleic Acid 
DOT 
 
Directly Observed Therapy 
DRC 
 
Democratic Republic of the Congo 
DSMB  
Data and Safety Monitoring Board 
EDC        
Electronic data capture 
EDTA  
Ethylene-diamine-tetra-acetic acid  
GCP 
 
Good Clinical Practice 
GCS 
 
Glasgow Coma Scale 
Hb           
Haemoglobin 
Hct 
 
Haematocrit 
IM 
 
Intramuscular 
IRB 
 
Institutional Review Board 
IV 
 
Intravenous 
KIMORU 
Kinshasa Medical-Oxford Research Unit 
LDH 
 
Lactate Dehydrogenase 
MORU  
Mahidol-Oxford Tropical Medicine Research Unit 
NIMR  
National Institute for Medical Research (Tanzania) 
NMCP  
National Malaria Control Programme 
PI 
 
Principal Investigator 
PCR 
 
Polymerase Chain Reaction 
PCT 
 
Parasite Clearance Time 
QA 
 
Quality Assurance 
QC 
 
Quality Control 
RDT 
 
Rapid Diagnostic Tests 
SAE 
 
Serious Adverse Event 
SmPC  
Summary of product characteristics 
SOP 
 
Standard Operating Procedure 
SSIs 
 
Semi-structured Interviews 
SUSAR 
Suspected unexpected severe adverse reaction 
WHO  
World Health Organisation 
 
 
 
 

 
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2. 
SYNOPSIS 
Study Title 
Convenience and cost-aspects of a new 1-step reconstitution injectable ar-
tesunate compared to conventional 2-step injectable artesunate for the treat-
ment of severe falciparum malaria: a multi-centre study 
ACRONYM 
1STEP-AS 
Trial Design 
Individually-randomised controlled non-inferiority trial comparing 1-step paren-
teral artesunate vs conventional 2-step parenteral artesunate, with ancillary 
qualitative and cost-evaluation components   
Trial      
Participants 
Part 1: 
 Children with severe falciparum malaria admitted to hospital 
Part 2: 
 Semi-structured Interviews (SSIs) with study staff, and other health staff who 
treat severe malaria patients 
 SSIs with malaria policy makers and stakeholders 
Sample size 
Part 1: 
Total 200 participants. Estimated 100 per site. 
 Korogwe District Hospital, Tanga, Tanzania (East Africa) 
 Kinshasa Medical Oxford Research Unit, D.R. Congo (Central Africa) 
Part 2: 
For both sites in total 40 SSIs with study staff, health staff, policy makers and 
stake holders; and survey/questionnaires with 150 health staff. 
Inclusion   
Criteria 
Part 1: 
 Male and female children aged >3months and <16 years. 
 Clinical diagnosis of severe P. falciparum malaria; or parasitological con-
firmed P. falciparum hyperparasitaemia >350,000/ uL. 
 Positive malaria test result, by rapid diagnostic test (RDT). 
 Weight of 5 kg or greater. 
 Written informed consent by the parent or guardian. 
Part 2: 
Study staff and health staff 
 Study staff who prepare and administer artesunate injection to patients in the 
study or health staff who have not administer the artesunate injection to pa-
tients in the study by themselves but are either aware of malaria treatment, 
artesunate injection, or have observed the treatment provided to severe ma-
laria patients. 
 Written informed consent by the study staff and health staff 
 
Study staff for a short video-record 
 Study staff who would like to participate in the video record of a procedure to 
show how 1-step and 2-step artesunate injections are prepared and admin-
istered.  
 Written informed consent by the study staff  
 

 
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Policymakers and stakeholders 
 Those who are working in the National Malaria Control Program (NMCP) or 
relevant organizations (WHO, INGOs/NGOs) within the country. 
 Written informed consent by the potential participant 
Exclusion  
Criteria 
Part 1: 
 Participation in other intervention studies 
 Known allergy to artemisinin derivatives. 
 Known history of parenteral treatment for severe malaria for the current epi-
sode of illness before admission. Treatment before admission with an oral 
antimalarial drug (used for the treatment of uncomplicated malaria) or a sin-
gle dose of pre-referral rectal artesunate are not exclusion criteria. 
Part 2: 
Study staff and health staff; Policymakers and stakeholders; Study staff and 
health staff for a short video-record 
 Unwilling to participate in the study 
 Unable to communicate 
Planned Trial 
Period 
18 months, start in Q4 2021. (Estimated patient recruitment November 2021 – 
October 2022. Patient duration of participation 1 month.) 
Co-Primary    
Objectives 
 Assessment of:  
1.Convenience and rapidness of administration of 1-step vs. conventional 2-
step parenteral artesunate formulations 
          and  
2. Costs of administration of 1-step vs. conventional 2-step parenteral ar-
tesunate formulations 
Secondary 
Objective 
1. To assess the acceptability, policy and implementation perspectives, and 
health care worker satisfaction regarding the use of 1-step formulation of par-
enteral artesunate.. 
Exploratory 
Objectives 
1. To assess and compare P. falciparum parasite clearance rates of 1-step vs. 
conventional 2-step parenteral artesunate formulations.  
2. To assess and compare time from intravenous treatment to follow up treat-
ment with oral drugs with 1-step vs. conventional 2-step parenteral ar-
tesunate formulations. 
3. To assess and compare disease outcome parameters between 1-step vs. 
conventional parenteral artesunate formulations. 
4. To assess and compare adverse events between 1-step vs. conventional 2-
step parenteral artesunate formulations. 
Co-primary  
endpoints 
1. Time to administration of treatment comparing 1-step vs. conventional 2-step 
parenteral artesunate formulations (by time-and-motion methods).  
and  
2. Costs of administration of 1-step vs. conventional 2-step parenteral ar-
tesunate formulations at health facility, and at health system level. 

 
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Secondary 
endpoint 
1. A mixed method social science study will assess feasibility, practicability, and 
satisfaction of 1-step formulation of parenteral artesunate. (To include study 
staff, health staff, and policymakers and stakeholders.) 
Exploratory 
endpoints 
1. Parasite clearance half-life and other parasite clearance parameters (PC50, 
PC90, 12-hour parasite reduction ratio) compared between 1-step vs. con-
ventional 2-step parenteral artesunate formulations. 
2. Time from start parenteral treatment to follow up treatment with an oral ACT 
(recovery to per os treatment) of 1-step vs. conventional 2-step parenteral 
artesunate formulations. 
3. Fever clearance time (i.e. the time taken for the tympanic temperature to fall 
below 37.5˚C and remain there for at least 24 hours) of 1-step vs. conven-
tional 2-step parenteral artesunate formulations.  
4. Incidence of adverse events and serious adverse events by study arms within 
the first 28 days. 
Drugs 
 
 
Artesunate (1-step parenteral) VERSUS Artesunate (conventional 2-step par-
enteral)  
Then oral artemisinin combination therapy as follow-on treatment from paren-
teral treatment: artemether-lumefantrine (A/L), if available and no contraindica-
tion, otherwise other ACT. Rescue treatment: quinine. 

 
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3. 
BACKGROUND AND RATIONALE 
3.1 
Background  
Parenteral artesunate is the first-line treatment for severe malaria.1,2 The two largest ever treatment 
trials conducted in patients hospitalised with severe malaria, which compared parenteral artesunate 
(produced by Guilin/ Fosun) with quinine: SEAQUAMAT in Asia in 1,461 patients3, and AQUAMAT 
in Africa in 5,425 children4. In both trials artesunate was associated with a significant and substantial 
reduction in mortality compared to quinine (a 34.7% relative reduction in deaths in SEAQUAMAT, 
22.5% in AQUAMAT), which was not at the expense of an increase in severe sequelae. These 
findings resulted in a change of the WHO recommended first line antimalarial therapy for severe 
malaria in all endemic settings, and it has been estimated by the Medicines for Malaria Venture that 
since 2011 this has saved well over 500,000 young lives in Africa (https://www.mmv.org/our-im-
pact/achievements/168-million-vials-artesun-delivered-treat-children-severe-malaria). 
The conventional formulation of injectable artesunate requires a 2-step reconstitution and dilution of 
the artesunate hemisuccinate powder, including reconstitution in a sodium bicarbonate solution fol-
lowed by further dilution in 5% dextrose or normal saline. The 2-step procedure takes time and is 
error prone, dissolving the artesunate powder in the bicarbonate solution is sometimes difficult, and 
the 
2-step 
procedure 
requires 
additional 
consumables, 
like 
sterile 
syringes 
(https://www.severemalaria.org/toolkits-training/injectable-artesunate-tools-training). Preparation of 
conventional injectable artesunate (Artesun SmPC) requires shaking the vial for 3 to 5 minutes to 
mix well until the powder is completely dissolved and the solution is clear. Another disadvantage of 
the conventional artesunate is the two steps needed to reconstitute artesunate powder by sodium 
bicarbonate first then to dilute the solution by sodium chloride should not be exchanged. Otherwise, 
artesunate will not be dissolved. Such malpractice can cause a waste of medicine and put critical ill 
severe malaria patient under risk. 1-step artesunate can avoid such mistakes.5 
For treatment of severe malaria, a medical emergency, this poses important disadvantages, 
in particular in under-resourced healthcare settings in Sub-Saharan Africa. A new formula-
tion of injectable artesunate has been developed by Fosun Pharma requiring a simpler 1-step 
reconstitution. Bio-equivalence of the new formulation to the conventional formulation was shown in 
healthy volunteers led by Prof. Joel Tarning, University of Oxford (report attached in Appendix 6). 
The summary of the results for artesunate and dihydroartemisinin were “Parenteral administration 
of test and reference formulations showed matching exposures to the combined exposure to ar-
tesunate and dihydroartemisinin, and bioequivalence of the test formulation could be demonstrated 
both when administered IV (Table 3) and IM (Table 6)”. The new formulation is currently awaiting 
WHO prequalification and is expected to be launched in 2022, “Argesun” WHO prequalification 
reference number MA168 (Michelle Xiong, Fosun Pharma, personal communication).6 
The new 1-step artesunate parenteral formulation is thus expected to be equally effective, but likely 
more convenient and faster to use then conventional formulation. And to avoid reconstitution mis-
takes in field practice. Also, for the conventional formulation, the volumes of 0.9% sodium chloride 
used for IV route and IM route are different, for IV route: After reconstitution and dilution, one ml of 
solution for injection contains 10 mg artesunate. IM route: After reconstitution and dilution, one ml 
of solution for injection contains 10 mg artesunate. This can cause confusion among health workers 
and lead to mistakes. The 1-step formulation uses the same volume of solvent for IV and IM. In 
addition, the 1-step reconstitution is expected to be cheaper to administer, because it will use less 
of the health professional’s time and will use less consumables. We propose a study to compare 
and quantify convenience and costs of the new 1-step artesunate parenteral formulation versus the 
conventional formulation in a randomised study. This study will also integrate social science studies 
to explore and compare acceptability of 1 step artesunate with the conventional formulation using 

 
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SSIs and surveys among study staff, health staff and policymakers. In addition, efficacy data and 
adverse events will be captured.  
 
 
3.2 
Study Rationale 
We seek to evaluate the practical benefits of the new formulation in a clinical trial supported by an 
ancillary social sciences study, and a cost analysis informed by the first two activities. The random-
ised study will formally compare between the two artesunate formulations: the speed and conven-
ience of preparation and use, the costs of drug administration, basic pharmacodynamic measures 
and adverse events. A mixed method social science study will explore the opinion of healthcare 
workers regarding the use of the new artesunate formulation, including the policy and implementa-
tion perspectives from policymakers. Previous comparisons of artesunate suppositories and paren-
teral artesunate have reported parasite clearance times7 (https://www.severemalaria.org), and alt-
hough both arms of the trial contain an identical active drug (artesunate) in the same dosages, we 
will also collect this information as a precaution to exclude the possibility of an unexpected, substan-
tial difference in drug activity in patients with severe malaria.8 
 
A feasibility assessment of injectable AS is important.9 Previous analyses have shown the mortality 
benefit and cost-effectiveness of reduced delays to effective treatment for severe malaria.10,11 Stud-
ies to evaluate new treatments for severe malaria should not only rely on efficacy (mortality) out-
comes, but also include factors determining effectiveness under field conditions.12 An important fac-
tor is the convenience to use the antimalarial drug. An objective measure of this is the time needed 
to correctly prepare the artesunate solution for injection, which will be evaluated in this study. In 

 
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addition, social science studies will explore the practicalities such as convenience, policy and imple-
mentation related issues and perceived benefits of using the new 1-step formulation compared to 
the conventional 2-step formulation.  
 
Cost effectiveness of drug treatment for severe malaria is important and needs to be based on 
reliable evidence in the context of the high mortality caused by the disease.13 Previous assessments 
have shown that compared to parenteral quinine, AS is highly cost effective for the treatment for 
severe malaria in Asia and Africa.14,15 In the current study we will focus on the costs of the two 
different artesunate formulations and the consumables needed for their administration. These direct 
costs are important at the hospital level, but also for deployment in the wider health system. For 
example, for the public health system: the shipment cost for the 1-step artesunate will be cheaper 
than the cost for the conventional 2-step artesunate because the unit volume per pack (box) is 
smaller for the 1-step artesunate, and lighter. 
 
The new formulation contains the same dose of active compound, artesunate, as the conventional 
formulation, and has shown bioequivalence in a comparative study in healthy subjects (Prof Joel 
Tarning, University of Oxford, personal communication). However, it has not been deployed, yet, for 
the treatment of severe malaria patients. Although not the primary goal of the study, we will accu-
rately document efficacy, safety and tolerability outcomes using the new formulation. As an explor-
atory endpoint, these outcomes will be compared with the conventional artesunate formulation, 
since the study is not powered to compare these formally. Efficacy, safety and tolerability will be 
assessed through in-hospital monitoring of vital signs, physical examinations, blood smears, bio-
chemistry assays and full blood counts. Adverse events will be recorded.16 As an important phar-
macodynamic measure of the drug, parasite clearance dynamics will be assessed by repeated as-
sessments of the parasite counts after the start of parenteral antimalarial treatment.17  
 
The sites have been chosen based on their ability to recruit patients with severe malaria, presence 
of established clinical research programme, and the feasibility to perform the proposed research 
activities. They also represent large African countries, one French-speaking in Central Africa, and 
one English-speaking in East Africa, and both with a substantial burden of severe falciparum ma-
laria. Moreover, advanced marketing authorisation has been approved in Tanzania and the DRC, 
and in two other countries, Malawi and The Gambia (Michelle Xiong, Fosun Pharma, personal com-
munication). 
 
All the organisations in this collaboration will work closely with local counterparts including the Na-
tional Malaria Control Programmes (NMCPs), non-governmental and other relevant organisations. 
The sites have extensive experience of conducting trials of severe malaria.18 If 1-step parenteral AS 
is more feasible than the existing formulation, the study will facilitate the decision of countries 
whether to switch to the new formulation within a reasonable time frame.19 
3.3 
Proposed activities and outcome 
This individually randomised study will compare the two artesunate formulations: the speed and 
convenience of preparation and use, the costs of drug administration, and basic pharmacodynamic 
measures as well as adverse events. A mixed method social science study will explore the opinion 
of healthcare workers and policymakers regarding the use of the new compared to the old ar-
tesunate formulation. To ensure policymakers and stakeholders are familiar with the topic for the 
SSIs, i.e. 1-step artesunate injection versus 2-step artesunate injection (conventional treatment), a 
brief video documenting how the artesunate injection is prepared and administered (1-step versus 
2-step artesunate injection) will be recorded. The video will only serve to familiarize the topic for 

 
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SSIs with the policymakers.  
The main activity is an objective assessment of the convenience to use the artesunate formulations, 
as well as an in vivo clinical and parasitological assessment in 200 participants with severe falcipa-
rum malaria at two sites: 1 in DRC and 1 in Tanzania. The subjects will be randomized between the 
1-step parenteral AS and conventional 2-step parenteral AS (currently standard of care at both 
sites).  
The secondary activity proposed is a cost analysis of 1-step AS vs conventional 2-step parenteral 
AS. 
The third activity is a feasibility and acceptability survey using mixed methods social science study 
with health workers and policymakers to explore their experience and opinions related to using 1-
step AS compared to the old formulation. 
All research-related activities, from study design, planning, implementation through to analysis and 
writing of reports will be performed jointly with local counterparts. Both on-the-job training and formal 
training will be provided when needed, including Good Clinical Practice (GCP) skills. The close in-
teraction between WHO and its regional offices will ensure that new knowledge is disseminated 
efficiently and effectively. The trial will be overseen by a Data and Safety Monitoring Board (DSMB). 

 
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4. 
OBJECTIVES 
4.1. 
Co-primary Objectives 
Assessment of:  
(1) Convenience and rapidness of administration of 1-step vs. conventional 2-step parenteral 
artesunate formulations 
  and 
(2) Costs of administration of 1-step vs. conventional 2-step parenteral artesunate formulations  
4.2. 
Secondary Objective 
(1) To assess the acceptability, policy and implementation perspectives, and health care worker 
satisfaction regarding the use of 1-step formulation of parenteral artesunate. 
4.3. 
Exploratory Objectives 
(1) To assess and compare P. falciparum parasite clearance rates of 1-step vs. conventional 2-
step parenteral artesunate formulations.  
(2) To assess and compare time from intravenous treatment to follow up treatment with oral 
drugs with 1-step vs. conventional 2-step parenteral artesunate formulations. 
(3) To assess and compare disease outcome parameters between 1-step vs. conventional 2-
step parenteral artesunate formulations. 
(4) To assess and compare adverse events between 1-step vs. conventional 2-step parenteral 
artesunate formulations. 
 

 
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5. 
TRIAL DESIGN 
5.1 
Study sites 
The study will take place at 1 site in the DRC and 1 site in Tanzania.  
- 
Magunga District Hospital, National Institute for Medical Research (NIMR) Korogwe Re-
search Laboratory, Korogwe, Tanga Region, Tanzania.  
- 
The Kinshasa Mahidol Oxford Research Unit (KIMORU), Kinshasa, DRC.  
Malaria transmission at both sites is endemic and both sites estimate numbers of pediatric patients 
attending with suspected severe malaria is greatly in excess of the number of patients necessary 
for screening and enrollment into the present study. 
5.2 
Summary of trial design 
Part 1  
A comparison of 1-step parenteral artesunate vs. conventional 2-step parenteral artesunate in pa-
tients with severe malaria to assess the feasibility of administration, parasite and fever clearance 
times of 1-step parenteral AS to conventional AS in 2 countries. Patients with severe malaria will be 
enrolled and randomly allocated to treatment with conventional injectable artesunate or 1-step in-
jectable artesunate. A Time and Motion study will record the time to prepare the artesunate solution 
for injection and administer treatment, number of actions performed to prepare treatment, and con-
sumables used. Clinical, parasitological, and laboratory assessments will be recorded while patients 
are admitted in hospital and then weekly up to day 28 to assess recovery and determine final status.   
Part 2  
A mixed method social science study that entails SSIs and survey with study staff (involved in part 
1), health workers (who treat severe malaria) and policymakers and stakeholders (who are involved 
in devising national malaria policy and its implementation), to assess the acceptability, feasibility, 
pros and cons, costs, and logistics and training implications of 1-step AS vs conventional AS. For 
both sites, SSIs will be conducted with minimum of a total of 40 respondents consisting of study 
staff, health staff and policy makers and stakeholders. The ultimate sample for SSI will be dependent 
on the data saturation [20]. For survey/questionnaire, a maximum number of relevant participants 
(study staff and health care staff) will be attempted to be recruited from two sites. A minimum of 150 
study staff and health care staff will be recruited in the survey.    
Part 3  
A cost analysis of 1-step parenteral AS using data from Part 1 & Part 2. This will assess health 
facility-level costs, and also health system costs to encompass all costs of a potential change from 
conventional to 1-step artesunate, including re-training, materials, drug replacement.20 
5.3 
Study duration 
The recruitment phase of the study is expected to last 12 months once a site starts to recruit. The 
sites intend to start recruiting patients during Q4 2021. Training will precede study execution by up 
to 1 month. The mixed method social science study and costing analysis will take place during Q1 
and Q2 2022 and run in parallel with the main study. SSIs with policy stakeholders will take place in 
Q2 and Q3 2022 to allow findings from the study and experiences and opinions of health workers to 
be discussed. Data management and analysis, and report writing and submit for publication in peer-
reviewed medical journal are expected to take about 6 months per site. Therefore, the total time to 
complete the study will be about 18 months. 

 
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5.4 
Primary and secondary endpoints 
5.4.1. Primary Endpoint 
(1) Time to administration of treatment comparing 1-step vs. conventional 2-step parenteral ar-
tesunate formulations (by time-and-motion methods).  
           and 
(2) Costs of administration of 1-step vs. conventional 2-step parenteral artesunate formulations 
at health facility, and at health system level. 
5.4.2. Secondary Endpoints 
(1) A mixed method social science study will assess feasibility, practicability, and satisfaction of 
1-step for-mulation of parenteral artesunate. (To include study staff, health staff, and policy-
makers and stakeholders) 
5.4.3. Exploratory endpoints 
(1) Parasite clearance half-life and other parasite clearance parameters (PC50, PC90, 12-hour 
parasite reduction ratio) compared between 1-step vs. conventional 2-step parenteral ar-
tesunate formulations. 
(2) Time from start parenteral treatment to follow up treatment with an oral ACT (recovery to per 
os treatment) of 1-step vs. conventional 2-step parenteral artesunate formulations. 
(3) Fever clearance time (i.e. the time taken for the tympanic temperature to fall below 37.5˚C 
and remain there for at least 24 hours) of 1-step vs. conventional 2-step parenteral ar-
tesunate formulations.  
(4) Incidence of adverse events and serious adverse events by study arms within the first 28 
days. 
5.5 
Trial Participants 
5.5.1. Overall Description of Trial Participants 
This will be an open-label, randomised trial. All study patients must meet the applicable inclusion 
and exclusion criteria. The treating physician will decide whether the patient is severely ill and eligi-
ble for inclusion. 
5.5.2. Inclusion criteria 
Part 1: 
 
Male and female children aged >3months and <16 years. 
 
Clinical diagnosis of severe P. falciparum malaria; or parasitological confirmed P. falciparum 
hyperparasitaemia >350,000/ uL. 
 
Positive malaria test result, by rapid diagnostic test RDT. 
 
Weight of 5 kg or greater. 
 
Written informed consent by the parent or guardian. 
 
Part 2: 
Study staff and health staff 
 
Study staff who prepare and administer Artesunate injection to patients in the study or health 
staff who have not administer the Artesunate injection to patients in the study by themselves 

 
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but are either aware of malaria treatment, Artesunate injection, or have observed the treat-
ment provided to severe malaria patients. 
 
Written informed consent by the study staff and health staff 
Study staff for a short video-record 
 
Study staff who would like to participate in the video record of a procedure to show how 1-
step and 2-step Artesunate injections are prepared and administered.  
 
Written informed consent by the study staff  
Policymakers and stakeholders 
 
Those who are working in the National Malaria Control Program (NMCP) or relevant organi-
zations (WHO, INGOs/NGOs) within the country. 
 
Written informed consent by the potential participant 
5.5.3. Exclusion criteria 
Part 1: 
 
Participation in other intervention studies 
 
Known allergy to artemisinin derivatives. 
 
Known history of parenteral treatment for severe malaria for the current episode of illness 
before admission. Treatment before admission with an oral antimalarial drug (used for the 
treatment of uncomplicated malaria) or a single dose of pre-referral rectal artesunate are not 
exclusion criteria. 
 
Part 2: 
Study staff and health staff; Policymakers and stakeholders; Study staff and health staff for a short 
video-record 
 
Unwilling to participate in the study 
 
Unable to communicate 

 
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6. 
PROCEDURES 
Part 1 
A trial nurse will receive all children who could have severe malaria and are potentially eligible to 
participate in the study and call the attending physician. The diagnosis of falciparum malaria will be 
made by a PfHRP2-based rapid malaria test. If the test is positive, and there is a clinical judgement 
that the patient has severe disease (according to a check list provided in the Case Report Forms 
[CRFs]), the patient can be enrolled, provided written informed consent has been obtained and all 
eligibility confirmed. The screening sequence will differ for patients with hyperparasitaemia only with 
no symptoms of severe malaria, as their eligibility will be determined when microscopy results are 
available, if performed. 
Once the patient is enrolled, the randomisation deciding the drug allocation will be carried out. This 
is done in the following way: The next in a series of numerically sequenced envelopes is opened. 
The envelope will contain the unique participant number. From the moment the envelope is opened 
the patient is considered in the study whether or not the protocol is followed correctly thereafter. The 
envelope contains a slip of paper with a treatment box code number. The treatment box with this 
code number is then opened. 
With the help of the study nurse, the attending physician will take the patient’s history, and do a 
physical exam, where the list in the Case Report Forms (CRFs) serves as a guideline. Parameters 
include basic demographic parameters, questions regarding the previous history and current history, 
vital signs, coma score, and others. Patient monitoring during admission: to assure the best possible 
treatment of each study patient the following variables will be monitored based on WHO guidelines21 
A detailed monitoring sheet will outline the planned observations and their frequency. In case of 
abnormal findings staff will be trained to repeat the test and to inform the key decision makers re-
garding the need to change the management of the patient. To help the treating physician, a prac-
tical guideline on the treatment of severe malaria (appendix 4) will be provided to all involved physi-
cians.  
 
 

 
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When the patient is well enough to take and retain oral medication the attending clinician will be free 
to prescribe first line antimalarial therapy, according to national guidelines ensuring that a complete 
course of treatment is provided. In the case of Tanzania and DRC this will be an ACT (to be arte-
mether-lumefantrine if available and not contraindicated, otherwise or other ACT and will be pre-
scribed according to weight. The patient will be encouraged to stay on the ward until the complete 
course of ACT is taken. If the patient is discharged from hospital before the full course of ACT is 
administered, the remaining doses will be given to the attending caregiver with clear instructions. 
A time and motion design will be employed to record ease of administration of 1-step vs conventional 
artesunate. Each nurse administering the IV artesunate will be paired with an additional study team 
member acting as an observer. The observer starts the stopwatch when the nurse breaks the seal 
of the IV artesunate package and stops the stopwatch when preparation of the artesunate solution 
for injection is completed. The time, in minutes and seconds is recorded by the observer in the CRF. 
This methodological approach is considered appropriate for short tasks and provides detailed field 
data, and typically requires a 1:1 observer to subject ratio.22 
6.1. 
Informed Consent 
Part 1: 
Informed consent will be sought from the parent/guardian of the patient before any study specific 
procedures are performed according to standard Good Clinical Practice regulations. Written partic-
ipant information and informed consent in the local language will be presented to the parent/guard-
ian of the participants detailing no less than: the exact nature of the study; the implications and 
constraints of the protocol; the known side effects and any risks involved in taking part. It will be 
clearly stated that participation is voluntary and that the participant or their parent/guardian is free 
to withdraw consent for participation from the study at any time for any reason without prejudice to 
future care, and with no obligation to give the reason for withdrawal.  
The parent/guardian will be allowed as much time as possible to consider the information and take 
the opportunity to question the Investigator, or other independent parties to decide whether they will 
(or allow his/her child to) participate in the study. However, the study team will try to ensure that no 
more than one hour elapses between presentation and treatment either on or off the study.  
Written informed consent will then be obtained by means of the parent/guardian’s dated signature 
and dated signature of the person who presented and obtained the informed consent. If the par-
ent/guardian is illiterate and unable to read and write, a witness is required to be present during the 
entire informed consent process. The parent/guardian provides his/her thumbprint, and the witness 
provides his/her signature and date on the consent form. A copy of the signed informed consent 
document(s) will be given to the parent/guardian of the patient.   
Assent is not required for either of the countries where the study will recruit.  
Part 2: 
A total of three various types of written informed consents will be used.  
The first written informed consent will be used to study staff and health staff. Both SSIs and survey 
will be conducted among study staff and health staff.  
The second informed consent for video record will be conducted among study staff to record the 
procedure of preparing the 1-step versus 2-step artesunate injections and administering it to pa-
tients. This video will be used to familiarize the policymakers before conducting the SSIs with them.  
The third written informed consent will be collected from policymakers and stakeholder who will be 
interviewed using SSI-guide. 

 
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Part 3: 
No specific consent process is required for this sub-study. 
6.2. 
Screening, Eligibility and Baseline Assessments 
Part 1: 
Patients who present at the participating sites will be screened to assess eligibility. Full consent will 
be obtained before any enrolment procedures are conducted. A screening log will be kept.  
6.2.1. Screening tests 
These will be EDTA-anticoagulated blood or a finger prick for: 
• 
Malaria RDT 
If no signs of severe diseases and RDT-positive, then where microscopy is available promptly:  
• 
A parasite count from Giemsa or Field stained thick and thin blood films 
• 
Haematocrit 
6.2.2. Demographics and Medical History 
Basic demographic data (e.g., sex, age, address, prior treatment and previous participation in this 
or previous studies), and a full medical history will be recorded by the study staff. To reduce the 
waiting time to drug administration, all information that are not immediately relevant for the inclusion 
and clinical care of the patient (such as epidemiological data regarding malaria risk factors) might 
be collected after the patient is stabilised and parents/caregivers feel comfortable. 
6.2.3. Physical Examination and Vital Signs  
Physical examination will be conducted by a qualified study team member. Weight, height, pulse 
rate, blood pressure, respiratory rate, temperature, and spleen and liver size will be recorded if 
palpable. Non-invasive neurological exams will be performed to monitor recovery and neurological 
sequalae. This will be done before discharge from the study ward, on day 28 of follow up. And, for 
participants who have sequalae at day 28, neurological exams will be done at month 3, month 6, 
and month 12. 
6.2.4. Drug history  
All prescribed or over-the-counter and traditional medications used within the last 7 days will be 
recorded. Any drug allergies will be recorded.  
6.3. 
Randomisation and blinding 
Patients will be randomised to treatment with either conventional 2-step parenteral artesunate (1) or 
1-step parenteral artesunate (2). Patients who fulfil all the inclusion criteria and have none of the 
exclusion criteria will be randomised 1:1 to one of the two treatment arms according to a randomi-
sation schedule. Randomisation will be in blocks of 8-12. Allocation will be done by drawing the next 
sequential numbered opaque envelope, which contains the study number and treatment allocation.  
 
The patients will be assigned a study arm through a computer-generated randomisation schedule 
by the study statistician in MORU.  Individual, sealed and sequentially numbered envelopes will be 
provided for each trial site with one envelope per patient, indicating the treatment allocation. This is 
an open-label study so the blinding of investigators and patients is not applicable. However, the 
randomisation procedure allows for adequate drug allocation concealment before envelopes are 

 
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opened. All laboratory investigations will be performed without knowledge of the treatment alloca-
tion.   
6.4. 
Procedures during hospitalisation 
A physical examination will be performed daily and every six hours on indication. Vital signs recorded 
hourly for unstable patients, then 6 hourly for stabilised patients, and at each FU visit. A symptom 
questionnaire will be taken daily to help identify adverse events. All studies procedure will follow 
appendix 3.  
6.5. 
Follow-up visits  
Patients will be asked to come back for a follow-up visit at day 7, 14, 21 and 28. Patients will not be 
followed up longer. In case of unresolved important sequelae at day 28, the patient will be followed 
and treated longer in order to provide the appropriate clinical care. All follow up studies procedure 
will follow appendix 3. 
Additional unscheduled visits 
Patients presenting to the clinic with a fever or other symptoms on unscheduled days will be as-
sessed by the study physician. Their temperature will be recorded and blood smear will be made for 
any patient with a documented fever (tympanic temperature ≥ 37.5˚C) or a history of fever. Patients 
will be treated as clinically indicated.  
The monitoring of the patients is not strictly defined in the protocol and should be done according to 
good medical practice. An exception is monitoring of blood glucose. Blood glucose will be measured 
on admission and between 4 and 6 hourly thereafter for at least 24 hours or until the patient recovers 
consciousness and can eat if longer than 24hrs. Blood glucose can be checked at any other time 
as clinically indicated. The parameters that will be monitored during admission will vary slightly be-
tween the study sites, according to different requirements expressed by the IRBs of the different 
countries. If a patient’s clinical situation deteriorates the doctor on call has to be informed immedi-
ately. Appropriate steps for the treatment of (complications of) severe malaria are outlined appendix 
4. 
Time window for follow up visits 
The time-window for the visit on Day 7, 14, 21 is +/-3 days and for the visits on Days 28 is -3/+7 
days 
6.6. 
Blood sampling 
6.6.1. On admission (time 0) 
Patients will have an intravenous catheter inserted for at least the first 24 hours. An SOP will be 
provided instructing how this is to be done and how to take blood for protocol tests. 
On study admission, immediately before drug administration, blood will be collected according to 
appendix 3 for the following: 
 
Parasite count (thick and thin films) and Hct.  
 
Haemoglobin 
 
Full blood count  
 
Reticulocyte count (EDTA-anticoagulated) 
 
Biochemistry assessments including bilirubin, ALT, AST, Alkaline Phosphatase, and creati-
nine levels, LDH and any other tests that might be deemed relevant by the treating physician.  

 
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Blood glucoseIn this study patients will be enrolled based on clinical signs of severity and the results 
of the Rapid Diagnostic Test for reasons of administering the treatment for severe malaria as soon 
as possible, as the microscopy results are not available before 1 hour. In the case the slides from 
screening and admission are negative the treating physician will review the diagnosis and change 
the patient management accordingly. The patient will however be retained in the study (intention to 
treat). 
6.6.2. During hospitalisation 
During hospitalisation, patients will have blood taken for malaria films and haematocrit at 4h, 8h and 
12h and thereafter every 6 hours until parasite clearance (when two consecutive malaria slides are 
negative). Haematocrits will be done whenever a malaria blood film is made.   
During hospitalisation (24 hr, 48 hr 72 hr and 96 hr and follow-up visits (day 7, 14, 21, 28), blood will 
also be taken for: 
• 
1 mL EDTA: Full blood count, , and Hb  
• 
Reticulocyte count 
• 
1 mL heparinised blood: biochemistry assessments including bilirubin, ALT, AST, Alkaline 
Phosphatase, and creatinine levels, and LDH.  
Other tests that might be deemed relevant by the treating physician for the care of the patients can 
be performed.  
Note: Once parasitemia has been cleared and the patient tolerates oral antimalarial medications. 
The patients can be discharged according to the judgement of treating physician.  
6.6.3. Blood volumes 
The blood volumes for the protocol mandated tests are detailed in the study schedule. Maximum 
blood volumes are presented below for children. The maximum blood volume will be approximately 
14 ml. For children of 5 kg and more, this is less than 4% of the total blood volume during the whole 
study period and well below the 10% of total blood volume taken over 8 weeks as recommended by 
WHO Bulletin of the World Health Organization 2011:89:46-53 (On average the total blood volume 
is 80 ml/kg body weight]). 
Test 
n. test 
mL 
blood 
for one 
sample 
N. 
Total 
Time points 
RDT 
1 
0.02 
1 
0.02 
Admission 
Malaria film 
1 
0.06 
25 
1.5 
Admission and H0,4,8,12, then +6 
hourly until H48, then 12 hourly until 2 
consecutive negative slides, day 7, 14, 
21, 28 and unscheduled (n) (max ex-
pected 25 blood slides) 
Biochemistry tests 
(ALT, AST, BIL, 
AKP, Cr, LDH) 
5 
1 
9 
9 
 H0, 24, 48, 72 then day 7, 14, 21, 28, n 
Haemoglobin 
1 
0.08 
9 
0.72 
 H0, 24, 48, 72 then day 7, 14, 21, 28, n 
Haematocrit 
1 
0.05 
25 
1.25 
 Same time points as slides 
Full Blood Count 
1 
0.1 
9 
0.9 
 H0, 24, 48, 72 Days,7,14,21,28,n 
Reticulocytes 
1 
0.05 
9 
0.45 
 H0, 24, 48, 72 Days,7,14,21,28,n 
Total  
13.84 
  
 

 
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Part 2: 
A mixed method social science study that entails SSIs and survey with study staff, health workers 
and policymakers and stakeholders, to assess the acceptability, feasibility, pros and cons, costs, 
and logistics and training implications of 1-step AS vs 2-step conventional AS. Each interview will 
take around 30 - 45 minutes. The interview will be audio-recorded, if participant allowed. Topic guide 
will be used during the interview.  
For survey/questionnaire, a maximum number of relevant participants (150 study staffs and health 
care staffs) will be attempted to be recruited from two sites.  
 
Part 3:  
1. 
Gather all necessary data from multiple sources. 
2. 
Summarize relevant findings related to real-life practice from Part 1 & Part 2 of study. 
3. 
Calculate cost types: consumables, training, time savings, shipping, wastage, storage. 
4. 
Calculate costs: fixed, one-time, variable costs 
5. 
Calculate unit costs   
6. 
Compare costs and over period of time under different scenarios 
7. 
Rank best options over selected time periods 
8. 
Assessment of uncertainties and externalities 
The costing analysis will occur during the second half of the trial as data from Part 1 and Part 2 
become available.  
A cost analysis of 1-step parenteral AS using data from Part 1 & Part 2. This will assess health 
facility-level costs, and health system costs to encompass all costs of a potential change from con-
ventional to 1-step artesunate, including re-training, materials, drug replacement. Unit costs will be 
assigned to healthcare worker time spent on managing patients with severe malaria (derived from 
the time and motion surveys). Micro costing will be carried out in each of the sites to estimate the 
costs of equipment and consumables associated with provision of artesunate with each of the for-
mulations. The resulting labour and consumable mean costs will be compared in patients treated 
with 1-step vs conventional artesunate formulation. 
In addition to time measurement, the observer will also record the resources used for the admin-
istration of artesunate. This will include the vials themselves, as well as other consumables required 
for the administration (syringes, needles, catheters, etc.). 
Unit costs for these resources will be obtained online and this does not require data collection on 
site. Costs can be obtained by communication with representatives of companies, hospital adminis-
trators and malaria control programme officers. This will be sufficient to capture the specific costs 
for the administration of the treatments, and assumes that other care and length of stay will not be 
affected (consistent with the working assumption that there will be no difference in clinical out-
comes). 

 
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6.7. 
Study drug regimens 
 
Patients will be treated with weight-based doses according to the schedule in Appendix 1. 
The ACT used will be artemether-lumefantrine if available, given according to manufacturer’s in-
structions. The ACT will be administered by study medical or nursing staff while the patients are 
hospitalised. Directly Observed Therapy (DOT) will be done if possible, but in all cases the first dose 
of ACT will be by DOT. During DOT, if the patient vomits within half an hour after intake of ACT, the 
full dose will be repeated. If vomiting occurs between half and one hour, half of the dose will be 
repeated. If vomiting occurs more than one hour after drug administration, no repeat dosing will be 
done. Repeat doses will be recorded on the CRF. If vomiting within 1 hour occurs more than one 
time, no repeat dosing is allowed. The patient will be treated at the discretion of the investigator. 
6.8. 
Discontinuation/ Withdrawal of Participants from the Study  
Each participant (or the responsible caregiver) has the right to discontinue the study drug or the 
study participation at any time without giving a reason.  
The investigators may as well decide to discontinue participation in the study of a participant if nec-
essary. 
The reason for withdrawal or discontinuation, if available, will be recorded in the CRF. If the study 
drug or participation in the study is discontinued due to an adverse event, the investigator will ar-
range for follow-up visits at least until the adverse event has resolved or stabilised.  
6.9. 
Source Data 
Part 1 and 2 
Overview of drug regimens 
1-step AS-arm 
2-step AS-arm 
1-step parenteral AS 
New injectable artesunate (Argesun) 60mg 
 
Each vial of powder contains 60mg ar-
tesunate. 
Each ampoule of 6 ml solvent contains: so-
dium bicarbonate 8.4mg/ml; arginine 
20mg/ml. 
 
 
Guilin Pharma, Guangxi, China 
Artesunate 2.4 mg/kg STAT on admission, 
12hrs, then daily. <20 kg children will get ar-
tesunate 3.0 mg/kg. Minimal 3 doses. 
 
FOLLOWED BY 
 
Oral artemisinin combination therapy x 3 
days 
 
Conventional 2-step parenteral AS 
Conventional injectable artesunate                  
(Artesun) 60mg 
Each vial of powder contains 60 mg ar-
tesunate. 
Each ampoule of 1 ml solvent contains 
50 mg sodium bicarbonate. 
Each ampoule of 5 ml diluent contains 
45 mg sodium chloride. 
 
Guilin Pharma, Guangxi, China 
Artesunate 2.4 mg/kg STAT on admission, 
12hrs, then daily.  <20 kg children will get 
artesunate 3.0 mg/kg. Minimal 3 doses. 
 
FOLLOWED BY 
 
Oral artemisinin combination therapy x 3 
days 
 

 
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Source documents are original documents, data, and records from which participants’ CRF data are 
obtained. These include, but are not limited to, hospital records (from which medical history and 
previous and concurrent medication may be summarised into the CRF), clinical and office charts, 
laboratory and pharmacy records, diaries, microfiches, radiographs, and CRFs.  
CRF entries will be considered source data if the CRF is the site of the original recording (e.g., there 
is no other written or electronic record of data). In this study, the CRF will be used as the source 
document for most of the data points. 
All documents including audio-records, survey questionnaire forms will be stored safely in confiden-
tial conditions. On all study-specific documents, other than the signed consent form, the participant 
will be referred to by the participant number, not by name. 
6.10.  Definition of end of the trial 
The end of the trial will be the date of the last visit of the last participant.  
 

 
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7. 
STUDY DRUGS 
7.1 
Storage of Study Drugs 
All efforts will be made to store the study drugs in accordance with the manufacturers' recommen-
dations in a secure area.  
7.2 
Compliance with Study Drugs 
Parenteral study drugs will be administered by study medical staff (either a doctor or nurse). The 
first dose of ACT will be administered by DOTs and if the patient vomits ACT, and is re-dosed; this 
will be recorded in the CRF. If vomiting within 1 hour occurs again after retreatment, no repeat 
dosing is allowed. In this case the patient will be treated at the discretion of the Investigator. The 
patient may be discharged if recovered in the opinion of the study physician even if the full 3-day 
course of ACT is not complete. All drug doses will be recorded in the CRF.   
7.3 
Accountability of the Study Treatment 
All movements of study medication will be recorded. Both study medication of individual patient and 
overall drug accountability records will be kept up to date by the study staff.  
7.4 
Concomitant Medication 
Throughout the study, investigators may prescribe concomitant medications or treatments deemed 
necessary. Any medication, other than the study medication taken during the study will be recorded 
in the CRF.  

 
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8. 
SAFETY REPORTING 
This trial will use parenteral artesunate followed by an ACT (expected to be artemether-lumefantrine, 
or other ACT), drugs that are registered and have been evaluated extensively.   
To allow for comparison of safety and tolerability of 1-step injectable artesunate compared to con-
ventional injectable artesunate we will record and review all Adverse Events (AEs) and Serious 
Adverse Events, (SAEs) that occur in the study.  
A symptom questionnaire will be performed daily during hospitalization and at each subsequent visit 
to the health care facility, to aid in the identification of adverse events. 
The investigator is responsible for the detection and documentation of events meeting the criteria 
and definition of an adverse event (AE), or serious adverse event (SAE), as provided in this proto-
col.   
All SAEs, and AEs will be promptly documented from the moment of randomization in the study to 
discontinuation of the patient from study participation. Any events occurring between screening and 
randomization will be considered as baseline, pre-existing conditions. Any conditions that were pre-
sent at baseline will not be considered adverse events unless the grade of the condition deterio-
rates. 
Each adverse event will be graded according Common Terminology Criteria for Adverse Events 
(CTCAE) version 5.0: 
https://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm#ctc_50  
All adverse events must be recorded in the AE /SAE CRF. To avoid colloquial expressions, the 
adverse event should be reported in standard medical terminology. Whenever possible, the adverse 
event should be evaluated and reported as a diagnosis rather than as individual signs or symp-
toms.  If a definitive diagnosis is not possible, then the individual symptoms and signs should be 
recorded. Whenever possible, the aetiology of the abnormal findings will be documented on the 
CRF.  Any additional relevant laboratory results obtained by the Investigator during the course of 
this study will be recorded on the CRF.  
8.1 
Definitions 
8.1.1. Adverse Event (AE) 
An AE is any undesirable event or clinical deterioration that occurs to a study participant during the 
course of the study; that is, from the time of administration of study drugs until study ends (i.e., until 
the follow up visit) whether or not that event is considered related to the study drugs, or to a con-
comitant drug or procedure, e.g.     
 
any unfavourable and unintended symptom 
• 
physical sign 
• 
abnormal laboratory result 
• 
an illness 
• 
any pre-existing condition that has worsened in grade 
Any new clinical sign or clinical deterioration that occurs between signing the consent form and the 
administration of study drugs is not an AE. This information will be recorded in the medical records, 
as a pre-existing condition. 
 

 
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Condition associated with severe malaria 
Common conditions resulting from a deterioration of severe malaria as per list should not be con-
sidered or reported as Adverse Events. They are recorded in the specific section of the CRF.  
A list of the most common conditions in severe malaria includes,  
 
Deterioration of BCS or GCS 
 
Coma not present at admission 
 
Convulsions not present at admission 
 
Posturing not present at admission 
 
Decompensated shock (children systolic BP <70 mm Hg) 
 
Compensated shock (capillary refill >3sec /temperature gradient) 
 
Respiratory distress 
 
Hypoglycaemia (glucose <3 mmol/L) 
 
Severe anaemia 
 
Severe bleeding (requiring blood transfusion) 
 
Hemoglobinuria 
 
Severe jaundice  
 
Renal failure (urine output <0.5 mL/kg/hr >24 hours) 
8.1.2. Serious Adverse Event  
A serious adverse event is an AE that: 
 
results in death 
 
is life-threatening i.e. the patient was at risk of death at the time of the AE 
 
requires inpatient hospitalization or prolongation of existing hospitalization 
 
results in persistent or significant disability/incapacity  
 
Any other significant medical condition 
More than one of the above criteria can be applicable to the one event. Other significant medical 
conditions may be considered an SAE when, based upon appropriate medical judgment, they may 
jeopardize the patient or require medical or surgical intervention to prevent one of the outcomes 
listed in the definition above.   
All AEs must be followed until resolution, or until the AE is deemed permanent or leads to death. 
8.2 
Reporting Procedures for Serious Adverse Events (SAEs)/ SUSARs 
All SAEs are recorded in a CRF. They need are to be reported as follows: 
 
Safety team:  
All SAEs are to be reported to Safety team (PI, Sponsor representative (CTSG), project coordinator, 
and medical monitor) by e-mail to 1stepsafetyteam@tropmedres.ac within 24 hours of site aware-
ness. If further data is required, additional documentation can be submitted, but an initial report 
should be submitted within the 24-hour timeframe.  

 
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SAE, including death, resulting from a deterioration of severe malaria will not follow expedited re-
porting (24-hour timeframe), but reported monthly. 
 
DSMB:  
All SAEs are reported to DSMB on a monthly basis 
 
Ethics Committee and the Regulatory Authorities: 
All SAEs must also be reported to the ECs and the Regulatory Authorities as per required by local 
guidelines 
8.3 
Evaluating Adverse Events and Serious Adverse Events 
8.3.1. Assessment of Intensity AE or SAE 
Each adverse event will be graded according Common Terminology Criteria for Adverse Events 
(CTCAE) version 5.0. This will be included in the safety monitoring plan. 
If an adverse event is not listed in the CTCAE table, the Investigator will assess the severity using 
the following guidelines: 
1 = Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; interven-
tion not indicated. 
2 = Moderate; minimal, local or noninvasive intervention indicated; limiting age appropriate 
instrumental ADL* 
3 = Severe or medically significant but not immediately life-threatening; hospitalization or 
prolongation of hospitalization indicated; disabling; limiting self-care ADL** 
4 = Life-Threatening consequences; urgent intervention indicated 
5 = Death related to AE 
*Instrumental ADL refer to preparing meals, shopping for groceries or clothes, using the telephone, 
managing money, etc.  
**Self care ADL refer to bathing, dressing and undressing, feeding self, using the toilet, taking med-
ications, and not bedridden. According to age- & culture-appropriateness. 
8.3.2. Clarification of the difference in meaning between ‘SEVERE’ and ‘SERI-
OUS’  
The term “severe” is often used to describe the intensity (severity) of a specific event (as in mild, 
moderate, or severe myocardial infarction); the event itself, however, may be of relatively minor 
medical significance (such as severe headache). This is not the same as “serious”, which is based 
on the outcome or criteria defined under the serious adverse event definition and the defined study 
specific SAEs. An event can be considered serious without being severe if it conforms to the seri-
ousness criteria, similarly severe events that do not conform to the criteria are not necessarily seri-
ous.  Seriousness (not severity) serves as a guide for defining regulatory reporting obligations. 
8.3.3. Assessment OF RELATEDNESS OF AE OR SAE TO STUDY DRUGS 
The investigator is obligated to assess the relationship between study drug and the occurrence of 
each AE/SAE using the following categories of relatedness: 
 
Definite: clear-cut temporal association  

 
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• 
Probable: clear-cut temporal association, with improvement upon drug withdrawal, and not 
reasonably explained by the patient’s known clinical state or other aetiology. 
• 
Possible: less clear temporal association; other aetiologies are possible. (Other possible ae-
tiologies should be recorded on the CRF). 
• 
Not related: no temporal association with the study drug; assessed as related to other aeti-
ologies such as concomitant medications or conditions, or patient’s known clinical state. 
The investigator will provide the assessment of causality as per the AE/SAE case record form.  
8.3.4. Outcome 
The investigator will follow-up the AE and SAE until resolution, death, deemed permanent and no 
further medically relevant information can be expected. AE and SAE outcome will be classified as 
follows: 
• 
Continuing/ongoing 
• 
Resolved 
• 
Resolved with sequelae 
• 
Permanent  
• 
Fatal 

 
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9. 
STATISTICAL CONSIDERATIONS 
9.1. 
Sample size justification  
Part 1: 
Sample size calculations for non-inferiority study is based on dissolution test data from Guilin Phar-
maceutical Co. Ltd. (“Study report on the solubility of artesunate for injection (60mg), Doc. RR-QC-
ZSYQHHZ (60mg )RJX-2021 30th April 2021).23 This is supported by unpublished in-house experi-
ence (from a bioequivalence study in healthy volunteers, personal communication, Dr Podjanee 
Jittmala, Mahidol University) that the conventional formulation takes about 4 minutes with a standard 
deviation of 2 minutes to administer injectable artesunate. Our non-inferiority margin is 1 minute of 
drug re-constitution for the new simpler artesunate formulation i.e. if participants in the 1-step ar-
tesunate formulation will have a mean of the time of 5 minutes or less of drug re-constitution, with a 
standard deviation of 2 minutes, then the new formulation will be considered to be non-inferior to 
the old formulation. With this non-inferiority margin, detecting non-inferiority with 90% power and 
with a one sided alpha of 0.025, we will need to recruit 85 participants in the new formulation and 
85 in the old formulation arm giving a total of 170 participants. In order to compensate for a 15% 
loss to follow-up or withdrawal, we will need 100 participants in each arm giving a total of 200 par-
ticipants in the two arms combined. These calculations were performed in Stata 16 (StataCorp LLC 
Software). 
The sample size calculation dovetails with pragmatic needs for the other study activities the 200 
participants provides sufficient variability of participant characteristics to allow staff to gain experi-
ence of using 1-step artesunate and be able to provide an informed opinion of its pros and cons. 
Recruitment of 100 patients per site is feasible over 12 months based on the expected numbers of 
cases of severe malaria (Dr Fanello and Dr Gesase, personal communication April 2021). The sam-
ple size calculation is based only on the time-to-treatment of participants and not on the costing 
analysis. 
Part 2: 
Number of respondents (sample size) for this study will be based on the principles of 'data satura-
tion', that is data are collected until no new data/themes emerge from further interviews. A minimum 
of 40 respondents in total will be recruited for the SSIs, and at least 150 health workers will be 
interviewed with the survey questionnaire.   
9.2. 
Analysis approach 
Part 1: 
The time and motion study will record the number of steps and time taken to administer the correct 
dosage of artesunate. We will compare median (IQR, ranges) times for 1-step artesunate and con-
ventional artesunate. Analysis of other endpoints will be described in a Statistical Analysis Plan. We 
assume 1-step parenteral artesunate is bioequivalent to conventional parenteral artesunate. A brief 
overview is given below.  
9.2.1 
General Analysis Strategy 
The principle of intention to treat (ITT) will be the main strategy of analysis for the primary outcome. 
These analyses will be conducted on all patients assigned to the treatment groups as randomised. 
Any patients subsequently found not to be eligible during the trial or that did not receive a full course 
of study drug will be included in these analyses. Per Protocol (PP) analysis will be conducted to 
examine robustness of ITT results. This will be a form of sensitivity analysis to the intention to treat-
ment analysis principle. In the PP analyses, all patients wrongly included in the study based on the 
inclusion/exclusion criteria will be excluded from analyses. 

 
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The cost analysis of 1-step parenteral AS will assess health facility-level costs, and health system 
costs to encompass all costs of a potential change from conventional to 1-step artesunate, including 
re-training, materials, drug replacement. Unit costs will be assigned to healthcare worker time spent 
on managing patients with severe malaria (derived from the time and motion surveys). Micro costing 
will be carried out in each of the sites to estimate the costs of equipment and consumables associ-
ated with provision of artesunate with each of the formulations. The resulting labour and consumable 
mean costs will be compared in patients treated with 1-step vs conventional artesunate formulation.  
9.2.2 
Proportions 
These will be compared using chi squared or Fisher’s exact test, as appropriate. Crude proportions 
will be calculated with the exact 95% confidence intervals (CI), where relevant.  
9.2.3 
Continuous data 
These will be summarised by medians (IQR, ranges) and means (standard deviations, 95% CIs), as 
appropriate, and will include the parasite counts and laboratory parameters. Comparisons of contin-
uous data will be assessed using the paired/unpaired t tests or the sign rank/Mann Whitney U tests, 
as appropriate. Analyses of the parasite clearance data will be conducted. 
9.2.4 
Safety analysis 
This is not a study designed chiefly to determine the safety of 1-step artesunate vs conventional 2-
step artesunate, as both contain identical drugs. Moreover, this is a small study, and thus the patient 
populations may vary by chance or by another factor. However, clinical outcome data will be rec-
orded. Safety analyses will be based on the whole population that get administered the study drug. 
Safety data will be presented in tabular and/or graphical format and summarized descriptively. Any 
clinically relevant abnormalities or values of potential clinically concern will be described. 
Part 2: 
All transcripts and the interviewer’s notes will be first cross-checked with the audio-recordings. Tran-
scripts and the notes will be coded line by line in qualitative data analysis soft-ware NVivo 12 (QSR 
International, Doncaster, Australia). Coding of data will be based on the initial codebook prepared 
based on the interview guide (deductive approach) and will be supplemented by revision of codes 
based on the emerging themes (inductive approach) as the analysis progresses. Two investigators 
will independently check the coded data against the transcripts. Regular de-briefings will be held 
between the team members concerning the final themes and their interpretation to reach a consen-
sus. Themes and the supporting quotes will be presented as the findings of this study to address 
the research question. Survey data will compare the findings between the study staff, and health 
staff. Differences in acceptability and satisfaction among these two groups of respondents will be 
evaluated using relevant statistical tests. 
Part 3: 
In the current study we will focus on the costs of the two different artesunate formulations and the 
consumables needed for their administration. These direct costs are important at the hospital level, 
but also for deployment in the wider health system. For example, for the public health system: the 
shipment cost for the 1-step artesunate will be cheaper than the cost for the conventional 2-step 
artesunate because the unit volume per pack (box) is smaller for the 1-step artesunate, and lighter. 
Finally, using data on the incidence of severe malaria admissions at the sites (primary data) and 
nationally (national and international annual malaria reports) the total per annum costs of treating 
patients with the different formulations at the facility and national levels will be estimated. 

 
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In the unlikely event that there is an indication of a clinical benefit for the new formulation as com-
pared with the 2-step artesunate, and should it be more costly, we will also perform a cost-effective-
ness analysis to determine whether the apparent clinical benefit justifies the incremental cost. 
 

 
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10. 
DIRECT ACCESS TO SOURCE DATA/DOCUMENTS  
Direct access will be granted to authorised representatives from the sponsor and host institutions 
and the regulatory authorities, if applicable, to permit trial-related monitoring and inspections.  

 
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11. 
QUALITY CONTROL AND QUALITY ASSURANCE PROCEDURES  
The study will be conducted in accordance with the current approved protocol, ICH GCP, any na-
tional regulations that may apply to this study and standard operating procedures. Regular external 
monitoring of all sites will be coordinated by the MORU CTSG according to ICH GCP and a Moni-
toring Plan. Their role will include but not be limited to monitoring adherence to SOPs for collection 
of clinical data and laboratory specimens and quality checks (curation) of clinical and laboratory data 
according to standard methodologies.  
An online site initiation visit will cover GCP, and study-specific procedures, including: CRF comple-
tion, screening and enrolment procedures, data management, follow up scheduling.  
11.1. Monitoring 
Study sites may have in place a system for internal monitoring. In addition, regular external moni-
toring of all sites will be performed by the MORU CTSG according to ICH GCP and a Monitoring 
Plan. Data will be evaluated for compliance with the protocol and accuracy in relation to source 
documents. The monitors will check whether the clinical trial is conducted and data are generated, 
documented and reported in compliance with the protocol, GCP and the applicable regulatory re-
quirements.  
11.2. DSMB   
An independent Data Safety and Monitoring Board (DSMB) will be set up consisting of qualified 
volunteers with the necessary knowledge of clinical trials. The DSMB will receive summary reports, 
prior to each meeting.  All data reviewed by the DSMB will be in the strictest confidence. A DSMB 
charter will outline its responsibilities and how it will operate.  
 
The DSMB will meet formally at the following timepoints: 
 Before the study starts 
 At the end of the study (i.e. after the last patient has finished follow up)  
 Unscheduled meetings can be held on the initiative of the Medical Monitor (Dr Jacqueline 
Deen, deen.jacqueline@gmail.com), Principal Investigator, or DSMB to consider e.g. serious 
adverse events as they are reported on monthly basis OR if an earlier safety review is thought 
to be indicated.  

 
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12. 
ETHICS 
12.1. Declaration of Helsinki 
The Investigator will ensure that this study is conducted in compliance with the current revision of 
the Declaration of Helsinki (Fortaleza 2013). 
12.2.  ICH Guidelines for Good Clinical Practice 
The Investigator will ensure that this study is conducted according to any National Regulations and 
that it will follow the principles of the ICH Guidelines for Good Clinical Practice. 
12.3.  Approvals 
The study protocol and its associated documents will be submitted to the Oxford Tropical Research 
Ethics Committee (OxTREC) and the appropriate local ethics committees for written approval.  
The Investigator will submit and, where necessary, obtain approval from the above parties for all 
substantial amendments to the original approved documents.   
12.4.  Risks 
Part 1: 
This study will use drugs that have been studied thoroughly and their toxicities are well described. 
In general, they are all well tolerated. 
12.4.1. Risks of parenteral artesunate 
One of the concerns about the artemisinin derivatives is neurotoxicity, in particular involving the 
brain stem24. Nevertheless, a discrepancy seems to prevail with regard to the toxicity and safety of 
the artemisinin family of antimalarials. While these compounds have been found to be virtually void 
of any serious side effects in humans, their neurotoxicity in animal models has raised concerns 
about their use25,26. The prolonged presence of artemisinins upon slow release from oil-based intra-
muscular formulations at several orders of magnitude above the therapeutic level appear to be the 
main cause of the observed toxicity in laboratory animals. 
 
Artesunate is rapidly and extensively converted to dihydroartemisinin (DHA), the active metabolite, 
primarily by plasma and erythrocyte esterases. DHA elimination from the blood compartment is also 
rapid (half-life approximately 45 min). The potential for drug-drug interactions with other medicinal 
products is limited. In vitro drug-interaction studies have demonstrated minimal effects of artesunate 
on cytochrome P450 isoenzymes. In the limited number of clinical drug-drug interaction studies that 
have been performed, however, no clinically significant drug-drug interactions have been identified. 
 
Delayed haemolytic anaemia following treatment with injectable artesunate has been observed in 
children in malaria endemic areas and in non-immune travellers presenting with severe falciparum 
malaria.27 The risk was most pronounced in patients with hyper-parasitaemia and in younger chil-
dren. Some cases have been severe and required blood transfusion. The risk of post-artesunate 
delayed haemolytic anaemia has been reported however to be very low in children in highly endemic 
settings (Mozambique and DRC) and statistically not different from intravenous quinine18.  Vigilance 
for delayed onset anaemia is therefore advised, particularly in hyper-parasitaemic patients and 
younger children, and prolonged follow-up should be considered (e.g. 14-28 days). As the overall 
benefit-risk ratio remains highly favourable for injectable artesunate in the treatment of severe ma-
laria, WHO strongly recommends its continued use. 
 

 
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The most important reported side effect of artesunate is a rare severe allergic reaction (estimated 
risk approximately 1 in 3000 patients), which can present as an urticarial rash or more severe allergic 
symptoms, including hypotension, pruritus, oedema, and/or dyspnoea. More common minor side 
effects described in association with parenteral administration of artesunate include dizziness, light-
headedness, rash, and taste alteration (metallic/ bitter taste). Nausea, vomiting, anorexia and diar-
rhoea have also been reported, however it is uncertain whether these are attributable to the drug or 
to the disease severe malaria. 
12.4.2. Risk of phlebotomy, venepuncture, finger stick  
The primary risks of phlebotomy include local discomfort, occasional bleeding or bruising of the skin 
at the site of needle puncture, and rarely haematoma or infection. 
Part 2: 
12.4.3. Risks to participation in social science studies 
Some participants may feel uncomfortable by the details they have to think through during the inter-
view. If the interviewer notices any inconvenience or distress, can divert the topic and ask if partici-
pant is comfortable for further discussion. However, we will ensure that participants are informed of 
their freedom not to answer questions. In addition, we will provide mechanisms to ensure responses 
are confidential when requested or needed. If in case interview goes longer than planned (e.g. more 
than 45 minutes), interviewer will remind the respondent and ask if he/she is comfortable to continue 
beyond the designated time. 
12.5. Benefits 
Part 1: 
Severe malaria is a disease that needs to be treated promptly. All patients will benefit from receiving 
efficacious treatment at no cost. They will be followed up closely and will be given rescue treatment 
if clinically indicated. 
Part 2: 
There are no direct benefits to the participants other than their perspectives will contribute to the 
evidence-generation, specifically about acceptability, and practicalities related to the treatment of 
sever malaria using 1-step versus 2-step artesunate injections. The feasibility, acceptability and 
practicalities will help inform the treatment guidelines for severe malaria. 
12.6.  Alternatives to Study Participation 
Patients or their parent/guardian can freely decline participation in this study. If so, they will receive 
standard care for their malaria. 
12.7.  Incentives & Compensation 
Part 1: 
The study will pay for food during hospitalization for the patients and the caregivers, and small ben-
efits such as insecticide treated nets and soap, plus local transport costs for the follow-up visits. Any 
additional reimbursement and the amount in monetary terms (e.g. for the time lost from work as a 
result of hospitalisation) will be at the instruction of the national ethics committees. We anticipate 
that these are not allowed in the DRC as they are considered coercive. The study will pay locally 
appropriate costs for treatment of drug-related SAEs or other research-related injuries. Although the 
study cannot pay for long term care for disability after hospital discharge resulting from complications 

 
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of the illness the study will pay the reasonable costs for treatment of such sequelae during the follow 
up assessments for 12 months.   
Part 2: 
Appropriate reimbursement will be provided to all the participants based on the valid invoices of their 
travel costs.   
12.8. Confidentiality 
The trial staff will ensure that the participants’ anonymity is maintained. The participants will be 
identified only a unique participant number on the CRF and the MACRO EDC database. All docu-
ments will be stored securely and be accessible to trial staff and authorised personnel only. The 
study will comply with the Data Protection Act 2018, which requires that personal data must not be 
kept as identifiable data for longer than necessary for the purposes concerned. 

 
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13. 
SAMPLE MANAGEMENT 
Samples collected will be used for the purpose of this study as stated in the protocol. 
 

 
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14. 
DATA HANDLING AND RECORD KEEPING 
Part 1: 
Study data will be recorded on standard Case Report Forms (CRF) and entered to MACRO EDC©, 
a GCP-compliant data management system. The database is password-protected and includes in-
ternal quality checks to identify data that appear inconsistent, incomplete, or inaccurate. 
Study participants will be identified by a unique participant number in the database. The study data 
management plan outlines all activities that will be carried out to ensure security and quality of the 
data. 
Subject records at site will, taking into account the ability of the sites, be stored in binders or scanned 
and stored electronically. The records will be retained until the youngest child participating in the 
trial reaches 21 or five years following completion of the study, whichever is longer. The study da-
tabase will be retained indefinitely. 
Participant’s data and results from blood analyses stored in the database may be shared according 
to the terms defined in the MORU data sharing policy with data repositories or other researchers to 
use in the future. All personal information will be de-identified so that no individual can be identified 
from their treatment records, through interviews. 
Part 2: 
All data collected during the interviews in addition to the written informed consent will be stored at 
password protected principal interviewer’s official computer (laptop) and an external hard drive until 
the end of the study. All data will be provided with a unique code that will link the personal data with 
the research data and will be kept separately from the research data. Research data will not have 
personal identifiers (e.g. name). Personal data such as their age, profession and workplace will be 
anonymized from the transcripts and immediately transferred and backed-up to a secure server at 
MORU. The audio-recordings (with personal identifiers) will be deleted after the end of the study. 
Duration of storage of transcripts will be guided by the MORU’s data access policy. The study will 
comply with the General Data Protection Regulation (GDPR), which requires that personal data 
must not be kept as identifiable data for longer than necessary for the purposes concerned which 
is approximately 5 years after study completion. 
.  

 
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15. 
SPONSORSHIP AND INSURANCE  
The University has a specialist insurance policy in place which would operate in the event of any 
participant suffering harm as a result of their involvement in the research (Newline Underwriting 
Management Ltd, at Lloyd’s of London). 
 

 
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16. 
FUNDER 
The funder, Shanghai Fosun Pharmaceutical Industrial Development Co., Ltd, had a role in the de-
sign of the study. The funder will not have any role in its execution, analyses, and interpretation of 
data or decision to submit results. 

 
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17. 
PUBLICATION POLICY 
Any data published in the peer-reviewed medical literature will protect the identity of the patients. 
This trial will be registered in a web-based protocol registration scheme. All those who have made 
a substantial contribution will be co-authors on publications. The sites have the right to publish their 
data individually and to include members of the sponsor’s team who have made a significant contri-
bution. There will also publications of pooled data which will be coordinated by the MORU group. All 
sites will have the opportunity to contribute to these publications.  
The research findings disseminated to policy makers, National Malaria Control Programmes 
(NMCPs) and other researchers.  
 

 
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18. 
REFERENCES 
1. 
WHO. World Malaria Report 2020. Geneva, 2020. 
2. 
WHO. Guidelines for the Treatment of Malaria. Geneva; 2015. 
3. 
Dondorp A, Nosten F, Stepniewska K, Day N, White N, South East Asian Quinine Artesunate 
Malaria Trial g. Artesunate versus quinine for treatment of severe falciparum malaria: a randomised 
trial. Lancet 2005; 366(9487): 717-25. 
4. 
Dondorp AM, Fanello CI, Hendriksen IC, et al. Artesunate versus quinine in the treatment of 
severe falciparum malaria in African children (AQUAMAT): an open-label, randomised trial. Lancet 
2010; 376(9753): 1647-57. 
5. 
Guilin Pharmaceutical Co. L. Artesunate 60mg for injection Summary of Product 
Characteristics (Artesun). Guangxi, China, 2021. 
6. 
Guilin Pharmaceutical Co. L. Artesuante 60mg for Injection Summary of Product 
Characteristics (Argesun). Guangxi, China, 2021. 
7. 
Barnes KI, Mwenechanya J, Tembo M, et al. Efficacy of rectal artesunate compared with 
parenteral quinine in initial treatment of moderately severe malaria in African children and adults: a 
randomised study. Lancet 2004; 363(9421): 1598-605. 
8. 
Fanello C, Hoglund RM, Lee SJ, et al. Pharmacokinetic Study of Rectal Artesunate in 
Children with Severe Malaria in Africa. Antimicrob Agents Chemother 2021; 65(4). 
9. 
Ntuku HM, Ferrari G, Burri C, Tshefu AK, Kalemwa DM, Lengeler C. Feasibility and 
acceptability of injectable artesunate for the treatment of severe malaria in the Democratic Republic 
of Congo. Malar J 2016; 15: 18. 
10. 
Gomes MF, Faiz MA, Gyapong JO, et al. Pre-referral rectal artesunate to prevent death and 
disability in severe malaria: a placebo-controlled trial. Lancet 2009; 373(9663): 557-66. 
11. 
Tozan Y, Klein EY, Darley S, Panicker R, Laxminarayan R, Breman JG. Prereferral rectal 
artesunate for treatment of severe childhood malaria: a cost-effectiveness analysis. Lancet 2010; 
376(9756): 1910-5. 
12. 
Cheah PY, Parker M, Dondorp AM. Development of drugs for severe malaria in children. Int 
Health 2016; 8(5): 313-6. 
13. 
Dondorp AM, Maude RJ, Hendriksen IC, Day NP, White NJ. Artesunate dosing in severe 
falciparum malaria. J Infect Dis 2012; 206(4): 618-9; author reply 22. 
14. 
Lubell Y, Riewpaiboon A, Dondorp AM, et al. Cost-effectiveness of parenteral artesunate for 
treating children with severe malaria in sub-Saharan Africa. Bull World Health Organ 2011; 89(7): 
504-12. 
15. 
Lubell Y, Yeung S, Dondorp AM, et al. Cost-effectiveness of artesunate for the treatment of 
severe malaria. Trop Med Int Health 2009; 14(3): 332-7. 
16. 
Ampadu HH, Dodoo ANO, Bosomprah S, et al. Safety Experience During Real-World Use 
of Injectable Artesunate in Public Health Facilities in Ghana and Uganda: Outcomes of a Modified 
Cohort Event Monitoring Study (CEMISA). Drug Saf 2018; 41(9): 871-80. 
17. 
Byakika-Kibwika P, Nyakato P, Lamorde M, Kiragga AN. Assessment of parasite clearance 
following treatment of severe malaria with intravenous artesunate in Ugandan children enrolled in a 
randomized controlled clinical trial. Malar J 2018; 17(1): 400. 
18. 
Fanello C, Onyamboko M, Lee SJ, et al. Post-treatment haemolysis in African children with 
hyperparasitaemic falciparum malaria; a randomized comparison of artesunate and quinine. BMC 
Infect Dis 2017; 17(1): 575. 
19. 
Ojo AA, Maxwell K, Oresanya O, et al. Health systems readiness and quality of inpatient 
malaria case-management in Kano State, Nigeria. Malar J 2020; 19(1): 384. 
20. 
Cunnama L, Sinanovic E, Ramma L, et al. Using Top-down and Bottom-up Costing 
Approaches in LMICs: The Case for Using Both to Assess the Incremental Costs of New 
Technologies at Scale. Health Econ 2016; 25 Suppl 1: 53-66. 

 
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1STEP-AS Protocol Version 2.0, dated 18 August 2021 
 
 
21. 
World-Health-Organisation. Severe and complicated malaria. Trans R Soc Trop Med Hyg 
2000; 94 (Supplement 1): 47. 
22. 
Lopetegui M, Yen PY, Lai A, Jeffries J, Embi P, Payne P. Time motion studies in healthcare: 
what are we talking about? J Biomed Inform 2014; 49: 292-9. 
23. 
Guilin Pharmaceutical Co. L. Solubility of artesunte for injection (60mg) RR-QC-
ZSYQHHZ(60mg) RJX-2021. Guangxi, China, 2021. 
24. 
Dayan AD. Neurotoxicity and artemisinin compounds do the observations in animals justify 
limitation of clinical use? Med Trop (Mars) 1998; 58(3 Suppl): 32-7. 
25. 
Gordi T, Lepist EI. Artemisinin derivatives: toxic for laboratory animals, safe for humans? 
Toxicol Lett 2004; 147(2): 99-107. 
26. 
Nontprasert A, Pukrittayakamee S, Dondorp AM, Clemens R, Looareesuwan S, White NJ. 
Neuropathologic toxicity of artemisinin derivatives in a mouse model. Am J Trop Med Hyg 2002; 
67(4): 423-9. 
27. 
Belard S, Brand J, Schulze-Sturm U, et al. Intravenous Artesunate for Imported Severe 
Malaria in Children Treated in Four Tertiary Care Centers in Germany: A Retrospective Study. 
Pediatr Infect Dis J 2019; 38(11): e295-e300. 
 

 
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APPENDIX 1. DOSING SCHEDULES 
The dosing scheme for parenteral artesunate is 2.4 mg/kg at hour 0, hour 12, hour 24, and each 
24 hours until the patient can take oral medication. Children <20 kg will get 3.0 mg/kg. At least 3 
parenteral doses should be given before switching to oral therapy can be considered i.e.: stop in-
jectable artesunate and give oral antimalarial. When the patient is improving and able to take oral 
tablets a switch to oral ACT should be considered. 
  
2-step conventional injectable artesunate. Refer to Artesun SmPC page 2&3. 
 
One unit box of Artesun (conventional injectable artesunate) contains: 
Each vial contains: artesunate powder 60 mg 
Each ampoule of solvent contains: sodium bicarbonate 50 mg/ml, 1 ml 
Each ampoule of diluentcontains: sodium chloride 9 mg/ml, 5ml (There is no need to use addi-
tional 5% dextrose for dilution.) 
  
For intravenous (IV) injection (10 mg/ml) 
After reconstitution and dilution one ml of solution for injection contains 10 mg artesunate. 
Using a syringe, add 5 ml of sodium chloride 0.9% for injection to the vial containing the reconsti-
tuted artesunate solution. This will yield 6 ml of a solution containing artesunate 10 mg/ml. Shake 
to mix well, ensuring that the resulting solution is still clear. If the solution appears cloudy or a pre-
cipitate is present, it should be discarded. 
The volume of the solution required (ml) will be: 
Volume (ml) = [dose (mg)] ÷ 10 
  
For intramuscular (IM) injection (20 mg/ml) 
After reconstitution and dilution one ml of solution for injection contains 20 mg artesunate. 
Using a syringe, add 2 ml of sodium chloride 0.9% for injection to the vial containing the reconsti-
tuted artesunate solution. This will yield 3 ml of a solution containing artesunate 20 mg/ml. Shake 
to mix well, ensuring that the resulting solution is still clear. If the solution appears cloudy or a pre-
cipitate is present, it should be discarded. 
The volume of the solution required (ml) will be: 
Volume (ml) = [dose (mg)] ÷ 20 
  
1-step injectable artesunate. Refer to Argesun SmPC page 2&3. 
 
Dose: Adults and children weighing more 20 kg or more: 60mg is administered at a dose of 2.4mg 
of artesunate / kg body weight, by intravenous (IV) or intramuscular (IM) injection, at 0, 12 and 24 
hours, then once daily until oral treatment can be substituted. Children weighing less than 20 kg: 
60mg is administered at a dose of 3 mg of artesunate/kg body weight, by intravenous (IV) or intra-
muscular (IM) injection, at 0, 12 and 24 hours, then once daily until oral treatment can be substi-
tuted (see section 5.1).   
 
New injectable artesunate (Argesun®) 60mg  should  be  administered  for  a  minimum  of  24  
hours  (3  doses),  regardless  of  the patient’s ability to tolerate oral medication earlier. After at 
least 24 hours of Argesun® 60mg and when able to tolerate oral medication, the patient should be 
switched to a complete treatment course of an oral antimalarial regimen.     
 
Preparation     
 
Because of the instability of artesunate in aqueous solutions, the reconstituted solution must be 
used within one hour of preparation. Therefore, the required dose of artesunate should be calcu-
lated (dose in mg = patient’s weight in kg x 2.4 for patients weighing more than 20 kg; or dose in 
mg = patient’s weight in kg x 3 for children weighing less than 20 kg) and the number of vials of 
artesunate needed  
should be determined prior to reconstituting the artesunate powder.   
 

 
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Reconstitution of the artesunate solution Following reconstitution the solution must be diluted ac-
cording to the method of injection, as described below.   
 
For intravenous (IV) injection & intramuscular (IM) injection (20 mg/ml), using a syringe, withdraw 
3 ml of the sodium bicarbonate and arginine solvent, which is half the volume of the ampoule, and 
inject this into the vial containing the artesunate powder. Gently shake the vial for up to 3-5 
minutes or until the powder is completely dissolved and the solution is clear. If the solution ap-
pears cloudy or a precipitate is present, it should be discarded. The reconstituted artesunate solu-
tion should always be used immediately, and discarded if not used within one hour. The end con-
centration of the solution will be 20 mg artesunate per ml solvent. Thus, the volume in ml for ad-
ministration to the patient will be equal to: (desired dose in mg)/20   
 
Withdraw the required volume of artesunate solution from the vial with a syringe and then administer 
to the patient by slow intravenous or intramuscular injection over 1-2 minutes. New injectable ar-
tesunate (Argesun®) 60mg should NOT be administered as an intravenous drip. Reconstituted vials 
of Artesunate for Injection and ampoules of the solvent Sodium bicarbonate and Arginine injection 
are for single use only. Discard unused portions. Do not use water for injection for reconstitution of 
the artesunate powder or for dilution of the resulting solution prior to injection.   
 

 
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APPENDIX 2. LIST OF STUDY SITES & PRINCIPAL INVESTIGATORS 
 
TANZANIA 
Site PI: Dr Samwel Gesase  
Site 1: Magunga District Hospital, NIMR Korogwe Research Laboratory, Korogwe, Tanga 
Region 
 
DRC 
Site Co-PIs: Prof Marie Onyamboko & Dr Caterina Fanello  
Site 1: KIMORU, Kinshasa  
 
 
 

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APPENDIX 3. TIME AND EVENT SCHEDULE 
  

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APPENDIX 4. 
TREATMENT GUIDELINES FOR SEVERE MALARIA 
Introduction 
Severe falciparum malaria is a medical emergency. Mortality is high and most deaths occur within 
24 hours after admission to the hospital. Cerebral malaria, the most prominent manifestation of se-
vere malaria carries a 16-20% mortality, but once multiple vital organ dysfunction occurs, the figure 
increases to as high as 30% (WHO 1990, 2000). The clinical manifestations depend on age. Hypo-
glycaemia, convulsions, and severe anaemia are relatively more common in children; acute renal 
failure, jaundice, and the acute respiratory distress syndrome (ARDS) are more common in adults. 
Cerebral malaria (with coma) and a severe metabolic (lactate) acidosis may occur at any age, and 
the severity of both features is a strong prognostic factor for a fatal outcome.  
 
Cerebral malaria is characterized by coma of varying depth, usually with no focal signs. Convulsions 
occur in up to 80% of cases in children, but in less than 10% of adults. If the patient survives, there 
are usually (>90%) no neurological sequelae. Unlike in septicaemia, circulatory shock (‘algid ma-
laria’) is not common in severe malaria. If hypotension is present, one should consider concomitant 
(gram negative) septicaemia or meningitis. Also, leucocytosis is not common in malaria, although it 
can be present in very severe disease. Leucocytosis with a shift to the left, should trigger the possi-
bility of concomitant bacterial infection. Thrombocytopenia is always present in severe malaria, but 
this is seldom accompanied by bleeding problems. Diffuse intravascular coagulation (DIC) is rare 
(less than 5% of severe cases), and can cause serious bleeding. Black water fever is a rare compli-
cation of falciparum malaria, with severe intravascular haemolysis and haemoglobinuria. It is asso-
ciated with the use of quinine and G-6-PD deficiency. About 10% of these patients have oliguric 
renal failure (Tran 1996). Table 1 gives a brief summary of the manifestations of severe malaria. 
Diagnosis and differential diagnosis 
In patients presenting with symptoms compatible with severe malaria, the diagnosis should be con-
firmed by a peripheral blood slide, or by rapid test based on the detection of the malaria antigen 
HRP2 (e.g., Paracheck-F test). The sensitivity of these rapid antigen test is high (97%), meaning 
that a negative test almost excludes the diagnosis falciparum malaria. However, the specificity de-
pends on the endemicity of the disease, since the test can remain positive for a few weeks after a 
malaria attack. Especially in highly endemic areas a positive test can thus be caused by a recent 
malaria episode, whereas the cause of the presenting fever can be a different one. The specificity 
of the test in non-endemic countries can be as high as 100% but drops to 85% in malaria endemic 
areas. A positive malaria slide, especially in the adult patient, does not prove that the presenting 
symptoms are caused by severe malaria, because of the high background prevalence of peripheral 
blood parasitaemia. Other causes of coma have thus also to be considered, including: hypoglycae-
mia, meningitis, septic shock and post-ictal coma (after febrile convulsion). Moreover, sedative 
drugs, severe anaemia, severe acidosis or severe hyponatraemia can contribute. All these factors 
(except meningitis and sedative drugs) can occur as a complication of severe malaria. Conse-
quently, blood glucose and Haematocrit should be checked in every patient (i-STAT or glucose-
stick), a lumbar puncture should be performed, and the blood pressure has to be measured. If avail-
able electrolytes and acid-base status should be checked. The treatment of these conditions is de-
scribed below 
 

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Antimalarial treatment 
The mainstay of the treatment of severe malaria is the immediate start of parenteral antimalarial 
treatment. The available antimalarial drugs to treat severe malaria are parenteral quinine and the 
parenteral artemisinin derivatives (artesunate).  
Artesunate belongs to the most rapidly acting and potent group of antimalarial drugs (artemisinin 
derivatives). They are safer and easier to administer compared to quinine. Artesunate and arteme-
ther are used widely in SE Asia, and increasingly in sub-Saharan Africa, for the treatment of uncom-
plicated and severe malaria as alternatives to quinine (Van Agtmael 1999). Injectable artesunate, 
which is water soluble, can be given intravenously and gives very reliable plasma levels. The dose 
of artesunate is 2.4 mg/kg i.v. or i.m. on admission, 12 hours, 24 hours, and then daily. Children <20 
kg will get 3.0 mg/kg.  If possible, to take oral medication, the patient can switch to an oral course 
of Coartem (dosing see above). The artemisinin derivatives have remarkably few side effects. Aller-
gic skin reactions and anaphylaxis have been reported. 
 
 
Treatment of specific complications. 
Generally, all patients who are in a critical condition (i.e., their survival is questionable) on admission 
should be transferred immediately to the intensive care unit. Patients who have been admitted to 
the ward and who show signs of deterioration which endangers their survival should be transferred 
from the ward to the ICU. 
 
Fluid management  
Severe malaria is a multi-organ disease, and supportive treatment for all kinds of organ failure can 
be indicated. Fluid management can be difficult. The patient is usually dehydrated on admission, 
and should be rehydrated to support the already compromised microcirculation. Hyponatraemia is 
common, and mainly a consequence of dehydration. Dextrose-Saline can be used for rehydration, 
and not only dextrose solutions. (Saline without dextrose can be used in adults but should never be 
used in paediatric patients.) Dextrose solutions without any NaCl will further lower the plasma so-
dium concentration, and will inadequately rehydrate the patient. However, there is a strong tendency 
to develop pulmonary oedema, so care should be taken to avoid too aggressive fluid infusion.  
 
Hypotension is not a common feature of severe malaria and in case of circulatory shock, concurrent 
septicaemia should be considered. Blood cultures should be taken and the patient should be treated 
empirically with antibiotics, covering gram-negative bacteria (e.g., the combination of cefotaxime 
and gentamicin). In case of hypotension, the patient should receive fluid resuscitation. Systemic 
salmonella infection may develop, presumably because of increased translocation of bacteria in the 
gut (Mabey 1987). If the patient has been admitted for several days in the ICU, hospital acquired 
infections should also be considered. Secondary pneumonia is common. 
 
Acidosis in severe malaria can be due to acute renal failure, but usually is a lactic acidosis resulting 
from tissue hypoxia, generally in the absence of hypotension. Treatment should therefore be di-
rected to optimize the microcirculation, but we have only limited tools to achieve this. Prompt treat-
ment of the parasite causing sequestration and obstruction in small vessels, optimal fluid manage-
ment and treatment of severe anaemia can all contribute. Using iSTAT results can help in the man-
agement of acidosis. If the arterial pH drops below 7.2, 100 ml 8.4% HCO3 over 30 minutes can be 
given.  
 

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Anaemia is a frequent feature, especially in young children with severe malaria. Transfusion of 
packed red cells can be restricted to those with haematocrit falling below 20%. It is essential that 
blood products are negative for transmissible diseases like HIV, hepatitis B, hepatitis C and syphilis.  
 
Disseminated Intravascular Coagulation (DIC) 
 For those rare patients who develop DIC with bleeding, fresh frozen plasma can be given. In addi-
tion, vitamin K should be administered, in a daily dose of 10 mg slowly i.v., for 3 days. 
Coma 
Hypoglycaemia as a cause for convulsions should be ruled out. A lumbar puncture should be con-
sidered. The usual nursing care for the unconscious patient should be applied. If available a naso-
gastric tube should be inserted and the stomach contents let out. To decrease the chances of aspi-
ration, enteral feeding should not be started on the first day of admission. The patient should be 
turned every 2 hours to prevent bedsores. If possible, it is preferable to insert a urethral (‘Foley’) 
catheter to prevent maceration of the skin and for monitoring fluid management. Eyes should be 
kept irrigated with saline or artificial tears and the lids kept closed with eye pads. The severity of 
coma should be graded using the Glasgow coma scale for adults and the Blantyre coma scale for 
children. Deterioration in the coma score should be reported immediately to the physician on call. 
 
Convulsions are very common in children with cerebral malaria. As for coma, hypoglycaemia as a 
cause for convulsions should be ruled out. A lumbar puncture should be considered. In adults, con-
vulsions are relatively rare, so that prophylaxis is not generally recommended. If seizures occur, 
they should be treated promptly with intravenous benzodiazepines (adults 10 mg iv, children 0.3 
mg/kg). Since children are prone to febrile convulsions, treatment to reduce fever (paracetamol, cold 
sponging, etc.) should be given if the rectal temperature is above 39C.  
 
Hypoglycaemia is particularly common in children and pregnant women with malaria, and, as men-
tioned above, with the use of quinine. It can be treated with 1 ml/kg of a 50% glucose solution. 
 
Oliguric renal failure is a common complication of severe malaria in adults. However, occasionally 
the renal failure is non-oliguric. If the adult patient is oliguric (< 20 ml per hour), this can be caused 
by dehydration or acute tubular necrosis. Dehydration requires rehydration with normal saline, 
whereas acute tubular necrosis (ATN) requires dialysis and carries the danger for fluid overloading 
since the patients is not likely restore diuresis with appropriate clearance during the following 2 to 5 
days. The clinical assessment of the hydration status (skin turgor, dry lips and mouth, tears, jugular 
venous pressure). If there is still no diuresis after adequate rehydration, furosemide can be given in 
increasing doses 40mg-100mg-200mg-400mg at half hour intervals. This will not improve renal func-
tion, but if diuresis is still absent after this procedure, it is likely that the patient has ATN.  
 
Acute respiratory distress syndrome (ARDS) is a feared complication of mainly adult severe 
malaria. The chest X-ray will generally show diffuse shadowing of the lung fields. In case of respir-
atory distress, the patient should be propped upright and receive oxygen therapy (nasal catheter or 
face mask). Furosemide should be tried to lower the venous pressure, but this will not often relief 
symptoms, since the pathogenesis is capillary leakage and not fluid overload per se.  
 
Blackwater fever with severe intravascular haemolysis can cause severe anaemia requiring trans-
fusion. On theoretical grounds alkalinisation of the urine can be recommended in this condition, 
although no clinical studies are available. 
 

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Conclusions. 
A patient with severe falciparum malaria with multiple organ failure is a challenge for the treating 
physician. If the patient, often a young individual, survives, there are usually no sequelae. Prompt 
diagnosis and start of antimalarial treatment are essential. But good supportive treatment, realizing 
the common complications of the disease, is equally important.  
 
 
 
 
 
 

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Table 1 Brief summary of the manifestations of severe malaria. 
 
Manifestations of severe 
malaria 
 
Pathophysiology 
Treatment 
Coma 
Compromised microcircula-
tion, other factors like local 
nitric oxide overproduction? 
Good nursing care.  
Lumbar puncture to rule out 
meningitis. 
Rule out hypoglycaemia. 
 
Convulsions 
Compromised microcircula-
tion, 
Hypoglycemia. 
Diazepam, phenobarbitone, 
phenytoin 
Lumbar puncture to rule out 
meningitis. 
Rule out hypoglycaemia.  
Severe anaemia 
Clearance 
of 
parasitized 
cells and rigid uninfected 
red cells.  
Transfusion if in distress, or 
<Hct 20% 
Hyperpyrexia 
TNF and other cytokines 
 
Paracetamol, sponging, etc. 
Hyperparasitaemia 
Host and strain dependant 
Anti-malarial drugs. 
Hypoglycaemia 
Increased use, decreased 
production, quinine related 
hyperinsulinism 
Glucose 10%, 50% 
Renal failure 
ATN 
dialysis 
Hepatic dysfunction, jaun-
dice 
 
 
No specific treatment, check 
plasma glucose. 
Fluid, electrolyte imbalance 
and metabolic acidosis 
Dehydration, slight capillary 
leakage, 
lactic 
acidosis 
(compromised microcircula-
tion), renal failure, severe 
anaemia 
Careful fluid resuscitation,  
HCO3 if pH<7.20,  
packed cell transfusion if 
Hct<20% 
ARDS 
Unknown (cytokines, com-
promised microcirculation). 
 
Careful fluid management. 
Black water fever 
Unknown, related to quinine 
use and G6PD deficiency. 
Transfusion if needed, alka-
linisation of the urine. 
Circulatory collapse 
Uncommon in malaria (NO 
binding?), consider concur-
rent septicaemia 
Fluids, vasopressor drugs, 
antibiotics. 
 

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References to treatment guidelines for severe malaria  
Artemether-Quinine Meta-analysis Study Group. A meta-analysis using individual patient data of 
trials comparing artemether with quinine in the treatment of severe falciparum malaria. Trans R Soc 
Trop Med Hyg 2001;95:637-650. 
 
Crawley J, Waruiru C, Mithwani S, Mwangi I, Watkins W, Ouma D, Winstanley P, Peto T, Marsh K. 
Effect of phenobarbital on seizure frequency and mortality in childhood cerebral malaria: a random-
ised, controlled intervention study. Lancet. 2000;355:701-706. 
 
Day NP, Phu NH, Bethell DP, Mai NT, Chau TT, Hien TT, White NJ. The effects of dopamine and 
adrenaline infusions on acid-base balance and systemic haemodynamics in severe infection. Lan-
cet. 1996 Jul 27;348(9022):219-23. 
Hien TT, Day NPJ, Phu NH, Mai NTH, Chau TTH, Loc PP, Sinh DX, Chuong LV, Waller D, Peto 
TEA, White NJ. A controlled trial of artemether or quinine in Vietnamese adults with severe 
falciparum malaria. N Engl J Med 1996;335:76-83. 
Ilett KF, Batty KT, Powell SM, Binh TQ, Thu le TA, Phuong HL, Hung NC, Davis TM. The pharma-
cokinetic properties of intramuscular artesunate and rectal dihydroartemisinin in uncomplicated fal-
ciparum malaria. Br J Clin Pharmacol 2002;53:23-30. 
 
Mabey DCW, Brown A, Greenwood BM. Plasmodium falciparum malaria and Salmonella infection 
in Gambian children. J Infect Dis 1987; 155: 1319-1321. 
 
Newton P, Angus BJ, Chierakul W, Teerapong P, Dondorp A, Ruangveerayuth R, Silamut K, Looa-
reesuwan S, White NJ. A randomised comparison of intravenous artesunate or quinine in the treat-
ment of severe falciparum malaria. Clin Infect Dis 2003; 37: 7-16.  
 
Phu NH, Hien TT, Mai NT, Chau TT, Chuong LV, Loc PP, Winearls C, Farrar J, White N, Day N. 
Hemofiltration and peritoneal dialysis in infection-associated acute renal failure in Vietnam. N Engl 
J Med. 2002;347: 895-902. 
 
Price RN, van Vugt M, Phaipun L,Luxemburger C, Simpson J, McGready R, ter Kuile F, Kham A, 
Chongsuphaijaisiddhi T, White N.J & Nosten F. Adverse effects in patients with acute falciparum 
malaria treated with artemisinin derivatives. Am J Trop Med Hyg 1999; 60: 547-550. 
 
Tran TH, Day NP, Ly VC, Nguyen TH, Pham PL, Nguyen HP, Bethell DB, Dihn XS, Tran TH, White 
NJ. Blackwater fever in southern Vietnam: a prospective descriptive study of 50 cases. 
Clin Infect Dis 1996; 6:1274-1281. 
 
Van Agtmael MA, Eggelte TA, van Boxtel CJ. Artemisinin drugs in the treatment of malaria: from 
medicinal herb to registered medication. Trends in Pharmacol Sci 1999; 20: 199-205. 
 
White NJ, Looareesuwan S, Warrell DA, Warrell MJ, Bunnag D, Harinasuta T. Quinine pharmaco-
kinetics and toxicity in cerebral and uncomplicated falciparum malaria. Am J Med 1982; 73: 564-
572. 
 
White NJ, Warrell DA, Chanthavanich P, Looareesuwan S, Warrell MJ, Krishna S, Williamson DH, 
Turner RC. Severe hypoglycemia and hyperinsulinemia in falciparum malaria. N Engl J Med 
1983;309:61-66.  

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White NJ. The treatment of malaria. N Engl J Med 1996;335:800-806. 
World Health Organisation. Severe and complicated malaria. Trans R Soc Trop Med Hyg 1990;84 
S2:1-65. 
 
World Health Organisation. Severe and complicated malaria. Trans R Soc Trop Med Hyg 2000;94 
S1:1-90. 
Yen LM, Dao LM, Day NP, Waller DJ, Bethell DB, Son LH, Hien TT, White NJ. Role of quinine in 
the high mortality of intramuscular injection tetanus. Lancet. 1994;344:786-7. 
 
 

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APPENDIX 5: PHARMACOKINETIC REPORT 
 
Dr. Richard Hoglund 
 
________________________________________________________________ 
(Head of Phamacometrics) 
 
 
 
 
 
 
 
Date 
 
 
Prof. Dr. Joel Tarning  
________________________________________________________________ 
(Head of Department)  
 
 
 
 
 
 
 
Date 
 
 
 
 

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Pharmacokinetic analysis was performed from 4 Frb 2019 to 22 Feb 2019 by: 
Dr. Richard Hoglund  
Head of Pharmacometrics  
____________________________ 
 
 
Pharmacokinetic report generated by: 
Dr. Richard Hoglund  
Head of Pharmacometrics  
____________________________ 
 
 
Pharmacokinetic report reviewed by: 
Dr. Junjie Ding 
 
Senior Scientist  
 
____________________________ 
 
 
Pharmacokinetic report approved by: 
Dr. Richard Hoglund  
Head of Pharmacometrics  
____________________________ 
 
Prof. Dr. Joel Tarning 
Head of Department 
 
____________________________ 
 
 

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APPENDIX 6: AMENDMENT HISTORY 
 
Amend-
ment No. 
Protocol Ver-
sion No. 
Date issued 
Author(s) of 
changes 
Details of Changes made 
NA 
NA 
NA 
NA 
NA