A Multi-centre Randomised Controlled Non-inferiority Trial to Compare the Efficacy, Safety and Tolerability of Triple Artemisinin-based Combination Therapies Versus First-line ACTs + Placebo for the Treatment of Uncomplicated Plasmodium Falciparum Malaria in Asia
Phase: PHASE3
Conditions: Plasmodium Falciparum Malaria (Uncomplicated)
Sponsor: University of Oxford

 
 
 
 
 
 
 
 
 
 
DeTACT-ASIA 
 
  A multi-centre, randomised, controlled, non-inferiority trial to compare the efficacy, 
safety and tolerability of Triple Artemisinin-based Combination Therapies versus first-
line ACTs+placebo for the treatment of uncomplicated Plasmodium falciparum malaria in 
Asia 
 
Short title: A study by the Development of Triple Artemisinin-based Combination Therapies 
(DeTACT) Project 
Protocol version: version 6.0 dated 23 March 2022 
Trial registration number: NCT03939104 
 
 
 

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A multi-centre randomised controlled non-inferiority trial to compare the efficacy, safety 
and tolerability of Triple Artemisinin-based Combination Therapies versus first-line ACTs 
+ placebo for the treatment of uncomplicated Plasmodium falciparum malaria in Asia 
A study by the Development of Triple Artemisinin Combination Therapies (DeTACT) 
Collaboration 
 
ACRONYM: DeTACT-ASIA study 
Protocol no.: MAL18005 
OxTREC ref: 36-18 
Principal Investigator:  
Prof. A.M. Dondorp 
Project coordinators 
Dr. Chanaki Amaratunga, Dr. Mehul 
Dhorda 
Sponsor 
University of Oxford 
Funder 
UKAid, Foreign & Commonwealth 
Development Office 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Protocol development team:  
AM Dondorp, NJ White, NPJ Day, MJ Dhorda, RW van der Pluijm, Hien TT, J Tarning, M Imwong, 
Z Bozdech, K Chotivanich, O Miotto, T Cope, M Mukaka, N Waithira, S Duparc, WRJ Taylor, L 
von Seidlein, K Stepniewska, MA Faiz, N Valecha, A Anvikar, S Satpathi, P Satpathi, EA Ashley, 
AP Phyo, R Huy, D Lek, I Sutanto, JK Baird, K Plewes, R Tripura, C Amaratunga 
 
Confidentiality Statement 

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This document contains confidential information that must not be disclosed to anyone other than 
the Sponsor, the Investigator Team, host institution, relevant ethics committee and regulatory 
authorities. 
 
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 
Tripartite 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: 
   
 
 
 
 
 
 
       
 
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, RATIONALE AND PROJECT STRUCTURE .......................... 13 
3.1. 
Background .................................................................................................................... 13 
3.2. 
Study rationale................................................................................................................ 15 
4. 
OBJECTIVES ...................................................................................................... 16 
4.1. 
Primary objectives .......................................................................................................... 16 
4.2. 
Secondary objectives ...................................................................................................... 16 
4.3. 
Exploratory objectives.................................................................................................... 16 
5. 
PRIMARY, SECONDARY AND EXPLORATORY ENDPOINTS ........................ 17 
5.1. 
Primary endpoint ............................................................................................................ 17 
5.2. 
Secondary endpoints ...................................................................................................... 17 
5.3. 
Exploratory endpoints .................................................................................................... 18 
6. 
TRIAL DESIGN ................................................................................................... 19 
6.1. 
Study sites ...................................................................................................................... 19 
6.2. 
Summary of trial design ................................................................................................. 19 
6.3. 
Study duration ................................................................................................................ 19 
7. 
PROPOSED ACTIVITIES ................................................................................... 19 
8. 
TRIAL PARTICIPANTS ...................................................................................... 21 
8.1. 
Overall description of trial participants .......................................................................... 21 
8.2. 
Inclusion criteria ............................................................................................................. 21 
8.3. 
Exclusion criteria............................................................................................................ 21 
8.4. 
Criteria for severe malaria .............................................................................................. 22 
9. 
PROCEDURES ................................................................................................... 22 
9.1. 
Informed consent ............................................................................................................ 22 
9.2. 
Screening procedures ..................................................................................................... 23 
9.3. 
Baseline assessments ...................................................................................................... 23 
9.3.1. 
Demographic and medical history .......................................................................... 23 
9.3.2. 
Drug history ............................................................................................................ 23 
9.4. 
Randomization and blinding .......................................................................................... 24 
9.5. 
Clinical procedures ......................................................................................................... 24 
9.5.1. 
Clinical procedures at baseline ............................................................................... 24 
9.5.2. 
Clinical procedures during hospitalization ............................................................. 25 

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9.5.3. 
Place of residence, work, travel history and mobile phone use. ............................. 25 
9.5.4. 
Clinical procedures during follow up ..................................................................... 25 
9.5.5. 
Clinical procedures in case of a recurrent infection ................................................ 26 
9.5.6. 
Clinical procedures in case of unscheduled visits................................................... 26 
9.6. 
Electrocardiographic recording ...................................................................................... 27 
9.7. 
Blood sampling .............................................................................................................. 27 
9.7.1. 
On admission/baseline ............................................................................................ 27 
9.7.2. 
During hospitalization ............................................................................................. 28 
9.7.3. 
Blood sampling during follow up ........................................................................... 28 
9.7.4. 
Blood sampling in case of a recurrent infection ..................................................... 29 
9.7.5. 
Blood sampling for pharmacokinetics .................................................................... 30 
9.7.6. 
Host genotyping ...................................................................................................... 31 
9.8. 
Special procedures related to baseline biochemistry measurements .............................. 31 
9.9. 
Time window for follow up visits .................................................................................. 31 
9.10. 
Blood volumes ............................................................................................................ 31 
10. 
STUDY DRUG ..................................................................................................... 32 
10.1. 
Study drug regimens ................................................................................................... 32 
10.2. 
Drug administration procedures in case of vomiting .................................................. 33 
10.3. 
Treatment in case of a recurrent infection .................................................................. 33 
10.4. 
Rescue treatment ......................................................................................................... 33 
10.5. 
Concomitant medication ............................................................................................. 33 
10.6. 
Study drug details ....................................................................................................... 34 
10.6.1. 
Artemether-lumefantrine ..................................................................................... 34 
10.6.2. 
Amodiaquine ....................................................................................................... 34 
10.6.3. 
Artesunate-mefloquine ........................................................................................ 34 
10.6.4. 
Piperaquine .......................................................................................................... 35 
10.6.5. 
Primaquine .......................................................................................................... 35 
10.6.6. 
Placebo for piperaquine ....................................................................................... 35 
10.6.7. 
Placebo for amodiaquine ..................................................................................... 35 
10.7. 
Storage of study drugs ................................................................................................ 35 
10.8. 
Accountability of the study drugs ............................................................................... 35 
11. 
DISCONTINUATION/ WITHDRAWAL OF PARTICIPANTS FROM THE STUDY
 
35 
12. 
SAFETY REPORTING ........................................................................................ 36 
12.1. 
Definitions .................................................................................................................. 37 

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12.1.1. 
Adverse events (AEs) .......................................................................................... 37 
12.1.2. 
Grading of laboratory abnormalities ................................................................... 37 
12.1.3. 
Serious adverse events (SAEs) ............................................................................ 38 
12.1.4. 
Study defined SAEs ............................................................................................ 38 
12.2. 
Reporting procedures for Serious Adverse events ..................................................... 38 
12.3. 
Evaluating adverse events and Serious adverse events .............................................. 39 
12.3.1. 
Assessment of intensity of AEor SAE ................................................................ 39 
12.3.2. 
Assessment of relatedness of AE or SAE to study drugs .................................... 39 
12.3.3. 
Outcome of AE and SAEs ................................................................................... 39 
12.4. 
Clarification of the difference in the meaning of ‘severe’ and ‘serious’ .................... 40 
13. 
SOURCE DATA .................................................................................................. 40 
14. 
LABORATORY STUDIES ................................................................................... 40 
14.1. 
Drugs concentration assays ........................................................................................ 40 
14.2. 
Ex vivo and in vitro sensitivity assays ........................................................................ 40 
14.3. 
Molecular studies ........................................................................................................ 41 
14.4. 
PCR for quantitative parasitaemia .............................................................................. 41 
14.5. 
Immunity .................................................................................................................... 41 
15. 
STATISTICAL CONSIDERATIONS .................................................................... 41 
15.1. 
Sample size justification ............................................................................................. 41 
15.2. 
Statistical analysis....................................................................................................... 42 
15.2.1. 
Proportions .......................................................................................................... 42 
15.2.2. 
Continuous data ................................................................................................... 42 
15.2.3. 
Pharmacokinetic data .......................................................................................... 42 
15.2.4. 
Safety analysis ..................................................................................................... 43 
16. 
DIRECT ACCESS TO SOURCE DATA/DOCUMENTS ...................................... 43 
17. 
QUALITY CONTROL AND QUALITY ASSURANCE PROCEDURES ............... 43 
17.1. 
Monitoring .................................................................................................................. 43 
18. 
DSMB AND PROJECT STEERING COMMITTEE ............................................. 43 
18.1. 
DSMB ......................................................................................................................... 43 
18.2. 
Project steering committee ......................................................................................... 44 
19. 
ETHICS ............................................................................................................... 45 
19.1. 
Declaration of Helsinki ............................................................................................... 45 
19.2. 
ICH Guidelines for Good Clinical Practice ................................................................ 45 
19.3. 
Approvals.................................................................................................................... 45 

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19.4. 
Risks ........................................................................................................................... 45 
19.4.1. 
Risks of artemether-lumefantrine ........................................................................ 45 
19.4.2. 
Risks of amodiaquine .......................................................................................... 45 
19.4.3. 
Risks of artesunate-mefloquine ........................................................................... 45 
19.4.4. 
Risks of piperaquine ............................................................................................ 46 
19.4.5. 
Risks of new partner drug combinations ............................................................. 46 
19.4.6. 
Risk of phlebotomy & finger stick ...................................................................... 46 
19.5. 
Benefits ....................................................................................................................... 46 
19.6. 
Alternatives to study participation .............................................................................. 46 
19.7. 
Incentives & Compensation........................................................................................ 46 
19.8. 
Confidentiality ............................................................................................................ 47 
20. 
SAMPLE SHARING AND STORAGE................................................................. 47 
21. 
DATA HANDLING AND RECORD KEEPING .................................................... 47 
22. 
SPONSORSHIP AND INSURANCE ................................................................... 47 
23. 
PUBLICATION POLICY ...................................................................................... 47 
24. 
REFERENCES .................................................................................................... 48 
APPENDIX 1. ................................................................................................................ 50 
STUDY SCHEDULE ............................................................................................................... 50 
BLOOD SAMPLING SCHEDULE ......................................................................................... 51 
APPENDIX 2. DOSING SCHEDULES .......................................................................... 52 
APPENDIX 3. LIST OF POTENTIAL STUDY SITES .................................................... 55 
 

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1. LIST OF ABBREVIATIONS 
ACPR  
Adequate clinical and parasitological response 
ACT 
 
Artemisinin-based combination therapy 
AE 
 
Adverse event 
AL 
 
Artemether-lumefantrine 
AQ 
 
Amodiaquine 
AS 
 
Artesunate 
ASMQ  
Artesunate-mefloquine 
AUC 
 
Area under the (plasma concentration-time) curve 
CRF 
 
Case record form 
CTSG  
Clinical Trials Support Group (MORU) 
CYP3A4 
Cytochrome P450 3A4  
DHA 
 
Dihydroartemisinin 
DNA                Deoxyribonucleic Acid 
DSMB  
Data and Safety Monitoring Board 
EDC                Electronic data capture 
EDTA  
Ethylene-diamine-tetra-acetic acid  
ERB 
 
Ethics Review Board 
G6PD  
Glucose-6-phosphate dehydrogenase 
GCP 
 
Good Clinical Practice 
Hb                   Haemoglobin 
Hct 
 
Haematocrit 
IM 
 
Intramuscular 
IV 
 
Intravenous 
MORU  
Mahidol-Oxford Research Unit 
MQ 
 
Mefloquine 
NMCP  
National Malaria Control Programme 
OxTREC 
Oxford Tropical Research Ethics Committee 
PBO 
 
Placebo 
PCR 
 
Polymerase Chain Reaction 
PCT 
 
Parasite Clearance Time 
PD 
 
Pharmacodynamic 
Pfmdr1 
P. falciparum Multi-Drug Resistance Gene 1 
PK 
 
Pharmacokinetic 
PPQ 
 
Piperaquine 
QA 
 
Quality Assurance 
QC 
 
Quality Control 
RNA 
 
Ribonucleic acid 
SAE 
 
Serious Adverse Event 
SNP 
 
Single-nucleotide polymorphism 
TACT  
Triple Artemisinin-based Combination Therapy 
TRAC  
Tracking Resistance to Artemisinin Collaboration 
WBC  
White Blood Cells 
WHO  
World Health Organisation 
WI 
 
Work Instruction 
WWARN 
Worldwide Antimalarial Resistance Network 
 
 

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2. SYNOPSIS 
Study Title 
A multi-centre, randomised, controlled non-inferiority trial to compare the efficacy, 
safety and tolerability of Triple Artemisinin-based Combination Therapies versus first-
line ACTs + placebo for the treatment of uncomplicated Plasmodium falciparum malaria 
in Asia 
ACRONYM 
DeTACT-Asia 
Trial Design 
A partially blinded randomised controlled non-inferiority trial comparing the efficacy, 
tolerability and safety of Triple ACTs artemether-lumefantrine+amodiaquine (AL+AQ) 
and artesunate- mefloquine+piperaquine (ASMQ+PPQ) and the ACTs artemether-
lumefantrine+placebo (AL+PBO), artesunate-mefloquine+placebo (ASMQ+PBO) (with 
single-low dose primaquine in some sites) for the treatment of uncomplicated 
Plasmodium falciparum malaria to assess and compare their efficacy, safety, 
tolerability. 
Trial          
Participants 
Subjects with acute uncomplicated P. falciparum malaria  
Sample size 
6 sites (5 countries) in Asia each site recruiting 228 subjects  
Currently identified sites are 1 each in Cambodia, Myanmar, Bangladesh, Indonesia 
and 2 sites in India.  
Note: In India, 2 locations in Rourkela and Midnapore will function as one site. In 
Cambodia, three locations Kravanh,Siem Pang and Chambak will function as one site.  
(detail in Appendix 3) 
Estimated sample size up to 1,368 subjects. 
Inclusion    
Criteria 
• Male or female, ≥ 6 months 
• Ability to take oral medication  
• Acute uncomplicated P. falciparum monoinfection 
• Asexual P. falciparum parasitaemia: 96 to 200,000/µL, determined on a  peripheral 
blood film 
• Fever defined as > 37.5°C tympanic temperature or a history of fever within the last 
24 hours 
• Written informed consent by the subject or by the parent/guardian in case of children 
lower than the age of consent and assent if required (per local regulations) 
• Willingness and ability of the subjects or parents/guardians to comply with the study 
protocol for the duration of the study 

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Exclusion  
Criteria 
 
Signs of severe malaria (adapted from WHO criteria see section 8.4) 
 
Patients not fulfilling criteria for severe malaria but with another indication for 
parenteral antimalarial treatment at the discretion of the treating physician 
 
Hematocrit < 20% at screening  
 
Subjects who have received artemisinin or a derivative within the previous 7 
days OR lumefantrine or amodiaquine within the previous 14 days OR 
mefloquine or piperaquine within the previous 30 days 
 
Acute illness other than malaria requiring systemic treatment 
 
Severe acute malnutrition  
 
Known HIV infection 
 
Known tuberculosis infection 
 
For females: pregnant, trying to get pregnant or are lactating 
 
History of allergy or known contraindication to any of the study drugs, including 
neuropsychiatric disorders and epilepsy 
 
Previous splenectomy 
 
Enrolment in DeTACT in the previous 3 months 
 
Participation in another interventional study in the previous 3 months 
Planned Trial 
Period 
Projected recruitment of 20 months March 2021 – October 2022; study projected to 
finish in March 2023. 
Primary      
Objective 
To compare the efficacy of the ACTs and TACTs as defined by the 42-day PCR 
corrected adequate clinical and parasitological response (ACPR) within each individual 
site 
Secondary 
Objectives 
 
To compare the safety and tolerability of ACTs and TACTs within and across 
sites and regions, including comparisons of ‘non-matching’ ACTs vs TACTs 
(AL+PBO vs ASMQ+PPQ, ASMQ+PBO vs AL+AQ) 
 
To compare additional measures of treatment efficacy between treatment arms, 
including the 63-day ACPR, the post-treatment prophylactic effect of ACTs and 
TACTs defined as the 42-day and 63-day PCR uncorrected ACPR, gametocyte 
carriage, parasite clearance rates and fever clearance. 
 
To assess pharmacokinetic and pharmacodynamic interactions between 
antimalarials in TACTs 

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Exploratory     
Objectives 
 
To assess molecular genetic and transcriptomic correlates for artemisinin and 
partner drug resistance of the infecting P. falciparum strains and to assess their 
ex vivo and in vitro drug susceptibility. 
 
To compare the selective effect of ACTs versus TACTs on parasites carrying 
mutations associated with resistance to antimalarial drugs 
 
To obtain additional safety data (in particular incidence, rate and magnitude of 
haemolysis) on the deployment of single low dose primaquine, stratified 
according to G6PD status/genotype 
 
To obtain additional data on the effect of the host genotypes known to affect 
pharmacokinetics and pharmacodynamics of antimalarials 
 
To obtain data on the place of residence, work, recent travel history and mobile 
phone usage in order to improve the understanding of local malaria 
transmission by identifying behaviours and risk factors associated with malaria 
infection and possible routes of spread of malaria and artemisinin resistance 
 
To assess new methods for determination of gametocytaemia, parasite 
phenotypes and genotypes  
 
To assess the correlation between anti-Plasmodium falciparum antibodies and 
drug efficacy measures 
 
To assess the prevalence of parasites carrying complete or partial deletions in 
pfhrp2 gene 
Primary   
endpoint 
42-day efficacy defined as PCR-corrected adequate clinical and parasitological 
response (ACPR).  
 
Secondary 
endpoints 
 
For safety and tolerability: Incidence of adverse events and serious adverse 
events within the first 42 days including markers of hepatic, renal or bone 
marrow toxicity; cardiotoxicity, in particular QT or QTc-interval above 500 ms at 
timepoint H4 and H52/H64 and between these time points; change in 
haemoglobin concentration at day 3, 7, 28, stratified for G6PD status/genotype; 
proportion of subjects requiring retreatment due to vomiting within 1 hour after 
administration of the study drugs; proportion of subjects that reports completing 
a full course of observed TACT or ACT without withdrawal of consent or 
exclusion from study because of drug related serious adverse event 

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 
For efficacy: 63-day PCR corrected and uncorrected efficacy;  42-day PCR 
uncorrected efficacy; parasite clearance half-life assessed by microscopy as 
primary parameter to determine parasite clearance; proportion of subjects with 
microscopically detectable P. falciparum parasitaemia at Day 3;  fever clearance 
time (i.e. the time taken for the tympanic temperature to fall below 37.5 ºC in 
patients who were febrile at inclusion); proportion of subjects with 
gametocytaemia during and after treatment stratified by presence of 
gametocytes at enrolment. 
 
For PK/PD interactions: Pharmacokinetic profiles and interactions (including 
Cmax and AUC) of artemisinin-derivatives and partner drugs in ACT and TACT 
treated subjects in correlation with pharmacodynamics measures of drug 
efficacy; day 7 plasma levels of partner drugs in correlation with treatment 
efficacy and treatment arm 
Exploratory  
endpoints 
 
Comparison of 63-day vs 42-day PCR corrected and uncorrected efficacy of 
ACTs vs TACTs 
 
Proportions of recurrent infections with parasites carrying mutations of known 
functional significance  
 
Proportions of specimens collected at baseline with parasites carrying 
mutations of known functional or operational significance (pfkelch13, pfcrt, 
pfmdr1, pfdhfr, pfdhps, pfplasmepsin2 , partial or complete deletions of pfhrp2 
and other current parasite genetic markers associated with resistance or 
identified over the course of the study) 
 
Candidate markers of resistance identified through genome wide association 
studies with in vivo or in vitro parasite drug sensitivity phenotypes 
 
In vitro sensitivity of P. falciparum to artemisinins and partner drugs according 
to study sites and genotype 
 
Accuracy of SNPs assessment from dry blood spots versus from whole genome 
sequencing in leukocyte depleted blood samples 
 
Correlation between qPCR based versus microscopy based assessments of 
parasite clearance dynamics 
 
Correlation of parasite clearance metrics as assessed by microscopy versus 
digital microscopy 
 
Comparison of transcriptomic patterns of drug sensitive and resistant parasites 
before treatment and 6, 12 and 24 hours  after start of treatment 
 
Levels of RNA transcription coding for male or female specific gametocytes at 
admission up to day 14, stratified by the presence of gametocytes at enrolment 

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 
Correlation 
between 
the 
host 
genotype 
(e.g., 
CYP2D6, 
CYP3A4, 
KCNQ1/LQT1, KCNH2/LQT2, SCN5A/LQT3) and the pharmacokinetics and 
pharmacodynamics of antimalarials. 
 
Correlations between the place of residence, work, recent travel history 
assessed by interview and mobile phone records to identify behaviours and risk 
factors associated with malaria infection.   
 
Correlation between specific antibody titres and measures of drug efficacy 
Drugs 
 
See  
Appendix 2 
for dosing 
regimens 
  
 Artemether-lumefantrine+placebo for 3 days. 
VERSUS 
 Artemether-lumefantrine+amodiaquine for 3 days. 
VERSUS 
Artesunate-mefloquine+placebo for 3 days  
VERSUS 
Artesunate-mefloquine+piperaquine for 3 days 
Primaquine 
According to the WHO guideline, all subjects except children under 10 kilograms will 
also be treated with a single dose of primaquine according to the local requirements or 
guidelines and WHO treatments schedule as a gametocytocidal treatment. Primaquine 
will not be deployed in study sites with median to high levels of malaria transmission 
(estimated Annual Parasite Incidence ≥ 50 per 1000 population per year according to 
the WHO World Malaria Report 2017) 
 

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3. BACKGROUND, RATIONALE AND PROJECT STRUCTURE 
3.1. 
Background 
Artemisinin combination therapies (ACTs) have been a major contributor to the substantial 
reductions in global malaria morbidity and mortality over the last decade. However, further gains 
are threatened by the recent emergence of artemisinin and partner drug resistance in Southeast 
Asia, a region which has been the epicentre for the evolution and spread of resistance to every 
important class of antimalarials.  
 
The Tracking Resistance to Artemisinin Collaboration (TRAC), coordinated by the Mahidol Oxford 
Research Unit (MORU) at sites in Asia and Africa, mapped areas of artemisinin resistance, 
defined as slow parasite clearance (clearance half-life >5 hours) [1]. In many areas with 
artemisinin resistance, this has now been compounded by ACT partner drug resistance [2]. 
Consequently, treatment failures after artemisinin combination therapies are becoming more 
widespread in Southeast Asia. Failures rates of >60% for dihydroartemisinin-piperaquine have 
been documented in Cambodia, Thailand and Vietnam [3-5], (TRACII project unpublished data).  
 
A lineage of artemisinin and piperaquine resistant parasites originating in Western Cambodia is 
now well established in Cambodia, Vietnam and Thailand [6]. In Cambodia, the first line treatment 
for uncomplicated P. falciparum malaria has recently been changed to artesunate-mefloquine, but 
it is feared that the current high efficacy of this combination can be lost rapidly.  
 
Loss of efficacy of first line ACTs jeopardizes current malaria control and elimination efforts and 
will accelerate the spread of drug resistance. A major concern is that artemisinin and partner drug 
resistance may spread across a wider geographic area, as chloroquine resistance did in the 
1960s and 1970s, moving from Southeast Asia to the Indian subcontinent and subsequently to 
Africa, which bears the vast majority of the global malaria burden. Furthermore, artemisinin 
resistance could worsen by extending beyond the current ring stage parasite resistance, although 
this has until now not been observed.  
 
New antimalarial drugs are not expected to come to the market within the next 5 years. There is 
an urgent need to evaluate alternative treatments using combinations of existing drugs which will 
not fall rapidly to resistance and can be deployed immediately. These treatments are needed now 
for areas in the Greater Mekong Subregion where ACTs are increasingly failing. In addition, 
regions where ACTs are currently still effective, including Myanmar, Bangladesh, India and Sub-
Saharan Africa, will need to be prepared with alternative treatments in case multidrug resistant 
falciparum malaria is imported or emerges de novo. For these regions it is important to develop 
strategies to prevent the spread or delay the emergence of artemisinin and ACT partner drug 
resistance and deployment of Triple Artemisinin Combination Treatments (TACT) could be part 
of such a strategy. 
 
The underlying scientific rationale for TACTs is similar to that underlying current ACTs and the 
treatment of tuberculosis, Human Immunodeficiency Virus, Helicobacter pylori, and several other 
infections. If drugs with different targets or resistance mechanisms are combined, then the 
probability that resistance will emerge to the combination will usually equate to the product of the 

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individual components’ resistance probabilities. As these individual probabilities are very small, 
combining drugs is a powerful method of reducing the emergence of resistance [7]. The 
emergence and survival of a mutant organism which is spontaneously (i.e. de novo) resistant to 
two or more drugs is rare. 
There appears to be a fortuitous inverse relationship between the resistance mechanisms to 
lumefantrine and amodiaquine. A similar inverse relationship might exist for piperaquine and 
mefloquine. Furthermore both drug pairs have reasonable well matched elimination kinetics 
providing mutual protection against resistance throughout the elimination phase of the remaining 
parasitaemia. Evidence supporting the counteracting resistance mechanisms of amodiaquine 
versus lumefantrine and piperaquine versus mefloquine comes from molecular genetic and 
genetic epidemiological studies. Transfection experiments in Plasmodium falciparum showed that 
introduction of N86Y into the parasite gene pfmdr1 confers amodiaquine resistance in vitro and 
this mutation is associated with increased rates of clinical failure after amodiaquine monotherapy 
[8, 9]. Yet this mutation increases in vitro drug sensitivity to lumefantrine. Whereas the mutant 
allele is more commonly seen in recurrent infections after artesunate-amodiaquine, the wild-type 
allele is selected after artemether-lumefantrine [10]. 
Amplification of the pfmdr1 (wild type) gene is associated with mefloquine resistance [11]. In 
Cambodia, where mefloquine resistance was widespread, it was observed that as piperaquine 
resistance emerged, sensitivity to mefloquine was restored and prevalent P. falciparum strains 
reversed to a single copy pfmdr1 genotype [12, 13]. Although this coincided with the decrease in 
mefloquine drug pressure, the observation that the marker for piperaquine resistance 
(amplification of the pfplasmepsin2 gene) is rarely detected in conjunction with the marker of 
mefloquine resistance (amplification of the pfmdr1 gene) suggests opposing resistance 
mechanisms [14, 15]. 
Whether this ‘mutual exclusiveness’ represents a role of pfmdr1 in piperaquine resistance (for 
instance by restricting the amount of piperaquine entering the food vacuole)  or is simply the effect 
of a relative low mefloquine pressure in the last decade in Cambodia and Vietnam needs further 
investigation. Importantly, although in low frequency, parasites bearing both markers of 
mefloquine resistance and piperaquine resistance (pfmdr1 and pfpfplasmepsin2-3 amplification, 
respectively) have been found in field isolates [16], and its prevalence was recently reported to 
have increased in Preah Vihear province in Cambodia, after the reintroduction of artesunate-
mefloquine as first line treatment [17]. The consequence of the double amplification of pfmdr1 
and pfplasmepsin2-3 for efficacy of the TACT DHA-piperaquine-mefloquine has not been 
established. 
An increase in the QTc-interval following intake of the antimalarials piperaquine and amodiaquine 
has been described [18-22]. In the recent TRACII study conducted primarily in adults, we also 
observed that the QTc interval increased after administration of DHA-piperaquine by a mean of 
around 20 milliseconds. Reassuringly, the addition of mefloquine to DHA-piperaquine did not lead 
to a further increase of the QTc-interval. Further, the incidence of a QTc prolongation following 
treatment of more than 60 milliseconds was comparable between subjects treated with DHA-
piperaquine and DHA-piperaquine + mefloquine. Data from the TRACII study also confirmed that 
a treatment with artemether-lumefantrine does not prolong the QTc-interval whereas the addition 
of amodiaquine to artemether-lumefantrine prolonged the QTc-interval by about 10 milliseconds 

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over the first 64 hours, which conforms to what has been previously described for amodiaquine. 
Amodiaquine did not increase the incidence of a QTc-prolongation >60 milliseconds above 
baseline, which is rare in the treatment with artemether-lumefantrine alone (about 1 in 300 
treatments). Any antimalarial treatment is associated with a drop in the heart rate in the first day 
of treatment. As the fever and/or clinical illness subsides the heart rate generally decreases. The 
TRACII study confirmed previous findings that amodiaquine use is associated with a bigger 
decrease in heart rate compared to other antimalarials and a higher incidence of bradycardia (<54 
beats/minute), both in adults and children. 
 
3.2. 
Study rationale 
The TRACII study has examined the safety, tolerability and efficacy of different Triple Artemisinin 
based Combination Therapies (TACTs) such as DHA-piperaquine+mefloquine (DHA-PPQ+MQ) 
and artemether-lumefantrine+amodiaquine (AL+AQ). The preliminary results of this study show 
that the TACT artemether-lumefantrine+amodiaquine is as effective and safe as the standard 
ACT artemether-lumefantrine, even in children recruited in the Democratic Republic of Congo. 
Further, the TACT DHA-PPQ+MQ was found to be highly efficacious at study sites in Cambodia, 
Thailand and Vietnam, even though the efficacy of the ACT DHA-PPQ was poor at these sites. 
However, in a study assessing the pharmacokinetics of the TACT DHA-PPQ+MQ in healthy 
volunteers, a significant drug-drug interaction was observed wherein the addition of MQ to the 
ACT DHA-PPQ significantly reduced the absorption of DHA (van der Pluijm et al.; manuscript in 
preparation). Similarly, a substantial reduction in the absorption of DHA was also observed in 
malaria patients included in the TRACII study though this did not affect parasite clearance half-
lives. Taken together, these data indicate that there is an increased risk of sub-therapeutic 
exposure to DHA at its current dosage when co-administered with piperaquine and mefloquine 
as a TACT. Therefore, drug combinations wherein DHA (target dose of 2.4 mg/ kg in the current 
fixed dose combination) is replaced with artesunate (target dose of 4 mg/kg), which is completely 
metabolised to DHA very rapidly after absorption [23], will be tested in this study as artesunate-
mefloquine (ASMQ) with or without PPQ (ASMQ+PPQ) along with AL with or without AQ.  
Co-blistered or co-formulated TACTs could be rapidly deployed in areas with multidrug resistant 
malaria. For other regions, the safety and efficacy of TACTs should be assessed in the local 
setting in order to guarantee rapid deployment in case resistance starts affecting treatment 
efficacy. Furthermore, deployment of TACTs on a wide scale could prevent or delay the 
emergence and spread of antimalarial resistance in areas where this has not yet happened. The 
efficacy, safety and tolerability of TACTs need extensive evaluation in adults and children before 
policy recommendations can change and widespread deployment can be considered.  
Therefore, we aim to conduct a large scale randomized clinical trial in 5 Asian countries  to 
compare the efficacy, safety and tolerability of the TACTs artemether-lumefantrine+amodiaquine 
and 
artesunate-mefloquine+piperaquine 
and 
the 
standard 
ACTs 
artemether-
lumefantrine+placebo, and artesunate-mefloquine+placebo. Given that the observations of low 
incidence of QTc prolongation are from a relatively small population, they need further monitoring 
and confirmation. Accordingly, in this study electrocardiograph measurements (ECGs) will also 
be performed at baseline and several time points thereafter to assess the effect of antimalarials 
on the QT or QTc interval. 

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In addition to the main clinical outcomes of the study, we aim to assess the extent of the spread 
or the de novo emergence of resistance to the antimalarials in the combinations through detailed 
in vivo and in vitro assessments and to study the pharmacokinetics and inter-drug interactions of 
the drugs, the parasite- and host-related factors affecting treatment outcomes. Finally, we aim to 
gain insights into the spread of resistance mediated by population movements and parasite gene 
flows in general through travel surveys and geographic localization of parasite genetic data. 
 
4. OBJECTIVES 
4.1. 
Primary objectives 
To compare the efficacy of the matching ACTs and TACTs as defined by the 42-day PCR 
corrected adequate clinical and parasitological response (ACPR) within each individual site 
Matching comparisons of ACT and TACT are as follows: 
 
AL+PBO versus AL+AQ 
 
ASMQ+PBO versus ASMQ+PPQ 
 
4.2. 
Secondary objectives 
 
To compare the safety and tolerability of ACTs and TACTs within and across sites and 
regions, including comparisons of ‘non-matching’ ACTs vs TACTs (AL+PBO versus 
ASMQ+PPQ, ASMQ+PBO versus AL+AQ). 
 
To compare additional measures of treatment efficacy between treatment arms, including 
the 63-day ACPR, the post-treatment prophylactic effect of ACTs and TACTs defined as 
the 42-day and 63-day PCR uncorrected ACPR, gametocyte carriage, parasite clearance 
rates and fever clearance. 
 
To assess pharmacokinetic and pharmacodynamic interactions between antimalarials in 
TACTs 
 
4.3. 
Exploratory objectives 
 
To assess molecular genetic and transcriptomic correlates for artemisinin and partner drug 
resistance of the infecting P. falciparum strains and to assess their ex vivo and in vitro 
drug susceptibility. 
 
To compare the selective effect of ACTs versus TACTs on parasites carrying mutations 
associated with resistance to antimalarial drugs 
 
To obtain additional safety data (in particular incidence, rate and magnitude of haemolysis) 
on the deployment of single low dose primaquine, stratified according to G6PD 
status/genotype 
 
To obtain additional data on the effect of the host genotypes known to affect 
pharmacokinetics and pharmacodynamics of antimalarials 

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 
To obtain data on the place of residence, work, recent travel history and mobile phone 
usage in order to improve the understanding of local malaria transmission by identifying 
behaviours and risk factors associated with malaria infection and possible routes of spread 
of malaria and artemisinin resistance 
 
To assess new methods for determination of gametocytaemia, parasite phenotypes and 
genotypes  
 
To assess the correlation between anti-Plasmodium falciparum antibodies and drug 
efficacy measures 
 
To assess the prevalence of parasites carrying complete or partial deletions in pfhrp2 gene 
5. PRIMARY, SECONDARY AND EXPLORATORY ENDPOINTS 
5.1. 
Primary endpoint 
42-day efficacy defined as PCR corrected adequate clinical and parasitological response (ACPR).  
 
5.2. 
Secondary endpoints 
 
For safety and tolerability: Incidence of adverse events and serious adverse events within 
the first 42 days including markers of hepatic, renal or bone marrow toxicity; cardiotoxicity, 
in particular QT or QTc-interval above 500 ms at timepoint H4 and H52/H64 and between 
these time points; change in hemoglobin concentration at D3, 7, 28 stratified for G6PD 
status/genotype; proportion of subjects requiring retreatment due to vomiting within 1 hour 
after administration of the study drugs; proportion of subjects that reports completing a full 
course of observed TACT or ACT without withdrawal of consent or exclusion from study 
because of drug related serious adverse event 
 
For efficacy: 63-day PCR corrected and uncorrected efficacy;  42-day PCR uncorrected 
efficacy; parasite clearance half-life assessed by microscopy as primary parameter to 
determine parasite clearance; proportion of subjects with microscopically detectable P. 
falciparum parasitaemia at Day 3;  fever clearance time (i.e. the time taken for the tympanic 
temperature to fall below 37.5 ºC in patients who were febrile at inclusion); proportion of 
subjects with gametocytaemia during and after treatment stratified by presence of 
gametocytes at enrolment. 
 
For PK/PD interactions: Pharmacokinetic profiles and interactions (including Cmax and 
AUC) of artemisinin-derivatives and partner drugs in ACT and TACT treated subjects in 
correlation with pharmacodynamics measures of drug efficacy; day 7 plasma levels of 
partner drugs in correlation with treatment efficacy and treatment arm 
 
 

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5.3. 
Exploratory endpoints 
 
Comparison of 63-day vs 42-day PCR corrected and uncorrected efficacy of ACTs vs 
TACTs 
 
Proportions of recurrent infections with parasites carrying mutations of known functional 
significance  
 
Proportions of specimens collected at baseline with parasites carrying mutations of known 
functional or operational significance (pfkelch13, pfcrt, pfmdr1, pfdhfr, pfdhps, 
pfplasmepsin2 , partial or complete deletions of pfhrp2 and other current parasite genetic 
markers associated with resistance or identified over the course of the study) 
 
Candidate markers of resistance identified through genome wide association studies with 
in vivo or in vitro parasite drug sensitivity phenotypes 
 
In vitro sensitivity of P. falciparum to artemisinins and partner drugs according to study 
sites and genotype 
 
Accuracy of SNPs assessment from dry blood spots versus from whole genome 
sequencing in leukocyte depleted blood samples 
 
Correlation between qPCR based versus microscopy based assessments of parasite 
clearance dynamics 
 
Correlation of parasite clearance metrics as assessed by microscopy versus digital 
microscopy 
 
Comparison of transcriptomic patterns of drug sensitive and resistant parasites before 
treatment and 6, 12 and 24 hours  after start of treatment 
 
Levels of RNA transcription coding for male or female specific gametocytes at admission 
up to day 14, stratified by the presence of gametocytes at enrolment 
 
Correlation between the host genotype (e.g., CYP2D6, CYP3A4, KCNQ1/LQT1, 
KCNH2/LQT2, SCN5A/LQT3) and the pharmacokinetics and pharmacodynamics of 
antimalarials. 
 
Correlations between the place of residence, work, recent travel history assessed by 
interview and mobile phone records to identify behaviours and risk factors associated with 
malaria infection.   
 
Correlation between specific antibody titres and measures of drug efficacy 
 
 

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6. TRIAL DESIGN 
6.1. 
Study sites 
The study will take place in Cambodia, Myanmar, Bangladesh, Indonesia and 2 sites in India. Two 
sites in India, one will be in Agartala and the second will be constituted of two institutions in India, 
located in Rourkela and Midnapur, which will function as a single site and will recruit a total of 228 
subjects through competitive enrollment. Similarly three locations in Cambodia located in 
Kravanh,Siem Pang and Chambak, will function as a single site and will recruit a total 228 subjects 
through competitive enrollment.  
Estimated sample size is 1368 subjects. 
 
6.2. 
Summary of trial design 
A partially blinded randomised controlled non-inferiority trial of the Triple ACTs artemether-
lumefantrine + amodiaquine (AL+AQ) and artesunate- mefloquine+piperaquine (ASMQ+PPQ) 
with the ACTs artemether-lumefantrine + placebo (AL+PBO) and artesunate- mefloquine + 
placebo (ASMQ+PBO) for the treatment of uncomplicated Plasmodium falciparum malaria to 
assess and compare their efficacy, safety, tolerability. (See sub-section 9.4 for further details 
regarding partial blinding). 
 
6.3. 
Study duration 
Projected recruitment duration of 20 months March 2021 – October 2022; study projected finish 
in March 2023. 
 
7. PROPOSED ACTIVITIES 
Subjects will be randomized to up to four arms: artemether-lumefantrine + amodiaquine, 
artemether-lumefantrine + placebo, artesunate-mefloquine + piperaquine and artesunate-
mefloquine + placebo. As a contingency measure in case of significant differences in the efficacy 
or safety of one of the combinations being tested and/or study drug expiry or unavailability, 
subjects may be randomised to 2 arms with a matching ACT-TACT pair, i.e., with artemether-
lumefantrine + placebo or artemether-lumefantrine + amodiaquine OR artesunate-mefloquine + 
placebo or artesunate-mefloquine + piperaquine. 
Some sites may randomize between 2 arms only with matching ACT-TACT pairs, i.e., artemether-
lumefantrine + placebo or artemether-lumefantrine + amodiaquine OR artesunate-mefloquine + 
placebo or artesunate-mefloquine + piperaquine.  
In the control arms, the ACT will be co-packed with a matched (appearance) placebo.  
In lower transmission settings (Annual Parasite Incidence <50 per 1000 population per year) the 
treatment will include a single 0.25 mg/kg gametocytocidal dose of primaquine as recommended 
by the WHO for children ≥10 kg. All drug administrations will be observed. 
Subjects will be treated in an in-patient unit for 3 days and followed up weekly up to D63. 
Microscopy to detect and quantify malaria parasitaemia will be performed daily (more frequently 
in patients with parasite density of >5000/µL at inclusion) during hospitalization, at all weekly and 
unscheduled visits. A physical examination and measurements of vital signs along with a 
symptom questionnaire for tolerability will be performed and recorded through a standardized 

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method at baseline, daily during admission and weekly during follow up through D42 and at all 
unscheduled visits. Physical exam, vital sign measurements and assessments of symptoms will 
be performed on D49, D56, and D63 only for patients who are parasitaemic or those who report 
fever or other symptoms. Electrocardiographs will be performed during admission (H0, H4, H52, 
or H64) and day 42 of follow up to assess and compare the effect of ACTs and TACTs 
antimalarials on QT or QTc-intervals. 
Safety assessments will be performed by measuring markers of renal and hepatic toxicity, 
haemoglobin, platelet counts, absolute and differential white blood cell counts and ECGs. 
Pharmacokinetic profiles in a subset of subjects will be linked to measures of efficacy and toxicity. 
To avoid extensive blood sampling, especially in children, a population pharmacokinetic approach 
will be followed, requiring sparse blood sampling reducing the burden of sampling for the patient 
[21]. 
Blood samples for parasite genotyping as well as genomic, transcriptomic and immunology 
studies will be collected at baseline and at selected time-points on follow-up and also on the day 
of a recurrent infection. 
In patients with parasite densities >5000 per µL at screening, parasite clearance rates will be 
assessed by repeated assessments of the parasite counts after the start of the antimalarial 
treatments. At each visit a capillary blood sample will be taken for parasite count.  
If a patient presents with a new uncomplicated falciparum malaria infection after 3 months or 
longer after the initial enrolment, the patient or relative (in case of a child) will be asked to re-enter 
the patient in the trial.  
In selected study sites, P. falciparum parasites will be cryopreserved for in vitro antimalarial drug 
sensitivity testing. Where possible, ex vivo or in vitro assessments of parasite susceptibility to 
artemisinins and partner drugs will be assessed. 
The in vivo and ex vivo data on artemisinin and partner drug sensitivity will potentially be used to 
identify new genetic or transcriptomic markers/patterns of artemisinin or partner drug resistance.  
The pharmacogenetics of antimalarial agents are poorly known despite the fact that application 
of pharmacogenetics might be critical in optimizing treatment of malaria in individuals but also 
populations at large. Blood samples (dried blood blots) for human genotyping will be obtained and 
stored from all subjects recruited with subject’s consent. 
Subjects or their guardians will be asked a short set of questions on their place of residence, place 
of work and their history of travel in the last 2 months. In addition, basic questions on use of mobile 
phones will be asked. These questions will help in understanding the use of mobile phones in 
each country in subjects prone to malaria infections which can inform future malaria studies or 
interventions.  
All the organisations in this collaboration will work closely with local counterparts including the 
National Malaria Control Programmes (NMCPs), non-governmental and other relevant 
organisations. Training is an integral part of this collaborative working relationship, and the 
building of local research capacity is an essential component of all research plans.  

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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, in particular for Good Clinical Practice (GCP) skills.   
The close interaction between WHO and its regional offices will ensure that new knowledge is 
disseminated efficiently and effectively throughout the region. The Worldwide Antimalarial 
Resistance Network website (www.wwarn.org) will be also used as a medium to disseminate 
information. 
 
8. TRIAL PARTICIPANTS 
8.1. 
Overall description of trial participants 
Asian sites: Male and non-pregnant female subjects aged 6 months and above with acute 
uncomplicated falciparum malaria are the target study population. All study subjects must meet 
the applicable inclusion and exclusion criteria.  
 
8.2. 
Inclusion criteria 
 
Male or female, ≥ 6 months  
 
Ability to take oral medication  
 
Acute uncomplicated P. falciparum monoinfection  
 
Asexual P. falciparum parasitaemia: 96 to 200,000/µL, determined on a peripheral blood 
film 
 
Fever defined as > 37.5°C tympanic temperature or a history of fever within the last 24 
hours 
 
Written informed consent by the subject or parent/guardian in case of children lower than 
the age of consent and assent if required (per local regulations)   
 
Willingness and ability of the subjects or parents/guardians to comply with the study 
protocol for the duration of the study 
 
8.3. 
Exclusion criteria 
 
Signs of severe malaria (adapted from  WHO criteria see section 8.4) 
 
Patients not fulfilling criteria for severe malaria but with another indication for parenteral 
antimalarial treatment at the discretion of the treating physician 
 
Haematocrit < 20% at screening  
 
Subjects who have received artemisinin or a derivative within the previous 7 days OR 
lumefantrine or amodiaquine within the previous 14 days OR mefloquine or piperaquine 
within the previous 30 days  
 
Acute illness other than malaria requiring systemic treatment 
 
Severe acute malnutrition  
 
Known HIV infection 

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 
Known tuberculosis infection 
 
For females: pregnant, trying to get pregnant or are lactating 
 
History of allergy or known contraindication to any of the study drugs, including 
neuropsychiatric disorders and epilepsy 
 
Previous splenectomy 
 
Enrolment in DeTACT in the previous 3 months 
 
Participation in another interventional study in the previous 3 months 
 
8.4. 
Criteria for severe malaria 
 
Impaired consciousness (Glasgow Coma Scale, Blantyre Coma Scale) 
 
Prostration 
 
Respiratory distress (defined as maximal respiratory rate, by age) 
 
≥2 convulsions in the past 24 hours 
 
Circulatory collapse 
 
Pulmonary oedema 
 
Abnormal bleeding 
 
Visible jaundice 
 
Haemoglobinuria (blackwater) 
 
Hyperparasitaemia (>10%) 
 
9. PROCEDURES 
Study procedures will be performed according to the schedule of assessments (Appendix 1). 
Potential patients will be screened.  If eligible and they have agreed to enter the trial, they will be 
admitted to the hospital for at least 72 hours and continue to be followed up as outpatients on a 
weekly basis until Day 63 (9 weeks).  
 
9.1. 
Informed consent 
Full consent (and assent if required) will be obtained before any study specific enrolment 
procedures are conducted. It will be made clear from the outset that refusal to participate will not 
jeopardise subsequent antimalarial treatment.  
The patient (or witness if illiterate) and/or the parent/guardian of a minor must personally sign and 
date the latest approved version of the informed consent form before any study specific 
procedures are performed. Written and verbal versions of the participant information and informed 
consent in the local language will be presented to 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 

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participant or guardian is free to withdraw 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 patient and/or parent/guardian will be allowed as much time as possible to consider the 
information and to take the opportunity to question the Investigator, or other independent parties 
to decide whether they will (or allow his/her charge to) participate in the study. As far as possible, 
no more than two hours should elapse between presentation and treatment either within or 
outside of the study. For sites where this time window is not sufficient to complete all study-related 
procedures required before treatment, local approval will be sought to increase the time allowed 
for pre-treatment procedures.  
Written informed consent will be obtained by means of the participant’s or the participant’s  
guardian’s dated signature or thumb print (if unable to write), and the consent form must be signed 
and dated by a literate witness and dated signature of the person who presented and obtained 
the informed consent.  
If required by local ethics committees, children will be asked to sign or affix a thumbprint on an 
assent form. A copy of the signed informed consent/assent document(s) will be given to the 
subjects/parents.   
 
9.2. 
Screening procedures 
Subjects who present at the participating sites will be screened to assess eligibility using the 
inclusion and exclusion criteria summarized in section 8.2 and 8.3. 
A screening form will be completed for all subjects. A screening log will be kept. 
EDTA-anticoagulated blood (0.5 ml) will be collected for: 
 
Parasite count from Giemsa stained thick and thin blood films with or without malaria rapid 
diagnostic test 
 
Haematocrit 
After obtaining consent a urine pregnancy test for females of child bearing potential will be 
performed. 
 
9.3. 
Baseline assessments 
9.3.1. Demographic and medical history 
Basic demographic and epidemiological data (e.g. sex, age, address, bed net use, malaria risk 
factors, prior treatment and previous participation in this or previous studies), and a full medical 
history will be recorded by the study staff.  
9.3.2. Drug history 
All prescribed or over-the-counter and traditional medications used within the last 7 days will be 
sought and the available details recorded. Any drug allergies will be recorded.  
 

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9.4. 
Randomization and blinding 
In Asia, subjects who fulfil all the inclusion criteria and have none of the exclusion criteria will be 
randomised in an ACT:TACT:TACT:ACT ratio of 1:1:1:1, with the ACT arms consisting out of an 
ACT and placebo. 
The study drug will be provided by the pharmaceutical company in co-blistered or co-packed form 
in boxes. 
The boxes containing artemether-lumefantrine+amodiaquine and artemether-lumefantrine 
+placebo will be identical, and a combination of both study drugs boxes will be sequentially 
numbered. 
Also, the boxes containing artesunate- mefloquine+piperaquine and artesunate-mefloquine 
+placebo will be identical, and a combination of both study drugs boxes will be sequentially 
numbered. 
The absorption of lumefantrine is increased if the artemether-lumefantrine is taken with fat, which 
increases the efficacy. Therefore artemether-lumefantrine containing arms should be taken with 
fat. 
The absorption of piperaquine is also increased if it is taken with fat and can hence lead to 
increased prolongation of the QT or QTc interval. Therefore artesunate-mefloquine containing 
arms (with PPQ or PBO) should not be taken with fat. 
For this reason it is important that the investigator knows whether the allocated treatment should 
be taken with a fatty snack or drink or not. Therefore the randomization envelope will state that 
the allocated treatment potentially contains artemether-lumefantrine or artesunate-mefloquine. 
However it will not state whether a second partner drug (amodiaquine or piperaquine is included 
in the treatment). Furthermore the boxes containing either artemether-lumefantrine(+/-
amodiaquine) or artesunate-mefloquine(+/-piperaquine) will be clearly distinguishable. 
The subjects will be assigned a study arm through a computer-generated randomisation 
schedule.  Individual, sealed and sequentially numbered envelopes will be provided for each trial 
site with one envelope per patient, indicating whether the treatment for the subject should be 
taken from the set of artemether-lumefantrine+/-amodiaquine or the artesunate-mefloquine+/-
piperaquine containing set. Block randomisation will be used. 
This study will be partially blinded since it will not be known to the investigators nor the participants 
at the time of randomisation or drug administration whether they have been assigned to an ACT 
or a TACT arm. However, they will know whether they have been assigned to the AL or ASMQ 
based arms for the reasons outlined above and also given the differences in dosing, i.e., 6 doses 
for AL based arms vs 3 doses for ASMQ based arms. 
 
9.5. 
Clinical procedures 
9.5.1. Clinical procedures at baseline 
 
Standardized symptom questionnaire 
 
Physical examination 
 
Weight, height, pulse, blood pressure, respiratory rate, temperature.  

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 
Assessment of malnutrition status: Mid-Upper Arm Circumference (MUAC), presence and 
grading of (nutritional) oedema (if present)  
 
Spleen and liver size will be recorded if palpable. 
 
9.5.2. Clinical procedures during hospitalization 
Daily until day of discharge: 
 
Standardized symptom questionnaire 
 
Physical examination 
 
Pulse, blood pressure, respiratory rate 
 
Tympanic temperature (every 6 hours until two times <37.5 degrees Celsius) 
 
Recording of vomiting and retreatment 
 
Recording of adverse events 
 
9.5.3. Place of residence, work, travel history and mobile phone use. 
In order to have a greater understanding of the possible sites of malaria transmission, and to 
relate genetic diversity to geographical location, subjects or their guardians will be asked a short 
set of questions on their place of residence, place of work/location of school if applicable and their 
history of travel in the last 2 months. In addition, basic questions on use of mobile phones will be 
asked. These questions will help in understanding the use of mobile phones in each country in 
subjects prone to malaria infections. In separate studies, we will use anonymised, aggregated 
data on mobile phone use to model population movement and predict potential routes of spread 
of malaria and antimalarial drug resistance. We will use the mobile phone usage survey to 
understand how relevant these movement patterns are to subjects with malaria.  
We will review these travel histories obtained in the hospital and then select a representative 
sample of subjects for additional in-depth interviews with them and their peers to be conducted in 
their villages. This is to obtain a detailed understanding of the behaviours and risk factors for 
malaria infection.  
In some sites, we will GPS the households of all subjects and their places of work and places 
where their infection may have occurred, such as forests, farms or plantations. We will collect all 
available local malaria treatment records to describe how the study population compares to the 
overall population who receive treatment for malaria and this will allow us to better understand 
local malaria epidemiology and transmission patterns. All personal information will be de-identified 
so that no individual can be identified from their treatment records, through interviews, or from 
mapping data. 
 
9.5.4. Clinical procedures during follow up 
Day 7, 14, 21, 28, 35 and 42 
 
Standardized symptom questionnaire 
 
Physical examination 

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 
Pulse, blood pressure, respiratory rate 
 
Tympanic temperature 
 
Recording of adverse events 
Day 49, 56 and 63 
In principle follow up at day 49, 56 and 63 will consist only of performing a tympanic temperature 
measurement, blood smear, and dried blood spot. If the subject indicates new symptoms and/or 
a positive blood smear is found the subject will be seen by the study clinician and the following 
will be performed. A urine pregnancy test will be performed for women of child-bearing age at 
D63 only. 
 
Standardized symptom questionnaire 
 
Physical examination 
 
Pulse, blood pressure, respiratory rate 
 
Recording of adverse events 
 
9.5.5. Clinical procedures in case of a recurrent infection 
 
Standardized symptom questionnaire 
 
Physical examination 
 
Weight, height, pulse, blood pressure, respiratory rate 
 
Tympanic temperature 
 
Completion of recurrent infection form 
 
Treatment of recurrent infection. 
 
Recording of treatment for recurrent infection in the concomitant medication form 
Subjects with persistent asexual parasitaemia on day 7 or who develop a recurrent parasitaemia 
after day 7 with no signs of severity will be treated with either the same or another ACT or a 
different combination e.g. quinine and doxycycline or clindamycin, in accordance with local 
recommendations.  
Subjects who develop a non-falciparum parasitaemia during follow up will be treated according to 
local guidelines. 
In case of a recurrent infection, subjects should still be followed up according to the study protocol 
until day 63. An additional questionnaire on the place of living, work and travel and mobile phone 
use in the period between the initial infection and the recurrent infection will be completed. 
 
9.5.6. Clinical procedures in case of unscheduled visits 
Subjects presenting to the clinic with a fever or other clinical symptoms on unscheduled days will 
be assessed by the study physician. In any case the following will be recorded: 

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 
Standardized symptom questionnaire 
 
Physical examination 
 
Pulse, blood pressure, respiratory rate 
 
Tympanic temperature 
 
Recording of adverse events 
Subjects will be treated and further investigations conducted as clinically indicated.  
In the event that a patient becomes pregnant, on study, additional visits will be added at 3 months, 
6 months and 9 months (after birth), to allow documentation of the outcome of the pregnancy. 
 
9.6. 
Electrocardiographic recording 
Electrocardiograms (ECGs) will be recorded at D0H0, D0H4, D2H52 (for treatments containing 
ASMQ) or D2H64 (for treatments containing AL) and D42 in order to assess changes in the QT 
or QTc-interval. 
 
At the timepoint D0H4 and D2H52/D2H64 an abnormal automated electronic reading (QT or QTc-
interval > 500 milliseconds) will be considered a Serious Adverse Event and will lead to 
discontinuation of the study drug but not discontinuation of the patient from the trial. A specific 
work instruction will describe procedures such as identifying other causes of QT/QTc-
prolongation, study drug replacement and follow up of the QT/QTc-interval until normalization. 
QT/QTc intervals will be measured every six hours after the first abnormal QT/QTc-interval is 
recorded until the QT/QTc-interval has normalized in two consecutive ECGs.  
Additional blood samples will be taken for pharmacological measurements at the moment of the 
identification of the abnormal QT/QTc-interval and 6 and 12 hours after the first identification of 
the abnormal QT/QTc-interval in order to assess the correlation between the prolonged QT/QTc-
interval and the drug levels that could be leading to the prolonged QT/QTc-interval. 
 
9.7. 
Blood sampling 
9.7.1. On admission/baseline 
On study admission, immediately before drug administration, blood will be collected for the 
following: 
 
Repeat parasite count (thick and thin films). If it is found subsequently that this 
parasitaemia no longer meets the inclusion criterion for parasitaemia the patient will be 
kept in the study. 
 
Dry blood blots (200 microlitres, 4 spots collected on chromatography papers) for parasite 
and host genotyping (see section 14.3 for details on parasite genotyping and section 9.7.6 
for details on host genotyping).   
 
Full blood count OR WBC differential, HCT, Hb (0.5 mL EDTA-anticoagulated) 

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 
Parasite DNA and RNA measurements (packed cells from up to 10 ml for adult, up to 5 
ml for child) EDTA-anticoagulated blood; an aliquot of plasma will be stored for 
immunological assessments.  
 
Ex vivo/in vitro parasite cultivation for drug sensitivity and transcriptomic assays (3 ml 
adult, 2 ml child, heparinised blood, some sites). 
 
Baseline biochemistry assessments including bilirubin, ALT, AST, Alkaline Phosphatase 
and creatinine levels (1 mL heparin) 
 
Baseline pharmacological measurement (1 mL heparin) 
 
9.7.2. During hospitalization 
Blood smears and hematocrit 
Subjects with a parasite density of >5000 per µL will have blood taken for malaria films at, 6h, 
12h, 18h, 24h and thereafter every 12 hours until parasite clearance (when two consecutive 
malaria slides are negative).  
In all cases, malaria films and hematocrit measurements will be performed at H24, H48 and H72 
on all subjects (even if two consecutive negative blood smears have been seen before these 
timepoints)  
 
Other sampling during hospitalization 
 
D0 H6, Day 0 H12: Parasite DNA/RNA measurements: EDTA-anticoagulated blood (1 
mL). (some sites) 
 
Day 1 H24: Hct measurement (0.5 mL EDTA-anticoagulated) 
 
Day 1 H24: Parasite DNA/RNA measurements & qPCR: EDTA-anticoagulated blood (1 
mL). (some sites) 
 
Day 2 H48: Hct measurement (0.5 mL EDTA-anticoagulated) 
 
D2 H48: For qPCR: EDTA-anticoagulated blood (1 mL). (some sites) 
 
D2H52 (for artesunate-mefloquine based arms) OR D2H64 (for artemether-lumefantrine 
based arms) – Pharmacological measurement sample (1 mL Heparin) 
 
Day 3 H72: biochemistry assessments including bilirubin, ALT, AST, Alkaline 
Phosphatase and creatinine levels: 1 mL heparinised blood 
 
Day 3 H72: For qPCR: EDTA-anticoagulated blood (1 mL). (some sites) 
 
Day 3 H72: Full blood count OR WBC differential, Hct and Hb. (0.5 mL EDTA-
anticoagulated) 
 
9.7.3. Blood sampling during follow up 
Day 7 

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After subjects are discharged, they will be followed up at Day 7 for:  
 
Day 7: Malaria blood slide 
 
Day 7: Full blood count OR WBC differential, Hct and Hb (0.5 mL, EDTA-anticoagulated 
blood)  
 
Day 7: DNA/RNA for qPCR gametocyte quantification and characterization (0.5 mL 
Heparin & 0.5 mL EDTA blood in children and 1 mL each in adults), ) (some sites)  
 
Day 7: Basic biochemistry assessments including bilirubin, ALT, AST, Alkaline 
Phosphatase and creatinine levels: 1 mL heparin blood  
 
Day 7: Pharmacological measurement (1 ml, heparin) 
 
Day 14, 21, 28, 35 and 42 
After day 7, subjects will be followed up weekly until Day 42 for: 
 
Malaria blood slide  
 
Day 14, 21, 28, 35 and 42: DNA/RNA for qPCR gametocyte quantification and 
characterization: ( 0.5 mL Heparin & 0.5 mL EDTA blood in children and 1 mL each in 
adults)) (some sites) 
 
Day 28: Basic biochemistry assessments including bilirubin, ALT, AST, Alkaline 
Phosphatase and creatinine levels. (1 mL heparin blood) 
 
Day 28: Full blood count OR WBC differential, Hct and Hb (0.5 mL EDTA-anticoagulated) 
 
Day 49, 56 and 63; Unscheduled visits 
After day 42, subjects will be followed up weekly until Day 63 for: 
 
Malaria blood slide  
 
Dried blood spot 
9.7.4. Blood sampling in case of a recurrent infection 
Subjects with a recurrent falciparum parasitaemia (including mixed with another malaria species) 
during follow up will have blood taken for the following: 
 
Thick and thin films: parasite count.  
 
Dried blood spots (200 microlitres, 4 spots collected on chromatography paper) for 
parasite DNA genotyping  
 
Parasite DNA and RNA measurements (packed cells from up to 10 ml for adult, up to 
5 ml for child EDTA-anticoagulated blood); an aliquot of plasma will be stored for 
immunological assessments. 

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 
Ex vivo/in vitro parasite cultivation for drug sensitivity and transcriptomic assays (3 ml 
adult, 2 ml child, heparinised blood, some sites). 
 
Pharmacological measurement (1 ml, heparin) 
 
9.7.5. Blood sampling for pharmacokinetics 
PK sampling (1 ml whole blood in heparin per sampling occasion). Venous plasma will be used 
to evaluate the drug exposures to antimalarial drugs used in this study (E.g. artesunate, 
artemether, lumefantrine, amodiaquine, piperaquine, mefloquine, and their metabolites). A work 
instruction will be written to detail the technique for specimen collection, handling and storage. 
Samples will be centrifuged immediately and the plasma stored frozen at minus 80°C or lower in 
properly labelled cryotubes.  
A maximum of seven samples for PK/PD analyses will be collected in each patient over a total 
sampling period of 42 days: 
 
One fixed day 0 sample will be collected for lumefantrine, amodiaquine, piperaquine, and 
mefloquine (and their metabolites) concentration measurements in all subjects.  
 
One sample will be collected systematically at the same time as the ECG at H52 (for 
ASMQ containing arms) and H64 (for AL containing arms) 
 
One fixed day 7 sample will be collected for lumefantrine, amodiaquine, piperaquine, and 
mefloquine (and their metabolites) concentration measurements in all subjects  
 
Two samples at random time-points during the first 3 days of dosing will be collected for 
artemether, artesunate, lumefantrine, amodiaquine, piperaquine, and mefloquine (and 
their metabolites) concentration measurements in 300 patients 
 
Two samples within random time windows during the 42 days of follow up will be collected 
for lumefantrine, amodiaquine, piperaquine, and mefloquine (and their metabolites) 
concentration measurements in 300 patients  
 
In addition to the sampling mentioned above, up to 3 additional samples will be collected 
during the 42 days of follow up from adults who weigh >70 kg (~5%  of the patient 
population, based on the TRACII study) and receiving AL+amodiaquine or AL+placebo 
Additional PK blood samples will be collected in the following situations:  
 
In case of an abnormal QT/QTc-interval at H4, D42. A blood sample will be obtained at 
the moment of the first identification of the abnormal QT/QTc-interval.    
 
At 6 and 12 hours after the first abnormal QT/QTc-interval at any time-point (H4, H52, 
H64, D42) in order to assess the correlation between the prolonged QT-interval and the 
drug levels that could result in a prolonged QT/QTc-interval (maximum 3 ml heparin 
blood).  

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 
In case of a recurrent infection at the day of recurrence (1 ml heparin blood). 
 
9.7.6. Host genotyping 
Genetic samples (in the form of dried blood blots or extracted DNA) will be stored (for a maximum 
of 10 years) and genotyped at the Molecular Tropical Medicine Laboratory, Bangkok, Thailand. 
Potential targets for targeted genotyping are polymorphisms in the G6PD genes coding for 
enzymes related to drug metabolism (e.g. cytochrome P450 enzymes) and genes and mutations 
predisposing to long QT-syndrome such as but not limited to the genes KCNQ1 (LQT1), KCNH2 
(LQT2), and SCN5A (LQT3). 
 
In case a particular genetic test cannot be performed at the Molecular Tropical Medicine 
Laboratory, Bangkok, Thailand, the genetic samples may be transferred to another institute 
(which might be a foreign country) for genotyping. The subject will be asked for consent for this 
transfer during the initial informed consent process. A material transfer agreement will be in place 
when required before any samples are shipped. 
The results of the genotyping will not be reported back to the subjects unless the abnormality is 
found through a method with a clear diagnostic certificate and the finding is judged to be of clear 
clinical or therapeutic importance to the subject. 
 
9.8. 
Special procedures related to baseline biochemistry measurements 
Screening is performed without assessing biochemistry values. At baseline blood will be drawn 
for biochemistry assessments just minutes before baseline drug administration. Initial treatment 
at baseline will therefore be administered without knowledge of the baseline biochemistry values. 
If baseline biochemistry values turn out to be abnormal (grade 3 or 4 of the CTCAE grading table) 
the study physician in consultation with the medical monitor will decide how to continue treatment 
and further management of the patient.  In any case the subject will still be followed up according 
to the study protocol until day 63).  
 
9.9. 
Time window for follow up visits 
The time-window for the visit on Day 7 is + 1 day and for the visits on Days 14 - 63 is –1 to +2 
days.  
9.10. Blood volumes 
The blood volumes for the protocol mandated tests are detailed in the study schedule (Appendix 
1) and will vary slightly between sites depending on whether sites can perform all of the tests of 
this protocol e.g. not all sites will be able to do the full blood count, store the plasma PK samples 
or do the ex vivo parasite culture. Also, it is likely that only a minority of subjects will develop a 
recurrent parasitaemia and be requested to give further blood samples. 
Concerning blood volumes, an age of 12 years and older will be referred to as ‘adult’, an age of 
less than 12 years will be referred to as ‘child’.  
Maximum blood volumes are presented below for adults and children for 63 days of follow up. 
The maximum blood volume is the total amount taken if the subjects remained in hospital for 3 
days, had all blood samples taken and where part of the pharmacokinetic as well as other 

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subsets (like qPCR validation and sampling for gametocyte genetics) and had one recurrent 
parasitaemia and/or unscheduled visit during follow up. The maximum blood volume will be 
approximately 69.5 ml for adults and 48.5 ml for children, which is less than 10% of total 
blood volume generally recommended as a maximum volume to be taken over 8 weeks. 
The maximum blood volume that will be drawn in children below the age of 12 is 17.5 ml in the 
first 24 hours of the study. This is below the 3 ml/kg in the first 24 hours as recommended only if 
subjects are  ≥6 kg  [24]. Accordingly, samples collected from children of <6 kg will only be those 
which are specifically required for the efficacy, safety and tolerability assessments, viz., blood 
smears, dried blood spots, venous samples for clinical biochemistry, haematology and PK 
samples. 
 
10. STUDY DRUG 
10.1. Study drug regimens 
Subjects will be treated with weight-based doses according to the schedule in appendix 2. 
The study drugs will be administered by study medical or nursing staff while the subjects are 
hospitalised.  
The study drugs containing artemether-lumefantrine+/-placebo will be taken with at least 1.2 
grams of fat to optimize absorption (comparable to 80-100 ml of a MILO milk carton or an 
equivalent fat containing beverage or snack).   
Overview DeTACT drug regimens 
TACT-arm 
ACT-arm 
In all  sites 
Artemether-lumefantrine x 3 days 
PLUS 
Amodiaquine x 3 days 
Artemether-lumefantrine x 3 days 
PLUS 
Placebo x 3 days 
 
 In all sites 
Artesunate-mefloquine x 3 days 
PLUS 
Piperaquine x 3 days 
Artesunate-mefloquine x 3 days 
PLUS 
Placebo x 3 days 
 
 
 
 
In low transmission settings subjects will receive a single low dose primaquine on 
day 1 according to the WHO guidelines and local regulations 

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No meals or snacks must be consumed for 1 hour before and after intake of study drugs 
containing artesunate-mefloquine+/-piperaquine. In case any food is taken, it must be non-fatty 
snacks (e.g., small quantity of rice, bread, crackers etc) 
 
10.2. Drug administration procedures in case of vomiting 
If the patient vomits within half an hour after intake of the antimalarial drugs, the 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. In this case the patient will be treated at the discretion of the 
investigator, for instance with intravenous artesunate. 
 
10.3. Treatment in case of a recurrent infection 
Subjects with persistent asexual parasitaemia on day 7 or who develop a recurrent parasitaemia 
after day 7 with no signs of severity will be treated with either an ACT or a different combination 
e.g. quinine and doxycycline or clindamycin, in accordance with local recommendations.  
Subjects who develop a non-falciparum parasitaemia during follow up will be treated according to 
local guidelines or recommendations. 
 
10.4. Rescue treatment 
The indication for rescue treatment is: 
• 
The development of any danger signs or signs of severe malaria at any point. 
Rescue treatment will consist of parenteral artesunate (per WHO Treatment Guidelines, 3rd 
edition, 2015) as below: 
- 
For subjects <20 kg bodyweight, 3 mg/kg IV/IM STAT, followed by 3 mg/kg IV/IM at 12 
hours and 24 hours and then daily until able to take oral medication  
- 
For subjects ≥20 kg bodyweight, 2.4 mg/kg IV/IM STAT, followed by 2.4 mg/kg IV/IM at 
12 hours and 24 hours and then daily until able to take oral medication.  
If needed, the rescue treatment will be adjusted to local guidelines. 
We will encourage the addition of  parenteral quinine to the treatment of severe malaria in areas 
where artemisinin resistance is clearly established and will be given in standard doses: 20 mg/kg 
(in 5% dextrose) IV over 4 hours, followed by 10 mg/kg every 8 hours until the patient is able to 
take oral medication. 
 
10.5. Concomitant medication 
Throughout the study, investigators may prescribe concomitant medications or treatments 
deemed necessary (e.g. antipyretics or anti-emetics) to provide adequate supportive care except 
for antibiotics with antimalarial activity unless unavoidable (e.g. doxycycline, azithromycin). If 
these are required the subjects will be kept in the study and this will be noted as a protocol 

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deviation.  Anti-emetics should not be prescribed as a prophylaxis if no nausea or vomiting is 
present.  
If anti-emetics are indicated metoclopramide is the preferred anti-emetic as this drug has the least 
QTc-interval prolonging effect of the anti-emetics that are commonly prescribed. 
Antimalarials for recurrent infections and non-falciparum malaria will be prescribed as described 
above. Any medication, other than the study medication taken during the study will be recorded 
in the CRF. 
 
10.6. Study drug details 
In the first year the Triple ACTs will consist out of co-blistered or co-packaged combinations of an 
ACT and a matching partner drug. If healthy volunteer studies comparing co-blistered/co-
packaged and co-formulated formulations of Triple ACTs prove bioequivalence of all drugs the 
Triple ACT arms will be changed if possible to co-formulated formulations in the second year.  
 
10.6.1. Artemether-lumefantrine 
Currently available as dispersible tablets containing 20 mg of artemether and 120 mg of 
lumefantrine, in a fixed-dose combination formulation. The flavoured dispersible tablet paediatric 
formulation facilitates use in young children.  
 
Target dose/range: 
The dose of artemether-lumefantrine is administered according to the treatment schedule in 
appendix 2, thereby approaching the WHO-recommended target ranges of artemether 5-24 
mg/kg and lumefantrine 29-144 mg/kg over 3 days. 
 
10.6.2. Amodiaquine 
Amodiaquine is available as dispersible tablets of 40 mg. The weight-based treatment schedule 
in appendix 2 aims for a dosage of approximately 10mg (4.5-15mg)/kg/day amodiaquine for three 
days.  
 
10.6.3. Artesunate 
Artesunate will be administered according to an optimised dosing schedule using tablets of 32 or 
100 mg artesunate with a dosing target of 4 mg/kg/day (see dosing schedule in Appendix 2) 
 
10.6.4. Mefloquine 
Mefloquine will be administered according to an optimised dosing schedule using tablets of 70 or 
220 mg mefloquine hydrochloride with a dosing target of 8.3 mg/kg/day (see dosing schedule in 
Appendix 2).  
 
 
 
 

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10.6.5. Piperaquine 
Piperaquine will be administered according to an optimised dosing schedule using tablets of 160 
or 500 mg of piperaquine tetraphosphate. t. The weight-based treatment schedule in appendix 2 
aims for a dosage of approximately  
- 
24 mg/kg/day in patients <25 kg (range16.0 – 32.0 mg/kg) piperaquine for three days, 
thereby approaching the WHO-recommended target range of 20 – 32 mg/kg per day. 
- 
18 mg/kg/day in patients ≥25 kg (range 15.0 – 29.4 mg/kg) piperaquine for three days, 
thereby approaching the WHO-recommended target range of 16 – 27 mg/kg per day. 
 
10.6.6. Primaquine 
Primaquine is available in tablets of 7.5 and 15 base mg. The weight-based treatment schedule 
in appendix 2 aims for a dosage of approximately 0.15-0.375 mg/kg on day one thereby 
approaching the 0.25 mg base/kg single dose recommended by the WHO. 
 
10.6.7. Placebo for piperaquine 
Placebo tablets for piperaquine are currently under development. They will be identical in size, 
shape and colour. We aim for a similar taste of piperaquine and the placebo. 
 
10.6.8. Placebo for amodiaquine 
Placebo tablets for amodiaquine are currently under development. They will be identical in size, 
shape and colour. We aim for a similar taste of amodiaquine and the placebo. 
 
10.7. Storage of study drugs 
All efforts will be made to store the study drugs in accordance with the manufacturers' 
recommendations in a secure area. This may be difficult at some sites where air-conditioned 
storage rooms are not available. The study drugs should be stored between 15°C to 30°C (59°F 
to 86°F).   
In case of doubts on storage conditions meeting the recommendations the artemisinin-derivatives 
and partner drug content of batches of ACTs and TACTs will be retested at the end of the study.  
 
10.8. Accountability of the study drugs  
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.  
 
11. DISCONTINUATION/ WITHDRAWAL OF PARTICIPANTS FROM THE STUDY 
Each participant has the right to discontinue the study drug or withdraw from the study at any 
time. Data accrued up until the time of discontinuation/withdrawal will be used in the analysis, 
unless the subject wishes to withdraw even the data which has already been collected in which 
case those data will be excluded as well.  
In general, the investigator must make every effort to perform the study procedure until day 63. 
In principle the following situations are NOT reasons to discontinue the patient from the study:  

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• 
Significant non-compliance with treatment regimen or study requirements 
• 
An adverse event which requires discontinuation of the study medication or results in inability 
to continue to comply with study procedures 
• 
Disease progression which requires discontinuation of the study medication or results in 
inability to continue to comply with study procedures 
• 
Development of severe malaria 
• 
Recurrent parasitaemia 
• 
Loss to follow up (every attempt should be made to re-contact the participant) 
• 
Discontinuation of the study drug 
 
However, the investigator may discontinue participation in the study of a participant if he or she 
considers it necessary. 
In addition, the participants always have the right to withdraw consent in writing or verbally.  
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 
arrange for follow-up visits at least until the adverse event has resolved or stabilised.  
Any pregnancy must be reported to the Principal Investigator within one working day of 
awareness. The PI must take all reasonable efforts to discover the outcome of the pregnancy 
and fill out the pregnancy form. If there is a congenital abnormality or a still born baby, this needs 
to be reported as a serious adverse event.  
 
12. SAFETY REPORTING 
This trial will use drugs that have either been registered or evaluated extensively.    
To allow for comparison of safety and tolerability of both new TACTs compared to the ACTs 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 hospitalisation and at each subsequent 
visit to the health care facility, to aid in the identification of adverse events.  An additional 
questionnaire will be administered to subjects who report psychological symptoms. 
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 
protocol.   
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 present at baseline will not be considered adverse events unless the grade of the condition 
deteriorates. 
Each adverse event will be graded according Common Terminology Criteria for Adverse Events 

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(CTCAE) version 5.0, adapted for paediatric populations where needed 
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. If a definitive diagnosis is 
possible, then it 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.  
 
If the event meets the criteria for “serious”, the SAE must be reported to the safety team within 
24 hours from the time that the event was identified. The safety team will consist out of the 
Principal investigator, the study coordinator, a representative of the CTSG and the Medical 
Monitor. If further data is required, additional documentation can be submitted, but an initial report 
should be submitted within the timeframe. All SAEs must be followed until resolution, or until the 
SAE is deemed permanent or leads to death. SAEs must also be reported to the ECs and the 
Regulatory Authorities as per required by local guidelines. 
 
12.1. Definitions 
12.1.1. Adverse events (AEs) 
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 concomitant 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. 
 
12.1.2. Grading of laboratory abnormalities 
Basic biochemical assessments of markers related to hepatic and renal toxicity will be performed 
on day 0 (baseline) day 3, day 7 and 28.  
In addition haemoglobin, platelet counts, white blood cell counts and white blood cell 
differentiation will be obtained at day 0, day 3, day 7 and day 28. 
If found to be abnormal the values will be graded according to the CTCAE table and followed up 
until resolved or deemed to be permanent. 
 

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12.1.3. Serious adverse events (SAEs) 
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 hospitalisation or prolongation of existing hospitalisation 
 
results in persistent or significant disability/incapacity  
 
is a congenital anomaly/birth defect 
 
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.  Examples of such medical events include allergic 
bronchospasm requiring intensive treatment in an emergency room or at home, blood dyscrasias 
or convulsions that do not result in hospitalisation, or development of drug dependency or drug 
abuse. 
 
12.1.4. Study defined SAEs 
For the purpose of this study, the following are considered SAEs 
 
Prolongation of the QT or QTc interval >500 milliseconds 
 
AST/ALT >10 times ULN 
 
ALT or AST >3 times ULN with Total Bilirubin >2 times ULN (Hy’s Law) 
 
Creatinine >3.5 times ULN 
 
12.2. Reporting procedures for Serious Adverse events 
All SAEs must be reported by the site investigator within one day of his or her awareness of the 
SAE to the Study PI, Study Coordinators, Medical Monitor and the CTSG by faxing or emailing 
the CRF documenting the SAE (Fax No.: +66 (0) 2 354 9169; email: 
DETACTsafetyteam@tropmedres.ac).   
Further reports should be submitted, if required, until the SAE is resolved, is deemed permanent 
or results in death. 
The site investigator must also report the SAEs to the local ethics committee and the regulatory 
authority in accordance with local requirements. 
 

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12.3. Evaluating adverse events and Serious adverse events 
12.3.1. Assessment of intensity of AEor SAE 
Each adverse event will be graded according Common Terminology Criteria for Adverse Events 
(CTCAE) version 5.0 (adapted for paediatric populations as needed). 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; 
intervention 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 
Activities of Daily Living (ADL)  
*Age-appropriate instrumental ADL which will be defined in study SOPs.  
**Age-appropriate self-care ADL which will be defined in study SOPs. 
 
12.3.2. 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  
• 
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 
aetiologies should be recorded on the CRF). 
• 
Not related: no temporal association with the study drug; assessed as related to other 
aetiologies 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.  
 
12.3.3. Outcome of AE and SAEs 
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 

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• 
Resolved with sequelae 
• 
Permanent  
• 
Fatal 
 
12.4. Clarification of the difference in the meaning of ‘severe’ and ‘serious’ 
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 seriousness criteria, similarly severe events that do not conform to the criteria are 
not necessarily serious.  Seriousness (not severity) serves as a guide for defining regulatory 
reporting obligations. 
13. SOURCE DATA 
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. 
 
14. LABORATORY STUDIES 
14.1. Drugs concentration assays 
Antimalarial drug concentrations will be measured in plasma samples at the end of the study 
period or earlier if requested, for instance by the DSMB. All assays will be performed using 
validated LC-MS/MS methodologies at the Department of Clinical Pharmacology, MORU, 
Bangkok, Thailand. Observed antimalarial drug measurements will be used for initial statistical 
analyses and group comparisons to assess potential drug-drug interactions between drugs, 
relationship between drug concentrations and safety parameters, and relationship between drug 
concentrations and efficacy parameters.   
All collected PK samples will also be analysed using nonlinear mixed-effects modelling to assess 
the possible drug-drug interactions and the relationship between drug concentrations and 
treatment outcomes (i.e. safety and efficacy outcomes). Individually predicted drug levels at the 
time of QT-measurements will also be used to evaluate a direct relationship between possible 
QTc-prolongation and drug exposures. 
 
14.2. Ex vivo and in vitro sensitivity assays 
Ex vivo and in vitro assays will be performed to measure parasite responses to artemisinin 
derivatives and partner drugs according to the latest standards at the time of assessment. 
Parasites will be also be cryopreserved for future studies.   

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14.3. Molecular studies 
Parasite DNA will be used for genetic studies including but not limited to microsatellite typing and 
single nucleotide polymorphisms (SNP) typing whole genome sequencing to identify parasite 
clones, to measure proportions of parasites carrying mutations of functional and/or operational 
relevance (genetic markers associated with drug resistance, complete or partial deletions in 
pfhrp2 gene), to generate data for genome-wide association studies with in vivo, ex vivo, and in 
vitro responses of parasites to artemisinin and controls. Further, the genotype data from different 
sample types will be compared to develop methods for sample collection methods adapted to 
resource-poor settings. 
Parasite RNA will be used for transcriptome analyses and for RNA-based detection, 
characterization and/or quantitation of gametocytes. 
Blood samples (dried blood blots) for host genotyping will be obtained and stored from all subjects 
recruited with their consent. Genotyping will be performed on the samples of subjects with 
suspected abnormal pharmacokinetics or pharmacodynamics (for instance in case of unexpected 
adverse events such as severe prolongation of the QTc-interval). Potential targets for targeted 
genotyping are polymorphisms in genes coding for enzymes related to drug metabolism (e.g. 
cytochrome P450 enzymes) and genes and mutations predisposing to long QT-syndrome such 
as but not limited to the genes KCNQ1 (LQT1), KCNH2 (LQT2), and SCN5A (LQT3).   
 
14.4. PCR for quantitative parasitaemia 
One of the objectives of this study is to measure assess the parasite clearance dynamics by PCR 
and compare these with clearance rates estimated using this method to microscopy. 
 
14.5. Immunity 
On enrolment and in case of recurrent parasitaemia, quantitative assessments for a panel of 
antibodies against Plasmodium falciparum will be performed. Antibody levels will be correlated 
with markers of disease outcome such as parasite clearance rates, 42 day efficacy and day of 
recrudescence or reinfection. 
15. STATISTICAL CONSIDERATIONS 
15.1. Sample size justification 
These studies will have a non-inferiority trial design. Each site will be powered for the efficacy 
endpoint. For the safety and tolerability endpoint, the sample size will be pooled across the 
DeTACT-Africa and DeTACT-Asia studies to achieve the desired power of at least 80% to detect 
rare events. 
 
For sample size calculations, the following assumptions have been used: The expected efficacy 
of ACTs (AL or ASMQ) in these countries is expected to be approximately 96%. The matching 
TACT efficacy is assumed to be at least 90% under the null hypothesis of inferiority based on the 
WHO 90% efficacy threshold. However preliminary TRACII study data suggest that TACTs 
potentially may have a better efficacy by about 1% to 3% higher in favour of TACT (i.e. 97%-99% 
efficacy) in the Asian countries.  
 

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A one-sided alpha of 0.025 has been used in sample size calculations as non-inferiority is in one 
direction. A sample size of 47 subjects in the ACT plus placebo arm and 47 subjects in the 
matching TACT arm would be needed to achieve approximately 80% power to detect a non-
inferiority margin difference between the group efficacy of  -6%. With an additional 20% to cover 
for loss to follow up, we would therefore need 57 subjects in the ACT plus placebo arm and 57 
subjects in the matching TACT arm in each of the sites. Since there will be 4 arms per site, it 
means that we will need 228 subjects per site with 114 subjects in the two ACT arms combined 
and 114 subjects in the two TACT arms combined.  
 
For the safety and tolerability endpoints, we will perform a pooled analysis of the data obtained in 
the DeTACT-Africa and DeTACT-Asia. A total of 1707 subjects in ACT arms (918 and 789 
subjects in the AL and ASMQ arms respectively) and 2787 subjects in h TACT arms 
(1494 and 1293 subjects in the AL+AQ and ASMQ+PPQ arms respectively) recruited in both 
studies combined, will allow us to detect increases of rare adverse events from incidences of 1 in 
100 subjects to 3 in 100 subjects, also with more than 80% power  
 
The sample size calculations were performed using a specialized sample size calculation 
software, PASS 15. 
  
15.2. Statistical analysis 
Analyses of other endpoints will be described in a Statistical Analysis Plan.  
A brief overview is given below.  
 
15.2.1. 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. 
 
15.2.2. 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 
continuous 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 to look for geographical and temporal 
differences. 
 
15.2.3. Pharmacokinetic data 
Pharmacokinetic parameters such as Cmax, Tmax and AUC of artemether, lumefantrine, 
amodiaquine, artesunate, piperaquine, and mefloquine (and their metabolites) will be estimated 
using nonlinear mixed-effects modelling. All available study data will be pooled and integrated for 
a population modeling approach for an in-depth analysis of the pharmacokinetic properties of the 
above drugs as well as their relationship to treatment outcomes (i.e. safety and efficacy 
outcomes).  
 

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15.2.4. Safety analysis 
Safety analyses will be based on the whole population that get administered the study drug. Safety 
and tolerability of TACTs versus ACTs will be assessed by comparing the frequency (%) of 
adverse events and serious adverse events, with particular attention to abdominal pain, appetite 
perturbation, biochemical markers of hepatic and renal toxicity and QT interval prolongation, using 
the Fisher’s exact test.  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. Subjects will be analysed according to an intention to treat and a per 
protocol method where appropriate. 
16. DIRECT ACCESS TO SOURCE DATA/DOCUMENTS 
Direct access will be granted to authorised representatives from the sponsor and host institution 
and the regulatory authorities and ethical committees, if applicable, to permit trial-related 
monitoring and inspections. 
 
17. QUALITY CONTROL AND QUALITY ASSURANCE PROCEDURES 
The study will be conducted in accordance with the current approved protocol, ICH GCP, any 
national regulations that may apply to this study and standard operating procedures. The Clinical 
Trials Support Group (CTSG) or their designees will be engaged in assuring QA/QC of study 
execution in collaboration with the WWARN Asia Regional Centre. Their role will include but not 
be limited to monitoring adherence to WIs for collection of clinical data and laboratory specimens 
and quality checks (curation) of clinical and laboratory data according to standard methodologies. 
Malaria slide QC will be performed by WWARN. A project steering committee will oversee the 
project. 
 
17.1. Monitoring 
Study sites may have in place a system for internal monitoring. In addition, regular external 
monitoring of all sites will be coordinated 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 requirements. Evaluation of on-site monitoring schemes, such as a reciprocal 
monitoring scheme, may be undertaken at selected sites by CTSG and WWARN. 
 
18. DSMB AND PROJECT STEERING COMMITTEE 
18.1. 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 
 after the first 60 subjects have been accrued into the study 

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 after the first 500 subjects have been accrued into the study 
  At additional time-points before the planned interim analyses, as indicated by the DSMB 
after their review, if deemed necessary 
 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 (Contact details will 
be summarized in DSMB Charter and investigators site file), Principal Investigator or DSMB to 
consider e.g. serious adverse events as they are reported OR if an earlier safety review is 
thought to be indicated.  
 
18.2. Project steering committee 
Project Steering Committee Composition 
1. Ric Price (Academia representative) Chair 
2. Sarthak Das (APLMA) 
3. Louis Da Gama (CSO representative) 
4. Melanie Renshaw (ALMA)  
5. Nick White 
6. Arjen Dondorp 
7. Peter Olumese (WHO Representative, Observer) 
 
Tasks of the Project Steering Committee 
The overall task of the committee is to provide high-level guidance to the Project Management 
Group for the proper execution of the project. 
 
This includes: 
1. Review the progress of the DeTACT project towards its interim and overall objectives (see 
attached table) 
 
2. To review progress of the trial in the context of relevant information from other sources, e.g. on 
the development of antimalarial drug resistance in the regions of the project 
 
3. Consider recommendations of the Data Safety Monitoring Board (DSMB), and when applicable 
the Ethics Committees. This includes recommendations of the DSMB regarding stopping or 
continuation of the clinical trial. 
 
4. Provide independent guidance for problem resolution when they arise during the project. 
 
5. Assist in communication of project findings to the respective constituencies of the committee 
members. 
 
Meeting Frequency 
The Project Steering Committee will meet at an annual basis, coinciding with the annual DeTACT 
investigators’ meeting. In addition the committee will meet at regular intervals 6 monthly either 
virtual or in person, or at an ad hoc basis whenever needed. 

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Reporting 
The Project Steering Committee will provide a written report with recommendations to the Project 
Management Group on a yearly basis for the duration of the project. Interim recommendations 
will be provided if necessary. 
Conflicts of Interests 
Project Steering Committee members will have to declare potential or perceived conflicts of 
interests. For this purpose, a Conflict of Interests form will need to be completed. 
 
19. ETHICS 
19.1. 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). 
 
19.2. 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. 
 
19.3. 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. If required by participating countries Regulatory Authority, the protocol will also be 
submitted for approval The Investigator will submit and, where necessary, obtain approval from 
the above parties for all substantial amendments to the original approved documents.    
 
19.4. Risks 
This study will use drugs that have been studied thoroughly and their toxicities are well described. 
In general, they are all well tolerated. 
 
19.4.1. Risks of artemether-lumefantrine 
Reported AL side effects have generally been mild. The main side effects are GI upset: anorexia 
(~18%), nausea (~5%), vomiting (~18%), abdominal pain (~5%), and diarrhoea (~10%), 
headache (~10%), dizziness (~4%), fatigue (~1%) and sleep disturbance (~2%). Other symptoms 
reported infrequently include palpitations, myalgia, arthralgia (all of which could be disease 
related), and rash. AL does not cause prolongation of the QTc interval.  
 
19.4.2. Risks of amodiaquine 
The main side-effects of amodiaquine are nausea, vomiting and fatigue which are mild to 
moderate in nature. When the drug was used for prophylaxis, rare adverse reactions of 
agranulocytosis and hepatotoxicity were observed. 
 
19.4.3. Risks of artesunate-mefloquine 
Side effects such as nausea and vomiting, dizziness and headache have shown to be consistently 
associated with ASMQ. Other adverse effects following treatments with ASMQ are fatigue, 

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nightmares and anxiety. Palpitations are also relatively more common with AS+MQ. Mild 
prolongations of QTc intervals have been reported following ASMQ treatments but these are less 
frequent as compared to DHA-PPQ. From an individual patient meta-analysis of 5,487 subjects 
treated for P. falciparum with ASMQ, 49% of patients had at least one adverse event, 3.4% of 
subjects had early vomiting and the incidence of serious neurological reaction was 2 per 1,000. 
 
 
19.4.4. Risks of piperaquine 
Piperaquine is generally very well tolerated. Occasional abdominal discomfort and diarrhoea have 
been reported in clinical trials of DHA-PPQ which may have resulted from piperaquine. Although 
piperaquine slightly prolongs the electrocardiogram QT interval, there is no evidence for clinically 
significant cardiovascular toxicity at the doses which will be administered in this study. 
 
19.4.5. Risks of new partner drug combinations 
No interactions between lumefantrine and amodiaquine or piperaquine and mefloquine are 
expected. Based on the relatively safe and limited side effect profiles of both drugs, no life-
threatening interactions between lumefantrine and amodiaquine are expected. Also no life-
threatening interactions between piperaquine and mefloquine are expected. 
In addition, the preliminary results of the TRACII trial indicate that the TACTs artemether-
lumefantrine+amodiaquine and DHA-piperaquine+mefloquine have a good safety and tolerability 
profile, although both TACTs were found to induce slightly higher vomiting rates within the first 
hour after administration of the study drugs, compared to their matching ACTs. The safety profile 
of ASMQ +/- PPQ is expected to be similar to that of DHA-PPQ +/- MQ.  
 
19.4.6. Risk of phlebotomy & 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. 
 
19.5. Benefits 
Malaria is a disease that needs to be treated promptly. All subjects will benefit from receiving 
efficacious treatment at no cost. They will be followed up closely and will be given rescue 
treatment if clinically indicated.  
 
19.6. Alternatives to study participation 
Subjects are able to decline freely participation in this study. If so, they will receive standard care 
for their malaria.   
 
19.7. Incentives & Compensation 
Study subjects or their guardian in the case of children will be compensated for time lost from 
work. Subjects and/or their guardians will be reimbursed for the time lost from work as a result of 
hospitalisation, the cost of local transport to attend for the follow up visits and will receive meals 
or a per diem to cover the costs of meals on those days. The amounts in monetary terms will be 
determined by each site. The study will pay for treatment for drug-related SAEs or other research-
related injuries. The study cannot pay for long term care for disability after hospital discharge 
resulting from complications of the illness.  

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19.8. Confidentiality 
The trial staff will ensure that the participants’ anonymity is maintained.  All documents will be 
stored securely and be accessible to trial staff and authorised personnel only. In the future, with 
the consent of the participants, or parents/guardians in the case of a child, anonymized 
specimens and data may be shared with other research groups.  
20. SAMPLE SHARING AND STORAGE 
Samples collected will be used for the purpose of this study as stated in the protocol and stored 
for future use. Consent will be obtained from subjects for sample storage and/or shipment of 
specific samples to collaborating institutions for investigations that cannot be performed locally. 
Any proposed plans to use samples other than for those investigations detailed in this protocol 
will be submitted to the relevant ethics committees prior to any testing. Material transfer 
agreements will be arranged and signed where appropriate/needed. 
 
21. DATA HANDLING AND RECORD KEEPING 
All 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 internal 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. Adult’s records will be retained for five years following 
completion of the study while for children, 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 database will be retained indefinitely. 
 
With participant’s consent, 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 such as the WorldWide Antimalarial Resistance Network (WWARN, terms of 
submission here: http://www.wwarn.org/tools-resources/terms-submission) or other researchers 
to use in the future. All personal information will be anonymised so that no individual can be 
identified from their treatment records, through interviews, or from mapping data.  
 
22. SPONSORSHIP AND INSURANCE 
The University of Oxford is the study sponsor and 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).    
For the sites in India local insurance will be obtained. 
 
23. PUBLICATION POLICY 
Any data published in the peer-reviewed medical literature will protect the identity of the subjects. 
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 

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contribution. 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.  
All the research findings from the programme and from relevant research outside the Programme 
will be analysed and integrated, and through the WWARN site and the WHO Global Malaria 
Programme will be disseminated to policy makers, National Malaria Control Programmes 
(NMCPs) and other researchers.  
24. REFERENCES 
1. 
Ashley, E.A., et al., Spread of artemisinin resistance in Plasmodium falciparum malaria. N 
Engl J Med, 2014. 371(5): p. 411-23. 
2. 
Saunders, D.L., et al., Dihydroartemisinin-piperaquine failure in Cambodia. N Engl J Med, 
2014. 371(5): p. 484-5. 
3. 
Amaratunga, C., et al., Dihydroartemisinin-piperaquine resistance in Plasmodium 
falciparum malaria in Cambodia: a multisite prospective cohort study. Lancet Infect Dis, 
2016. 16(3): p. 357-65. 
4. 
Phuc, B.Q., et al., Treatment Failure of Dihydroartemisinin/Piperaquine for Plasmodium 
falciparum Malaria, Vietnam. Emerg Infect Dis, 2017. 23(4): p. 715-717. 
5. 
Thanh, N.V., et al., Rapid decline in the susceptibility of Plasmodium falciparum to 
dihydroartemisinin-piperaquine in the south of Vietnam. Malar J, 2017. 16(1): p. 27. 
6. 
Imwong, M., et al., The spread of artemisinin-resistant Plasmodium falciparum in the 
Greater Mekong subregion: a molecular epidemiology observational study. Lancet Infect 
Dis, 2017. 17(5): p. 491-497. 
7. 
Nosten, F. and N.J. White, Artemisinin-based combination treatment of falciparum 
malaria. Am J Trop Med Hyg, 2007. 77(6 Suppl): p. 181-92. 
8. 
Folarin, O.A., et al., In vitro amodiaquine resistance and its association with mutations in 
pfcrt and pfmdr1 genes of Plasmodium falciparum isolates from Nigeria. Acta Trop, 2011. 
120(3): p. 224-30. 
9. 
Sisowath, C., et al., In vivo selection of Plasmodium falciparum pfmdr1 86N coding alleles 
by artemether-lumefantrine (Coartem). J Infect Dis, 2005. 191(6): p. 1014-7. 
10. 
Venkatesan, M., et al., Polymorphisms in Plasmodium falciparum chloroquine resistance 
transporter and multidrug resistance 1 genes: parasite risk factors that affect treatment 
outcomes for P. falciparum malaria after artemether-lumefantrine and artesunate-
amodiaquine. Am J Trop Med Hyg, 2014. 91(4): p. 833-43. 
11. 
Price, R.N., et al., Mefloquine resistance in Plasmodium falciparum and increased pfmdr1 
gene copy number. Lancet, 2004. 364(9432): p. 438-47. 
12. 
Lim, P., et al., Decreasing pfmdr1 copy number suggests that Plasmodium falciparum in 
Western Cambodia is regaining in vitro susceptibility to mefloquine. Antimicrob Agents 
Chemother, 2015. 59(5): p. 2934-7. 
13. 
Imwong, M., et al., Exploring the contribution of candidate genes to artemisinin resistance 
in Plasmodium falciparum. Antimicrob Agents Chemother, 2010. 54(7): p. 2886-92. 
14. 
Amato, R., et al., Genetic markers associated with dihydroartemisinin-piperaquine failure 
in Plasmodium falciparum malaria in Cambodia: a genotype-phenotype association study. 
Lancet Infect Dis, 2017. 17(2): p. 164-173. 
15. 
Witkowski, B., et al., A surrogate marker of piperaquine-resistant Plasmodium falciparum 
malaria: a phenotype-genotype association study. Lancet Infect Dis, 2017. 17(2): p. 174-
183. 
16. 
Amato, R., et al., Origins of the current outbreak of multidrug-resistant malaria in southeast 
Asia: a retrospective genetic study. Lancet Infect Dis, 2018. 
17. 
Rossi, G., et al., Emergence of Plasmodium falciparum triple mutant in Cambodia. Lancet 
Infect Dis, 2017. 17(12): p. 1233. 

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18. 
Agency, E.M., European public assessment report - Eurartesim (piperaquine 
tetraphosphate / artenimol). 2016, European Medicines Agency. 
19. 
Chotsiri, P., et al., Population pharmacokinetics and electrocardiographic effects of 
dihydroartemisinin-piperaquine in healthy volunteers. Br J Clin Pharmacol, 2017. 83(12): 
p. 2752-2766. 
20. 
Adjei, G.O., et al., Electrocardiographic study in Ghanaian children with uncomplicated 
malaria, treated with artesunate-amodiaquine or artemether-lumefantrine. Malaria journal, 
2012. 11: p. 420. 
21. 
Ogutu, B.R., et al., Efficacy and safety of artemether-lumefantrine and dihydroartemisinin-
piperaquine in the treatment of uncomplicated Plasmodium falciparum malaria in Kenyan 
children aged less than five years: results of an open-label, randomized, single-centre 
study. Malaria journal, 2014. 13: p. 33. 
22. 
West African Network for Clinical Trials of Antimalarial, D., Pyronaridine-artesunate or 
dihydroartemisinin-piperaquine versus current first-line therapies for repeated treatment 
of uncomplicated malaria: a randomised, multicentre, open-label, longitudinal, controlled, 
phase 3b/4 trial. Lancet, 2018. 391(10128): p. 1378-1390. 
23. 
Morris, C.A., et al., Review of the clinical pharmacokinetics of artesunate and its active 
metabolite dihydroartemisinin following intravenous, intramuscular, oral or rectal 
administration. Malar J, 2011. 10: p. 263. 
24. 
Howie, S.R., Blood sample volumes in child health research: review of safe limits. Bull 
World Health Organ, 2011. 89(1): p. 46-53. 
 

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APPENDIX 1.  
STUDY SCHEDULE 
 
 
 
D7
H0
H4
H6
H8
H12
H18
H24
H30
H36
H42
H48
H52
H54
H60
H64
H66
H72
H78
H84
H90
H168
Verbal consent (if applicable)
X
Informed consent
X
Demographic data/Medical history
X
X
Drug history
X
X
Temperature (until 2 measurements<37.5)
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Vital signs
X
X
X
X
X
X
X
X
X
X
X
[X]
[X]
[X]
X
X
Pregnancy test for females of child bearing potential
X
X
Height/weight
X
X
X
MUAC and other assesments of nutritional status
X
X
Physical examination
X
X
X
X
X
X
X
X
X
X
X
[X]
[X]
[X]
X
X
Symptom questionaire 
X
X
X
X
X
X
X
X
X
X
[X]
[X]
[X]
X
X
Place of residence, work, travel history and data on mobile phone 
use
X
X
Adverse/serious adverse events recording
X
X
X
X
X
X
X
X
X
X
[X]
[X]
[X]
X
X
Randomisation to study drug
X
Study drug administration (ASMQ+/-PPQ) (no fat)
X
X
X
Study drug administration (AL+/-AQ) (with fat)
X
X
X
X
X
X
Study drug administration (Primaquine)
X
Electrocardiographic recording
X
X
{X}
{X}
X
D35
D42
D3 (*see footnote for D4-D6)
DRE
C
D63
SCR
D0
D1
D2
D14
D21
D28
Unsc
h.
Test/application
D49
D56
DeTACT-Asia Project Clinical Activity Schedule
[X] On day 49, 56 and 63 follow up will consist of temperature mesaurement, blood smear and dried blood spot. However, if new symptoms and/or positive malaria smears then do all activities indicated as [X]. Additional examinations may be performed at the discretion 
of the clinician.
{X} ECG will be performed at H52 for patients in the ASMQ+/-PPQ arms and at H64 for the AL +/- AQ arms. 
If a recurrent infection is found or the subject reports symptoms spontaneously additional procedures will be performed: 
Temperature, Vital signs, Symptom questionaire and Physical examination
* All patients should remain in hospital a minimum of 72 hours; If patient still in hospital after Day 3: continue doing daily symptom questionaire, physical examination, pulse, heart rate, blood pressure, temperature, and adverse/serious events recording; if still febrile 
continue temperature every 6 hours until two consecutive measurements of <37.5 degrees Celsius
DREC= Day of recurrent P. falciparum infection (including mixed P. falciparum with another species); if patient blood smear is positive for P. falciparum during follow up then perform all indicated study activities and blood collection. 
Unsch= Unscheduled visit; Time window for scheduled visits: at Day 7, +1 day; at Days 14-63 is -1 to +2 days.

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BLOOD SAMPLING SCHEDULE 
 
D7
H0
H4
H6
H8
H12
H18
H24
H30
H36
H42
H48
H52
H54
H60
H64
H66
H72
H78
H84
H90
H168
Blood smear (*)
0.5
0.5
0.5
0.5
(*)
(*)
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5 (*)
HCT (EDTA)
Hb (EDTA)
Dried Blood Spot (EDTA) (aliquot of blood collected for microscopy)
(0.5)
(0.5)
(0.5)
(0.5)
(0.5)
0
In vitro/ex vivo sensitivity assays (Heparinized)
2
2
4
DNA/RNA/Immunological assesments (EDTA/Heparin)
5
1
1
1
1
1
1
1
1
1
1
1
5
21
PK sampling (**)
1
1
1
0.5
0.5
1
1
1
1
8
Biochemistry (heparinised blood)
1
1
1
1
4
Full blood count (EDTA)
0.5
0.5
0.5
0.5
2
Total volumes per time point (ml)
0.5
10
0
2.5
0
1.5
0.5
2.5
0
0.5
0
1.5
0.5
0
0
0.5
0
3
0
0
0
4
1.5
2.5
3
2.5
1.5
0.5
0.5
0.5
8.5
0
48.5
D7
H0
H4
H6
H8
H12
H18
H24
H30
H36
H42
H48
H52
H54
H60
H64
H66
H72
H78
H84
H90
H168
Blood smear (*)
0.5
0.5
0.5
0.5
(*)
(*)
0.5
0.5
0.5
0.5
0.5
0.5
0.5
0.5 (*)
HCT (EDTA)
Hb (EDTA)
Dried Blood Spot (EDTA) (aliquot of blood collected for microscopy)
(0.5)
(0.5)
(0.5)
(0.5)
(0.5)
0
In vitro/ex vivo sensitivity assays (Heparin)
3
3
6
DNA/RNA/Immunological assesments (EDTA/Heparin)
10
1
1
1
1
1
2
2
2
2
2
2
10
37
PK sampling (**)
1
1
1
0.5
0.5
1
1
1
1
8
Biochemistry (heparinised blood)
1
1
1
1
4
Full blood count (EDTA)
0.5
0.5
0.5
0.5
2
Total volumes per time point (ml)
0.5
16
0
2.5
0
1.5
0.5
2.5
0
0.5
0
1.5
0.5
0
0
0.5
0
3
0
0
0
5
2.5
3.5
4
3.5
2.5
0.5
0.5
0.5
14.5
0
66.5
0.5
D49
9.5
* Patients with >5000 parasites/μL at inclusion will have blood smears at 6h, 12h, 18h, 24h and thereafter every 12 hours until parasite clearance (when two consecutive blood smears are negative) even if blood smears stay positive longer than 72h. In all cases, blood smears 
must be collected at 24h, 48h, 72h and then at all visits, including unscheduled visits. If parasitemia <=5000 parasites/ul at inclusion, blood smears must still be perfomed at 24h, 48, and 72h.
** Day 0, day 7 and day of recurrence samples will be obtained in all subjects. In 300 subjects, two samples will be taken at a random timepoint in the first 72 hours and two samples will be taken at a random timepoint in the first 42 days.  
PK samples have been included in this table to calculate the total volume of blood to be collected but may not be collected at the time-points indicated on this table (e.g., H6, H24, D21, D35 PK samples). An additional PK sample of 1 mL will be collected at H52 or at H64 but has 
been inlcuded in this table as 0.5 mL at both time-points, again to calculate the total volume. In patients >70 kg, three additional samples will be taken at random timepoints in the first 42 days. For these patients the maximum total volume of blood will be 69.5 mL.
9.5
0.5 
(Hb & 
HCT if 
FBC 
not 
done)
0.5
0.5
0.5 
(Hb & 
HCT if 
FBC 
not 
done)
0.5 
(Hb & 
HCT if 
FBC not 
done)
0.5 
(Hb & 
HCT if 
FBC 
not 
done)
0.5 
(Hb & 
HCT if 
FBC 
not 
done)
0.5
0.5
D56
D63
DRE
C
0.5 
(Hb & 
HCT if 
FBC 
not 
done)
0.5 
(Hb & 
HCT if 
FBC not 
done)
0.5 
(Hb & 
HCT if 
FBC 
not 
done)
D56
D63
DRE
C
D21
D28
D35
D42
D49
* Patients with >5000 parasites/μL at inclusion will have blood smears at 6h, 12h, 18h, 24h and thereafter every 12 hours until parasite clearance (when two consecutive blood smears are negative) even if blood smears stay positive longer than 72h. In all cases, blood smears 
must be collected at 24h, 48h, 72h and then at all visits, including unscheduled visits. If parasitemia <=5000 parasites/ul at inclusion, blood smears must still be perfomed at 24h, 48, and 72h.
** Day 0, day 7 and day of recurrence samples will be obtained in all subjects. In 300 subjects, two samples will be taken at a random timepoint in the first 72 hours and two samples will be taken at a random timepoint in the first 42 days. 
PK samples have been included in this table to calculate the total volume of blood to be collected but may not be collected at the time-points indicated on this table (e.g., H6, H24, D21, D35 PK samples). An additional PK sample of 1 mL will be collected at H52 or at H64 but has 
been inlcuded in this table as 0.5 mL at both time-points, again to calculate the total volume.
DeTACT-Asia Project Blood Sampling Schedule (Children <12 years)
Sampling type and volume (ml)
SCR
D0
D1
D2
D3 (*see footnote for D4-D6)
0.5
Unsc
h.
Total 
(ml)
D14
DeTACT-Asia Project Blood Sampling Schedule  (Adults > 12 years)
Sampling type and volume (ml)
SCR
D0
D1
D2
D3 (*see footnote for D4-D6)
D14
D21
D28
Unsc
h.
Total 
(ml)
D35
D42

Version 6.0 dated 23 Mar 2022 
Page 52 of 55 
APPENDIX 2. DOSING SCHEDULES 
 
Artemether-lumefantrine + amodiaquine or placebo 
 
 
Artemether-lumefantrine + Amodiaquine or placebo 
Artemether-lumefantrine + Amodiaquine (or placebo)  dosing schedule 
Body weight (kg) 
Dose administered at 0h, 8h, 24h, 36h, 48h, 60h 
Artemether (mg) 
Lumefantrine (mg) 
Amodiaquine (mg) 
/ PBO 
5 to 9.9 
20 
120 
40 / 0 
10 to 15.9 
40 
240 
80 / 0 
16 to 29.9 
60 
360 
120 / 0 
30 to 54.9 
100 
600 
200 / 0 
≥ 55 
120 
720 
240 / 0 
 
 
 
 
 
 
 
Artemether-lumefantrine +/- Amodiaquine (or placebo)  dosing schedule 
One tablet of AL contains 20 mg artemether and 120 mg lumefantrine;  
One tablet of AQ contains 40 mg amodiaquine;  
Placebo contains no active pharmaceutical ingredient. 
Body weight (kg) 
Number of tablets per timepoint  
(0h, 8h, 24h, 36h, 48h, 60h) 
AL 
Amodiaquine / PBO 
Tablets 
Tablets 
5 to 9.9 
1 
1 
10 to 15.9 
2 
2 
16 to 29.9 
3 
3 
30 to 54.9 
5 
5 
≥ 55 
6 
6 

Version 6.0 dated 23 Mar 2022 
Page 53 of 55 
Artesunate-mefloquine + piperaquine or placebo 
Artesunate-mefloquine + piperaquine (or placebo)  dosing schedule 
Body weight (kg) 
Dose administered at 0h, 24h, 48h 
Artesunate (mg) 
Mefloquine HCl 
(mg) 
Piperaquine TP 
(mg) / PBO 
5 to 10.9 
32 
70 
160/ 0 
11 to 17.9 
64 
140 
320 / 0 
18 to 33.9 
100 
220 
500 / 0  
34 to 64.9 
200 
440 
1000 / 0 
≥ 65 
300 
660 
1500/ 0 
 
Artesunate-mefloquine + piperaquine or placebo 
Artesunate-mefloquine + piperaquine (or placebo) 
dosing schedule 
One Paediatric tablet of AS contains 32 mg artesunate, one Adult tablet contains 100 mg;  
One Paediatric tablet of MQ contains 70 mg mefloquine, one Adult tablet contains 220 mg;  
One Paediatric tablet of PPQ contains 160 mg piperaquine, one Adult tablet contains 500 mg;  
Paediatric and Adult placebos contain no active pharmaceutical ingredient 
 
Body weight (kg) 
Number of tablets per timepoint  
(0h, 24h, 48h) 
Artesunate 
Mefloquine HCl 
Piperaquine TP/ 
PBO 
Tablets 
Tablets 
Tablets 
5 to 10.9 
1 (Paed) 
1 (Paed) 
1 (Paed) 
11 to 17.9 
2 (Paed) 
2 (Paed) 
2 (Paed) 
18 to 33.9 
1 (Adult) 
1 (Adult) 
1 (Adult) 
34 to 64.9 
2 (Adult) 
2 (Adult) 
2 (Adult) 
≥ 65 
3 (Adult) 
3 (Adult) 
3 (Adult) 
 
 
 
 
 

Version 6.0 dated 23 Mar 2022 
Page 54 of 55 
Primaquine 
Primaquine dosing schedule 
One tablet of Primaquine contains either 7.5 or 15 mg of Primaquine 
Body weight (kg) 
Dose administered at 24 h 
Primaquine (mg) 
7.5 mg tablet 
15 mg tablet 
<25 
3.75 
0.5 
0.25 
25 – 50  
7.5 
1 
0.5 
>50 
15 
2 
1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Version 6.0 dated 23 Mar 2022 
Page 55 of 55 
APPENDIX 3. LIST OF POTENTIAL STUDY SITES  
Potential Sites’ Locations 
Kravanh,Siem Pang and Chambak, Cambodia (counted as one site) 
Ramu, Bangladesh 
Agartala, India 
Midnapore and Rourkela, India (counted as one site) 
Myanmar (site to be determined) 
Sumba, Indonesia