Efficacy and Safety of Artesunate + Amodiaquine Combined With a Single Low Dose of Primaquine (0.25 mg/kg) for the Treatment of Uncomplicated Plasmodium Falciparum Malaria in Zanzibar
Phase: PHASE4
Conditions: Plasmodium Falciparum Malaria
Sponsor: Professor Anders Björkman

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ZANZIBAR MALARIA ELIMINATION PROGRAMME 
 
STUDY PROTOCOL: 
 
 
EFFICACY AND SAFETY OF ARTESUNATE + AMODIAQUINE COMBINED 
WITH A SINGLE LOW DOSE OF PRIMAQUINE (0.25 MG/KG) FOR THE 
TREATMENT OF UNCOMPLICATED PLASMODIUM FALCIPARUM 
MALARIA IN ZANZIBAR 
 
 
VERSION 1.0 February 15, 2017 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
2
 
 
TABLE OF CONTENT 
 
COVER SHEET FOR THERAPEUTIC EFFICACY TEST PROTOCOL 
3 
SUMMARY 
4 
BACKGROUND 
5 
OBJECTIVES 
5 
3. METHODS 
6 
3.1  Study design and clinical trial registration 
6 
3.2 Study sites 
6 
3.3 Study population 
7 
3.4 Timing and duration of study 
7 
3.5 Inclusion criteria 
7 
3.6 Exclusion criteria 
7 
3.7 Loss to follow-up 
8 
3.8 Patient discontinuation or protocol violation 
8 
4. TREATMENT 
9 
4.1 Antimalarial treatment 
9 
4.2 Concomitant treatment and medication that should not be used 
9 
4.3 Rescue treatment 
10 
5. EVALUATION CRITERIA 
10 
5.1 Efficacy and safety evaluation 
10 
5.2 Clinical evaluation 
11 
5.3 Safety assessment 
14 
6. STUDY ASSESSMENT 
14 
6.1 Screening and enrolment 
14 
6.2 Follow-up 
15 
7. DATA MANAGEMENT 
16 
8. STATISTICAL METHODS 
16 
8.1 Sample size 
16 
8.2 Analysis of data 
16 
8.3 Dissemination of results 
17 
8.4 Amendments to the protocol 
17 
9. ETHICAL CONSIDERATIONS 
17 
9.1 Approval by the national ethical committee 
17 
9.2 Informed consent 
18 
9.3 Confidentiality 
18 
9.4 Health-care services 
18 
9.5 Inducement 
18 
9.6 Community 
19 
10. BUDGET TEMPLATE 
20 
11. CURRICULUM VITAE OF THE PRINCIPAL INVESTIGATOR 
22 
APPENDIX 1. DEFINITION OF SEVERE FALCIPARUM MALARIA 
26 
APPENDIX 2. MEDICATIONS (WITH ANTIMALARIAL ACTIVITY) THAT SHOULD NOT BE USED DURING THE STUDY 
PERIOD 
27 
APPENDIX 3. DOSING CHART OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE 
28 
APPENDIX 4. CLASSIFICATION OF TREATMENT OUTCOMES 
30 
APPENDIX 5. CASE SCREENING FORM 
31 
APPENDIX 6. SCHEDULE OF FOLLOW-UP ACTIVITIES 
33 
APPENDIX 7. CASE REPORT FORMS 
35 
APPENDIX 8. SERIOUS ADVERSE EVENT REPORT FORM 
46 
APPENDIX 9. GUIDELINES FOR ANALYSIS OF RESULTS 
48 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
3
APPENDIX 10. CONSENT AND ASSENT FORMS 
49 
REFERENCES 
61 
  
COVER SHEET FOR THERAPEUTIC EFFICACY TEST PROTOCOL  
 
Study Title/Acronym 
Efficacy and safety of artesunate + amodiaquine combined with a single low dose of 
primaquine (0.25 mg/kg) for the treatment of uncomplicated plasmodium infection in 
Zanzibar (ACO V) 
Protocol submission date 
 20th February 2017 
Protocol number/version 
Verison I, 2017 
Principal investigator 
Mr. Mwinyi I. Msellem, DMLS, ADMLS, MSc 
Mnazi mmoja hospital –Ministry of Health, Zanzibar 
E-mail: mmwinyi@hotmail.com +255 77 743 29 11  
Co-investigator 
Mr. Abdullah S. Ali 
Malaria Elimination Programme 
E-mail : busudi@gmail.com 
 
Ms. Fayza B. Abass 
Zanzibar Malaria Elimination Programme 
E-mail : fayzaabass@yahoo.com  
Co-investigator 
Prof Anders Björkman, MD, PhD, DTM&H,                        
Karolinska Instituttet, stockholm,  Sweden. 
E-mail: anders.bjorkman@ki.se 
 
Prof Andreas Mårtensson, MD, PhD, DTM&H,                        
Uppsala University, Uppsala, Sweden. 
E-mail: Andreas.martensson@kbh.uu.se  
Participating institutions  
Mnazi mmoja hospital 
Zanzibar Malaria Elimination Programme 
Karolinska Institutet, Stockholm, Sweden 
Uppsala University, Uppsala, Sweden 
Study dates 
April to October 2017 
Sponsors 
Ministry of Health, Zanzibar, Tanzania 
P.O. Box 236, Zanzibar, Tanzania. 
Global Fund: QNB-M-MOH 
Karolinska Institutet and Uppsala University, Sweden 
Clinical trial registration 
 
The study will be registered at ClinicalTrials.gov prior to commencement of the trial 
 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
4
SUMMARY  
Title: Efficacy and safety of artesunate + amodiaquine combined with a single low dose of 
primaquine (0.25 mg/kg) for the treatment of uncomplicated Plasmodium falciparum malaria 
in Zanzibar. 
Background:  Zanzibar introduced artemisinin combination therapy (ACT) for the treatment 
of uncomplicated P. falciparum malaria in 2003 with artesunate + amodiaquine as first-line 
treatment. Following wide scale deployment of ACT together with strengthened vector 
control with long lasting insecticidal nets (LLIN) and indoor residual spraying (IRS) the 
burden of malaria has declined markedly in Zanzibar to a level equivalent with malaria pre-
elimination. Artesunate+amodiaquine has previously shown to be safe and highly efficacious 
with polymerase chain reaction (PCR) corrected cure rates >90% by day 42 in clinical trials 
conducted 2003/4 and 2005. Recently, and in line with WHO recommendations for low 
transmission settings, a single low dose of primaquine (0.25 mg/kg), a P. falciparum 
gametocytocidal drug, has been introduced as policy. However, no updated efficacy data of 
the firstline treatment for uncomplicated malaria are available from Zanzibar.  
Objective: To assess the efficacy and safety of artesunate+amodiaquine combined with a 
single low dose of primaquine (0.25 mg/kg) for the treatment of uncomplicated P. falciparum 
malaria in Zanzibar.  
Methods: A one-arm prospective antimalarial drug efficacy trial will be conducted.  
Participants will be recruited from febrile patients, i.e. documented axillary temperature 
≥37.5 °C or history of fever during the past 48 hours, of 3 months and above years old, 
presenting at primary health care facilities in Zanzibar, with microscopy confirmed 
uncomplicated P. falciparum infection. Enrolled patients will receive directly observed 
treatment with artersunate + amodiaquine once daily for 3 consecutive days according to the 
national malaria treatment guidelines. A single low dose of primaquine (0.25 mg/kg) will be 
administerad together with the first artesunate + amodiaquine dose. Clinical and 
parasitological as well as safety parameters will be monitored over a 28-day follow-up 
period. The study will be conducted between April and October 2017. The results will be 
used to assist the Zanzibar Ministry of Health in assessing the current national treatment 
guidelines for uncomplicated P. falciparum malaria. 
 
 
 
 
 
 
 
 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
5
BACKGROUND  
Zanzibar was among the first regions in sub-Saharan Africa to introduce artemisinin 
combination therapy (ACT) for the treatment of uncomplicated P. falciparum malaria in 2003 
as a response to reports of unacceptable high treatment failure with chloroquine. The wide 
scale deployment of ACT, free of charge to all malaria patients through public health care 
facilities, together with strengthened vector control with long lasting insecticidal nets (LLIN) 
and indoor residual spraying (IRS) have resulted in a marked decline in burden of malaria in 
Zanzibar (Bhattarai et al 2007). 
Since September 2003 the first line-treatment of uncomplicated malaria in Zanzibar is 
artesunate + amodiaquine. Presently, a fixed dose combination of artesunate + amodiaquine 
(Artesunate Amodiaquine Winthrop®, Sanofi Aventis), prequalified by the WHO, is deployed 
for treatment of uncomplicated malaria infection once daily for 3 consecutive days in all 
primary health care facilities. The present alternative treatment in case of known intolerance 
to artesunate + amodiaquine is artemether-lumefantrine (ALU); however, in some cases other 
artemisinin based combination therapy are prescribed particularly in private facilities. ALU is 
rarely used. Artesunate injection is a drug of choice for severe malaria, if not available 
Artemether or quinine are acceptable alternatives, whereas Artesunate and amodiaquine is 
also used for intermittent screening and treatment in pregnancy (IST).  
Artesunate + amodiaquine as well as artemether-lumefantrine have previously shown to be 
safe and highly efficacious, with polymerase chain reaction (PCR) corrected cure rates >90% 
by day 42 in clinical trials conducted 2003/4 (Mårtensson et al 2005) and 2005 (Holmgren et 
al 2007) for the treatment of children with uncomplicated P. falciparum malaria in Zanzibar. 
Zanzibar has recently, and in line with WHO recommendations for low transmission settings, 
introduced as policy for uncomplicated malaria a single low dose of primaquine (0.25 
mg/kg), a P. falciparum gametocytocidal drug, in addition to standard ATC. However, no 
recent efficacy data of the presently recommended first-line treatment are available.  
The aim of this study is therefore to provide policymakers with updated efficacy and safety 
data of artesunate + amodiaquine in combination with a single low dose of primaquine (0.25 
mg/kg) and data on genetic markers of ACT tolerance/resistance, proposed as an early 
warning system for development and spread of antimalarial drug resistance, in Zanzibar. The 
study protocol is based on the new WHO guidelines for surveillance of antimalarial drug 
efficacy (WHO 2014).  
  
 
OBJECTIVES  
The general objective of this study is to assess the therapeutic efficacy and safety of 
artesunate + amodiaquine combined with a single low dose of primaquine (0.25 mg/kg) for 
the treatment of uncomplicated P. falciparum malaria patients in Zanzibar. 
The specific objectives are: 
 
to determine the clinical and parasitological efficacy of artesunate + amodiaquine and 
primaquine in the treatment of uncomplicated Plasmodium falciparum infection; 
 
to differentiate recurrent infections during follow-up, i.e. recrudescence from new 
infections, by PCR analysis; 
 
to evaluate the incidence of adverse events, particularly with regards to potential 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
6
hematological adverse events of primaquine; and 
 
to determine the polymorphism of molecular markers associated with artesunate + 
amodiaquine tolerance/resistance. 
 
to formulate recommendations, which will enable the Zanzibar Ministry of Health to 
make informed decisions about whether the current national antimalarial treatment 
guidelines should be updated or not.  
 
To determine efficacy rate of the first line treatment compared to the first efficacy trial 
thirteen years ago.   
 
3. METHODS 
3.1  
Study design and clinical trial registration 
This surveillance study is designed as a one-arm prospective evaluation of the clinical and 
parasitological responses to directly observed treatment for uncomplicated malaria WHO, 
2003 and 2009). People with uncomplicated malaria, who meet the study inclusion criteria 
will be enrolled, treated on site with artesunate + amodiaquine and a single low dose of 
primaquine (0.25 mg/kg) and monitored for 28 days. The follow-up will consist of a fixed 
schedule of check-up visits and corresponding clinical and laboratory examinations. On the 
basis of the results of these assessments, the patients will be classified as having therapeutic 
failure (early or late) or an adequate response. Blood samples from patients experiencing 
therapeutic failure during the follow-up period will be used to estimate the efficacy of the 
study drugs based on PCR analysis to distinguish between recrudescence (treatment failures) 
and reinfection (new infections).  
This study will be registered at the ClinicalTrials.gov registry platform before 
commencement of the trial. 
 
3.2 
Study sites 
The study will screen patients from 14 selected primary health care facilities (see below) in 
three different three districts of Zanzibar Islands. These facilities will classified as sattelite 
study sites and recruitment sites. The satellite facilities will be used for initially screening the 
eligible patients for the inclusion criterias; these includes signs of uncomplicated malaria, 
positive confimed using malaria Rapid Diagnostic Tests (mRDT), verbal consent for patients 
above 18 years and verbal asent from parent (s) for the children below 18 years. Any patient 
who will show eligibility to participate will be transferred to the recruitment sites.  
In each district there will be one recruitment study site of which patients will enrolled in 
based on the set eligibility criteria. Recruitment sites will equiped with microscope with all 
consumables, haemaque machine for hemaglobin and well trained technicians that recently 
has undergone a malaria microscopy refresher course to ensure the highest possible quality of 
microscopy service throughout the study. Responsible Clinicians will be oriented to the study 
protocol and assigned to recruit, treat, fill the case record form and follow up details inclusion 
and exclusion criterias. 
The 14 primary health care facilities included in the study are from 2 districts (West and 
Central and one district (Micheweni) of Unguja and Pemba Islands respectively. These 
facilities were chosen based on higher malaria cases detected on the previous three months 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
7
but also because they are located nearby to the one of the proposed recruitment sites. The 
proposed study sites are the following:  
Micheweni, Tumbe, Shumba viamboni (Micheweni District); Chukwani, Kizimbani, 
Shakani, Kombeni, Bububu, Selem, Magogoni (West District); Mwera, Miwani, Machui and 
Uzini (Central District). 
Proper communication between settalites and recruitment study sites will be established to 
make sure all screened patients with initial eligible criterias to be able transferred to the 
recruitment sites for detailed screening for study inclusion criterias. All eligible patients will 
be given written consent and asent forms to sign at the recruitment sites. Treatment, 
observation and follow up to the enrolled patients will be conducted in all three proposed 
recruitment study sites namely Micheweni (Pemba) and Bububu Jeshini and Uzini of Unguja 
Island.  
 
3.3 
Study population 
The population will consist of patients of all ages presenting at the study sites with symptom 
and signs compatible with uncomplicated P. falciparum malaria. All adult patients will be 
informed about the study and asked to sign the consent form for participation prior to 
enrolment. Parents or guardians will give informed consent on behalf of their children. 
Children over 12 years of age will sign an informed assent form. 
 
3.4 
Timing and duration of study 
The study is planned to be conducted for six months, from April to October 2017. 
 
3.5 
Inclusion criteria 
 
Age 3 months and above;  
 
P. falciparum infection detected by mRDT and confirmed by microscopy; 
 
presence of P. falciparum malaria asexual parasitaemia (any level);  
 
presence of axillary ≥37.5 °C  or history of fever during the past 48 hours 
 
ability to swallow oral medication; 
 
ability and willingness to comply with the study protocol for the duration of the study 
and to comply with the study visit schedule; and 
 
informed consent from the patient or from a parent or guardian in the case of children. 
 
3.6 
Exclusion criteria 
 
Presence of general danger signs in children aged under 5 years or signs of severe 
falciparum malaria according to the definitions of WHO (Appendix 1); 
 
mono-infection with a Plasmodium species other than P. falciparum detected by 
microscopy; 
 
presence of febrile conditions other than malaria (e.g. measles, acute lower respiratory 
tract infection, severe diarrhoea with dehydration) or other known underlying chronic 
or severe diseases (e.g. severe malanutrition, cardiac, renal and hepatic diseases, 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
8
HIV/AIDS); 
 
regular medication, which may interfere with the study drugs; 
 
history of hypersensitivity reactions or contraindications to any of the study 
medicines; and 
 
preganacy 
3.7 
Loss to follow-up  
Loss to follow-up occurs when, despite all reasonable efforts, an enrolled patient does not 
attend the scheduled visits and cannot be found. No treatment outcome will be assigned to 
these patients. Every effort must be made to schedule a follow-up visit for patients who fail to 
return to the study site, especially during but also after administration of the study drug. 
These patients will be classified as lost to follow-up and censored or excluded from the 
analysis. Patients who are lost to follow-up but who subsequently return to the study site 
before day 28 will not be turned away and will be encouraged to return for check-up visits. 
The principal investigator will decide whether the patient is to be definitely classified as lost 
to follow-up on the basis of his or her history or is to be maintained for the analysis.  
 
3.8 
Patient discontinuation or protocol violation 
Study patients who meet any of the following criteria will be classified as withdrawn. 
 Withdrawal of consent. A patient may withdraw consent at any time, without 
prejudice for further follow-up or treatment at the study site. 
 Persistent vomiting of the treatment. A patient who vomits the study medication 
twice will be withdrawn from the study and given rescue treatment. 
 Failure to attend the scheduled visits during the first 3 days. 
 Serious adverse events necessitating termination of treatment before the full 
course is completed. A patient can be discontinued from the study if the principal 
investigator decides so due to an adverse event of adequate nature or intensity. In 
this case, information on the adverse event and symptomatic treatment given must 
be recorded on a case report form. If the adverse event is serious, the principal 
investigator must notify the sponsor or its designee immediately and follow the 
reporting procedures described in section 5.3.  
 Enrolment violation: 
 severe malaria on day 0; or 
 erroneous inclusion of a patient who does not meet the inclusion criteria. 
 voluntary protocol violation: self- or third-party administration of antimalarial 
drug (or antibiotics with antimalarial activity) (Appendix 2); 
 involuntary protocol violation: 
 occurrence during follow-up of concomitant disease that would interfere with a 
clear classification of the treatment outcome; 
 detection of mono-infection with another malaria species during follow-up; or 
 misclassification of a patient due to a laboratory error (parasitaemia), leading to 
administration of rescue treatment. 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
9
Patients who are withdrawn will be followed up until recovery or to the end of follow-up, no 
treatment outcome will be assigned to these patients, and they will be censored or excluded 
from the analysis. The reasons for discontinuation or protocol violation will be recorded on 
the case report form. 
 
4. TREATMENT  
4.1 
Antimalarial treatment  
Artesuate + amodiaquine will be administered orally as a fixed dose combination, i.e. 
Artesunate/Amodiaquine Winthrop®, prequalified by the WHO, at a dose of approximately 
artesunate 4 mg/kg + amodiaquine 10mg/kg once daily for 3 consecutive days.  
Primaquine will be administered orally, i.e. ®, prequalified by the WHO, as a single dose 
(0.25 mg/kg) together with the first artesunate + amodiaquine dose of approximately 
artesunate 4 mg/kg + amodiaquine 10mg/kg once daily for 3 consecutive days.   
 
The study drugs, represent the present drugs deployed to public health care facilities by the 
Zanzibar Ministry of Health. 
The investigators will be instructed to record the batch number and expiry date of the test 
medicines. The correct drug dosages will be determined from the dosing charts (Appendix 3), 
which are in accordance with the national treatment guidelines in Zanzibar. 
All doses of medicine will be administered under direct supervision of a qualified member of 
the staff designated by the principal investigator. The study patients will be observed for 30 
minutes after medicine administration for adverse reactions or vomiting. Any patient who 
vomits during this observation period will be re-treated with the same dose of medicine and 
observed for an additional 30 minutes. If the patient vomits again after the second study drug 
administration, he/she will be withdrawn and offered rescue therapy (see below section 4.3 
Rescue treatment). 
 
4.2 
Concomitant treatment and medication that should not be used 
Fever ≥38.5°C will be treated with paracetamol according to national treatment guidelines.   
Prior treatment with antimalarial drugs will not be considered an exclusion criterion; 
however, during follow-up, if infections other than malaria require the administration of 
medicines with antimalarial activity, the patient will be withdrawn from the study. Patients 
given tetracycline as an eye ointment will not be excluded (Appendix 2). Patients will be 
withdrawn from the study in the case of self-medication or if an antimalarial drug or an 
antibiotic with antimalarial activity is administered by a third party. 
Adverse events requiring treatment can be treated according to local practice in Zanzibar. If 
there is a clinical indication for any additional medication during the course of the study, 
including medication given to treat an adverse event related to the study medicine, the name 
of the medicine, the dosage and the date and time of administration must be recorded on the 
case report form. 
The use of herbal remedies during the study should be avoided, and participants should be 
encouraged to return to the study site for treatment if they feel unwell. If any herbal remedies 
are taken during the study, this should be captured on the case report form, under ‘study 
medication administration’. 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
10
 
4.3 
Rescue treatment 
If a patient vomits a dose of the study medicine twice, he/she will be withdrawn from the 
study and receive Artesunate IV (preferred route) or IM p according to national treatment 
guidelines 
Women who are found to be pregnant at enrolment will be treated with tablets quinine 10 
mg/kg body weight 8 hourly for 7days if she is in the first trimester or AS 4mg/kg +AQ 10 
mg/kg body weight once a day for 3 days if she is in the second and third trimester will be 
used according to national treatment guidelines. 
Any patient with signs of severe or complicated malaria will be hospitalized and receive 
parenteral therapy with Artesunate according to national treatment guidelines. Initially, an 
intravenous loading dose of 2.4 mg/kg will be given at admission then at 12 hrs and 24 hrs, 
thereafter once a day. The total duration of treatment with parenteral Artesunate should be a 
minimum of 24hrs and a maximum of 7 days if the patient is still unable to tolerate oral 
medication for up to 7 days.Together with relevant supportive treatment, such as 
administration of glucose to avoid hypoglycaemia, antipyretic and other physical methods to 
control fever, blood transfusion if indicated and/or broad spectrum antibiotics if 
meningitis/septicaemia cannot be ruled out. .If the patient is re-infected with malaria species, 
he/she will receive artesunate 4 mg/kg + amodiaquine 10 mg/kg body weight once daily for 3 
days according to the national treatment guidelines. 
 
5. EVALUATION CRITERIA 
The study end-point is the classification assigned to a patient. Valid study end-points include: 
treatment failure, completion of the follow-up period without treatment failure, loss to 
follow-up, withdrawal from study, and protocol violation. At all times, the well-being of the 
patient will take priority over his or her continuation in the study. 
 
5.1 
Efficacy and safety evaluation 
5.1.1 Classification of treatment outcomes  
Treatment outcomes will be classified on the basis of an assessment of the parasitological and 
clinical outcome of antimalarial treatment according to the latest WHO guidelines (WHO 
2005). Thus, all patients will be classified as having early treatment failure, late clinical 
failure, late parasitological failure or an adequate clinical and parasitological response, as 
defined in Appendix 4.  
As parasitological cure is the goal of antimalarial therapy, all study patients who show 
treatment failure will be given rescue treatment. Follow-up will continue until recovery. The 
results from these patients do not need to be recorded systematically for the purpose of the 
surveillance study. 
 
5.1.2 Safety end-points 
The incidence of any adverse event will be documented. All patients will be asked routinely 
at each follow-up visit about previous symptoms and about any symptom that have emerged 
since the previous visit. When clinically indicated, patients will be evaluated and treated 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
11
appropriately. All adverse events will be recorded on the case report form. Serious adverse 
events (see definitions below section 5.3 Safety assessment) must be reported to the sponsor. 
 
5.2 
Clinical evaluation 
All patients will be evaluated clinically as described below. 
5.2.1 Physical examination 
A standard physical examination will be performed at baseline (day 0 before drug 
administration) and on days 1, 2, 3, 7, 14, 21 and 28. A complete medical history, 
demographic information and contact details will be taken at baseline. 
 
5.2.2 Body weight  
Body weight will be recorded on day 0 to the nearest kilogram using a Salter scale, a hanging 
or electronic weighing scale for young children. The scales will be properly calibrated. 
Patients should not wear excessive clothing while being weighed as this can overestimate 
their true weight. All young children should only wear undergarments while being weighed. 
The screening weight will be used to satisfy the inclusion or exclusion for nutrition status as 
well as to calculate the dose (number of tablets) to be administered. The reliability of the 
scales will be verified before the study begins and checked at regular intervals. 
The circumference of the left mid-upper arm will be measured, at the mid-point between the 
elbow and the shoulder, and will be recorded to the nearest 0.2 cm. 
Oedema will be assessed by thumb pressure for 3 s on the dorsal surface of both feet. 
 
5.2.3 Body temperature 
Axillary temperature will be measured at baseline (day 0 before drug administration) and on 
days 1, 2, 3, 7, 14, 21, 28. Temperature will be measured with a thermometer that has a 
precision of 0.1 °C. Temperature will also be measured as clinically indicated. If the result is 
<36.0 °C, the measurement will be repeated. The same route for assessing temperature should 
be used throughout the study. 
The quality of the temperature-taking technique and the thermometers should be assessed 
regularly. Thermometers should be tested in a water-bath of known temperature before the 
study begins and at regular intervals thereafter. 
 
5.2.4 Microscopic blood examination 
A thick film for asexual and gametocyte counts and species identification should be obtained 
and examined at screening on day 0 to confirm adherence to the inclusion and exclusion 
criteria. Thick blood films, again assessed for asexual and gametocyte parasitemia, will be 
also examined on days 1, 2, 3, 7, 14, 21, 28 or on any other day if the patient returns 
spontaneously and parasitological reassessment is required. Specimens will be labelled 
anonymously (screening number or study number, day of follow-up, date). 
A fresh Giemsa stain dilution will be prepared at least once a day and possibly more often, 
depending on the number of slides to be processed. Giemsa-stained thick films will be 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
12
examined at a magnification of 1000 (using x10 ocular lens and x100 objective) to identify 
the parasite species and to determine asexual and gametocyte parasite density. 
The study number of the patient, the date and the day of follow-up will be recorded either on 
the frosted edge of the slide or on the glass with a permanent glass pen. 
The thick blood smear will be used to calculate the parasite density, by counting the number 
of asexual parasites in a set number of white blood cells (typically 200) with a hand tally 
counter. Once a field has been started, it must be counted to completion; the final number of 
white blood cells will therefore rarely be exactly 200. If more than 500 parasites have been 
counted before 200 white blood cells have been reached, the count will be stopped after the 
reading of the last field has been completed. Parasite density, expressed as the number of 
asexual parasites per µl of blood, will be calculated by dividing the number of asexual 
parasites by the number of white blood cells counted and then multiplying by an assumed 
white blood cell density (typically 8000 per µl). 
 
 
Parasite density (per µl) = number of parasites counted  (8000) 
 
 
Number of leukocytes counted 
 
 
The same technique will be used to establish the parasite count on each subsequent blood 
film. When the number of asexual parasites is less than 10 per 200 white blood cells in 
follow-up smears, counting will be done against at least 500 white blood cells (i.e. to 
completion of the field in which the 500th white blood cell is counted). A blood slide will be 
considered negative when examination of 1000 white blood cells reveals no asexual parasites. 
The presence of gametocytes on an enrolment or follow-up slide will be recorded. 
In addition, 100 fields of the second thick film will be examined to exclude mixed infections; 
in case of any doubt, the thin film will be examined for confirmation. If examination of the 
thin film is not conclusive, the patient will be excluded from the analysis after complete 
treatment and follow-up. 
Two qualified microscopists will read all the slides independently, and parasite densities will 
be calculated by averaging the two counts. Blood smears with discordant results (differences 
between the two microscopists in species diagnosis, in parasite density of > 50% or in the 
presence of parasites) will be re-examined by a third, independent microscopist, and parasite 
density will be calculated by averaging the two closest counts. 
 
5.2.5 Genotyping of malaria parasites  
In order to differentiate a recrudescence (treatment failure/same parasite strain) from a newly 
acquired infection (reinfection/different parasite strain) among recurrent parasitemias found 
during follow-up, a genotype analysis will be conducted. This analysis is based on the 
extensive diversity in the following P. falciparum genes:  the merozoite surface protein 1 
(msp1) and 2 (msp2), and the glutamine-rich protein (glurp) (WHO 2008). The genotypic 
profiles of pre- and post-parasite strains are compared in a stepwise manner to distinguish 
recrudescence from reinfection. 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
13
In order to minimize discomfort to the patient due to repeated finger pricks, two to three 
drops of blood will be collected on a 3MM (Whatman) filter paper during screening or 
enrolment and each time blood smears are required according to the protocol from day 7. 
Specimens will be labelled anonymously (study number, day of follow-up, date), kept in 
individual plastic bags with desiccant pouches and protected from light, humidity and 
extreme temperature until analysed. Paired filter paper samples from day on enrolment (day 
0) and initial day of recurrent parasitemia during the 28 day follow-up period will be 
analysed by stepwise genotyping using previously described nested-PCR protocols at the 
Malaria Research Unit, Karolinska Institutet, Stockholm, Sweden (Snounou et al 2002). 
Unused filter papers will be destroyed immediately after the study.                                                                    
 
The identification of genetic alterations, i.e. single nucleotide polymorphisms (SNPs) and 
gene amplifications, associated with tolerance/resistance to ACTs (Sisowath et al 2005; 
Holmgren et al, 2006), has enabled a new potential surveillance tool, which may be of 
particular importance in areas with very low malaria transmission such as Zanzibar, as an 
early warnings system of development and spread of antimalarial drug resistance. Several 
markers of tolerance/resistance to antimalarial drugs, e.g. amodiaquine and lumefantrine, 
have been described, i.e. in the P. falciparum chloroquine resistance transporter gene (pfcrt) 
and the multidrug resistance gene 1 (pfmdr1). Furthermore, key markers of artemisinin 
tolerance/resistance in the K13 propeller region will also be analysed based on previously 
described protocols (Ariey et al, 2014).  
Analysis of SNPs and gene amplifications associated with tolerance/resistance to ACT will 
be performed according to established protocols at Karolinska Institutet, Stockholm, Sweden, 
from the previously described blood spots collected on 3MM filter paper. Thus, these parasite 
genetic analyses will not require any additional blood sampling from enrolled patients. The 
results will be compared with historical data from Zanzibar from clinical trials of artesunate + 
amodiaquine conducted 2003/4 and 2005 using trend analysis.  
 
5.2.6 Pregnancy test  
Female patients aged 15-49 years will be asked about their menstrual history according to 
standard and context specific case management of women of child-bearing age in Zanzibar.  
Women who are found to be pregnant at screening, and thus not enrolled, and estimated to be 
in the first trimester will be treated with oral quinine 10 mg/kg body weight 8 hourly for 7 
days, whereas pregnant women in the second and third trimester will receive artesunate 4 
mg/kg + amodiaquine 10 mg/kg treatment once daily for 3 days according to national 
treatment guidelines. 
Female study participants of child-bearing age, defined as above (menstruating women above 
49 years also will be considered), will be appropriately counselled about the risks of 
becoming pregnant and exposing the fetus to the study medicines and encouraged to use 
barrier methods for contraception during the entire study period. 
 
5.2.7 Haematological assessment haemoglobin 
Haemoglobin will be assessed systematically on all participants on days 0, 3, 7, 14 and 28 
using Hemocue, and at any time in case of clinical suspicion of anaemia, i.e. pallor, according 
to standard case management of malaria in Zanzibar.  

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
14
 
5.3 
Safety assessment 
Safety will be assessed by recording the nature and incidence of adverse events and serious 
adverse events. Adverse events will be assessed by direct questioning. An adverse event is 
defined as any unfavourable, unintended sign, symptom, syndrome or disease that develops 
or worsens with the use of a medicinal product, regardless of whether it is related to the 
medicinal product. All adverse events must be recorded on the case report form. 
A serious adverse event is defined as any untoward medical occurrence that at any dose: 
 
results in death, is life threatening; 
 
requires hospitalization or prolongation of hospitalization; 
 
results in a persistent or significant disability or incapacity; or 
 
is a congenital anomaly or birth defect. 
‘Life-threatening’ means that the person was at immediate risk of death; it does not refer to a 
adverse event that might have caused death if it were more severe. ‘Persistent or significant 
disability or incapacity’ means that a person’s ability to carry out normal life functions is 
substantially disrupted. 
All serious adverse events occurring during the study must be recorded and reported by the 
principal investigator to the sponsor, regardless of whether the principal investigator 
considers the events to be related to the investigated medicine. 
The investigator will collect information on all people who become pregnant while 
participating in this study and will record the information on the appropriate form. The 
person will also be followed to determine the outcome of the pregnancy. Generally, follow-
up will be no longer than 6–8 weeks after the estimated delivery date. Any premature 
termination of pregnancy will be reported. While pregnancy itself is not considered an 
adverse event or a serious adverse event, any complication of pregnancy or elective 
termination for medical reasons will be recorded as an adverse event or a serious adverse 
event. A spontaneous abortion is always considered a serious adverse event and will be 
reported as such. 
 
6. STUDY ASSESSMENT 
6.1 
Screening and enrolment  
All patients who meet the basic enrolment criteria (fever or history of fever within the last 48 
hours, symptoms of malaria, absence of danger signs in children in relation to malaria—child 
unable to drink or breastfeed, vomiting everything, recent history of convulsions, lethargic or 
unconscious state, unable to sit or stand, difficulty in breathing—, absence of signs of severe 
malaria, absence of severe malnutrition, pregnancy) during screening will be assigned a 
consecutive number and evaluated in greater depth by the health care staff at the study sites. 
In children, care will be taken to detect early signs of febrile diseases other than malaria, as 
their presence will necessitate exclusion from the evaluation. The most frequent confounding 
condition is a lower respiratory tract infection: cough or difficult breathing, together with fast 
breathing, is an indicator for exclusion. Fast breathing is defined as a respiratory frequency > 
50/min in infants under 12 months of age and > 40/min in children aged 12–59 months. Other 
relatively common febrile conditions are otitis media, tonsillitis, measles and abscesses. 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
15
Patients with these conditions will not be enrolled but should be treated for both malaria (if 
they have parasitaemia) and the other infection, as appropriate. 
The screening record form (Appendix 5) will be used to record the general information and 
the clinical observations on each patient being screened. If the patient meets the clinical 
criteria, he/she will be examined for presence of parasitaemia, initially with a RDT for 
malaria. For all screening patients with a positive RDT test, a confirmatory blood slide will 
be conducted to ensure presence of P. falciparum mono-infection. Once the patient meets all 
the enrolment criteria, he/she or a parent or guardian in case of children will be asked for 
consent to participate in the study. 
 
6.2 
Follow-up  
Patients who meet all the enrolment criteria will be given a personal identification number 
and will receive treatment only after the study has been fully explained to them and they have 
willingly provided informed consent. Any person who decides not to participate in the study 
will be examined, treated and followed-up by the health facility staff according to the 
standard of care established by the Zanzibar Ministry of Health. 
The basic follow-up schedule is summarized in Appendix 6. A case report form (Appendix 7) 
and a serious adverse event report form (Appendix 8) will be used to record the general 
information and clinical observations on each patient enrolled into the study. The 
appointment schedule will be clearly explained, and a follow-up card with a personal 
identification number will be provided. 
The day a patient is enrolled and receives the first dose of study medicine is designated ‘day 
0’. All antimalarial treatment will be given by a study team member under supervision. 
Enrolled patients will be observed for at least 30 min after treatment to ensure that they do 
not vomit the medicine. If vomiting occurs within 30 min of treatment, the full treatment dose 
will be repeated. Ancillary treatment, such as antipyretics, will be provided if necessary to 
patients by the study team and documented on the case report form. Patients with persistent 
vomiting (i.e. necessitating more than a single repeat dose) will be excluded from the study 
and immediately referred to the health facility staff for appropriate management. 
Thereafter, patients are required to undergo regular clinical reassessment. Blood films for 
asexual and gametocyte parasite counts will be made on days 2, 3 and 7 and then weekly for 
the remainder of the follow-up period, i.e. on days 14, 21 and 28. Patients will be advised to 
return on any day during the follow-up period if symptoms return and not to wait for the next 
scheduled visit day. In particular, parents or guardians should be instructed to bring children 
to the centre at any time if they show any sign of danger (unable to drink or breastfeed, 
vomiting everything, presenting with convulsions, lethargic or unconscious, unable to sit or 
stand, presenting with difficult breathing), if they are still sick or if there is any cause for 
worry. Clinical reassessment will be sufficiently thorough to ensure patient safety and will 
include assessment not only for potential treatment failure but also for potential adverse 
reactions to the medicine. Additionally, blood films will be obtained whenever 
parasitological reassessment is requested by the clinical staff. 
Because many medicines have to be given over several days, the initial visits are critical not 
only for assessing efficacy but also for ensuring patient safety; defaulters at this stage will not 
have received a complete course of treatment and may be at risk for clinical deterioration. All 
reasonable efforts will be made to find defaulters to ensure complete treatment. Similarly, the 
ultimate success of the study rests on minimizing loss to follow-up. While patients are 
encouraged to return on their own for scheduled follow-up visits, it is essential that 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
16
provisions be made ahead of time for locating patients at home if they do not attend as 
requested. This requires obtaining detailed directions to the home during enrolment, and 
study team members familiar with the community will be responsible for home visits and 
means of transport for the patients. Health attendant (community mobiliser) of each facility 
will be involved in this study. His/her main responsibility will be to take detail record of each 
enrolled patient, if patient did not show up at health facility on his/her scheduled day then 
active follow up is done by community mobiliser. The schedule of treatment and follow-up 
examinations given in this protocol must be followed to ensure data integrity. Patients who 
fail to return on days 1 and 2 and miss one dose of the treatment will be withdrawn from the 
study definitively. After day 3, patients who fail to return on day 7 but are present on day 6 or 
8 (likewise days 13/15, days 20/22, days 27/29 may still be included in the analysis. 
Deviation from the protocol of more than 1 day should, however, be avoided (see also section 
3.7).  
 
7. DATA MANAGEMENT  
The principal investigator will ensure that the study protocol is strictly adhered to and that all 
data are collected and recorded correctly on the case report form. Laboratory and clinical data 
will be recorded on a daily basis on the case report form designed for the study. Data derived 
from source documents should be consistent with the source documents, or the discrepancies 
should be explained. Any change or correction to a case report form should be dated and 
explained and should not obscure the original entry. All case report forms will be checked for 
completeness. 
After the study has been completed, data will be entered into a database by double 
independent data entry, according to WHO standard procedures (WHO/GMP). The trial data 
will be stored in a computer database, maintaining confidentiality.  
The principal investigator is responsible for keeping all screening forms, the case report form 
and the completed subject identification code list in a secure location. 
 
8. STATISTICAL METHODS  
8.1 
Sample size 
Sample size calculations is based on an assumed PCR corrected treatment failure rate of 
artesunate and amodiaquine by day 28 of 5%, a confidence level of 95% and a precision of 
5%. This corresponds to a sample of 73 + 20% to account for attrition, in total 90 patients. 
 
8.2 
Analysis of data 
Microsoft Excel-2007 program World Health Organization 2008 will be used for data 
management and analysis. Data will be double entered, validated and analysed by two 
methods: the Kaplan-Meier method and per-protocol analysis in accordance with WHO 
recommendations. In addition to the reasons for withdrawal listed in section 3.8, patients will 
be considered withdrawn from the analysis if the PCR results are unclassifiable or if the 
results of PCR indicate that the failure is due to reinfection with P. falciparum or P. vivax. 
 
The final analysis and report will include: 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
17
 
a description of all patients screened and the distribution of reasons for non-inclusion 
in the study; 
 
a description of all the patients included in the study; 
 
the proportion of adverse events and serious adverse events in all the patients included 
in the study; 
 
the proportion of patients lost to follow-up or withdrawn, with 95% confidence 
intervals and a list of reasons for withdrawal; 
 
the cumulative incidence of success and failure rates at day 28, PCR-uncorrected and 
PCR-corrected; and 
 
the proportion of early treatment failure, late clinical failure, late parasitological 
failure and adequate clinical and parasitological response at day 28, with 95% 
confidence intervals, PCR-uncorrected and PCR-corrected, as well as gametocyte 
carriage at each sampling occasion. 
 
polymorphism 
of 
genetic 
markers 
related 
to 
artesunate 
+ 
amodiaquine 
tolerance/resistance.  
Guidelines on calculating the cumulative success or failure rate, the proportion of adequate 
clinical and parasitological response and treatment failure are given in Appendix 9. 
 
8.3 
Dissemination of results 
At the end of the study, the principal investigator will submit a report on the study and its 
main outcome. This report will be shared with the Zanzibar Malaria Elimination Programme 
and the Zanzibar Ministry of Health. 
The results of the study will be presented during scientific meetings and submitted for 
publication in scientific journals. 
The patient data will be made available to WWARN, a global database on antimalarial drug 
efficacy/resistance. To ensure patient confidentially no patient names will be used; instead 
only the patient identification number, country of original (Zanzibar) and age will be used. 
All health facilities and their respective health authorities will be informed about the outcome 
of the study.  
 
8.4 
Amendments to the protocol 
After the protocol has been accepted, no change may be made without the agreement of the 
principal investigator, the sponsor(s) and the ethical review boards. 
 
9. ETHICAL CONSIDERATIONS 
9.1 
Approval by the national ethical committee 
Before the study, official ethical approval to conduct the study will be obtained from 
Zanzibar Medical Research Ethical Committee (ZAMREC). 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
18
 
9.2 
Informed consent 
Patients will be included in the study only if they, or a parent or guardian of children give 
informed consent. The consent request, available in English and translated into Swahili, will 
be read entirely to the patient, parent or guardian. Details about the trial and its benefits and 
potential risks will be explained. Once any questions have been answered, a signature will be 
requested on the document (Appendix 10). If the patient is illiterate, a literate witness must 
sign; if possible, the signatory will be selected by the participant and will have no connection 
to the research team. The principal investigator must also obtain the assent of children over 
the age of 12 years, but their assent should be accompanied by the consent of a parent or 
guardian. Consent statement for the pregnancy test is also required for female participants of 
child-bearing age who are sexually active, please see above section 5.2.6. 
 
9.3 
Confidentiality 
All information on patients will remain confidential and be shared only by the study team. 
Unique identifiers will be used for computer-based data entry and blood samples. In all cases, 
the principal investigator will ensure that screening forms, the case report form and the 
completed identification code list are kept in locked files. 
 
9.4 
Health-care services 
Free health care throughout follow-up for any illness related to malaria will be provided to 
the study patients regardless of treatment outcome; this includes any expenses related to 
hospital admission and to adverse medicine reactions, if required. 
When prospective or actual participants are found to have diseases unrelated to malaria, the 
study team should advise them to obtain, or refer them for, medical care. 
Any person who decides not to participate or who cannot be enrolled into the study because 
he/she does not meet the criteria will be referred to the health facility staff. Such people will 
be treated with the official first-line treatment, i.e. Artesunate Amodiaquine Winthrop®,   
once daily for 3 days combined with a single low dose of primaquine (0.25 mg/kg) and 
followed-up according to the standard of care established by the Zanzibar Ministry of Health 
and Social Welfare.  
If a patient is withdrawn from the study before he/she has completed the full course of the 
treatment, the clinician must make all necessary arrangements to provide the patient with the 
full dose of the medicine being tested or in case of intolerance to artesunate + amodiaquine 
with a full treatment course of artemether 20 mg – lumefantrine 120 mg (Alu) according to 
body weight at 0, 8, 24, 36, 48, and 60 hours as recommended in the national treatment 
guidelines. 
 
9.5 
Inducement  
Subjects will be reimbursed for their transport to attend all visits to the health centre.  

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
19
 
9.6 
Community 
Prior to study commencement, the health facilities catchment areas (Shehia) will be gathered 
together through their local leaders (Sheha). In these meetings investigators will brief the 
community leaders about the study and stress the importance of completion of the entire 
follow-up schedule of 28 days. They will be invited to ask questions and full explanation will 
be provided to any raised issue. A copy of the study consent form will be provided to each 
Sheha to enable any community member to read more about the study.     

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
20
10. BUDGET TEMPLATE  
Human resources 
Tsh 
USD 
·    professional scientific staff  3pple*300,000/- per month*12 
months 
       10 800 000,00          7 448,28  
·    technical staff 40pple*100,000/- per month*12 months 
       48 000 000,00        33 103,45  
·    local support 20pple*50,000/- per month*12 months 
       12 000 000,00          8 275,86  
Sub-total 
     70 800 000,00      48 827,59  
Transport for Local supervision  
  
  
24 visits*25lts*1,650/- per ltr 1st phase 
         1 980 000,00          1 365,52  
144 visits*25lts*1,650/- per ltr 2nd phase 
       11 880 000,00          8 193,10  
360 visits*25lts*1,650/- per ltr 3rd phase 
       29 700 000,00        20 482,76  
Sub-total 
     43 560 000,00      30 041,38  
Equipment and supplies 
  
  
·    equipment (thermometers, lab equips ets) 
         8 900 000,00          6 137,93  
·    supplies (slides, cotton, spirit, lancets, giemsa etc) 
       11 200 000,00          7 724,14  
·    operational costs (space rental, communication) 
         8 500 000,00          5 862,07  
Sub-total 
     28 600 000,00      19 724,14  
Contingency fees for clinical trials  
  
  
·    ethical review 
            450 000,00            310,34  
Sub-total 
          450 000,00           310,34  
  
  
  
Patient incentive costs (bus fares for follow up and free LLIN)  
  
  
Patients bus fares (100pts*1,000per trip*9trips) 
           2,250 000,00  
    1,551.52 
Free LLINs (7,000/- pet net*100 nets) 
            700 000,00             482,76  
Sub-total 
       2 950 000,00          2,033.28  
Technical assistance  
  
  
Training for 20 Lab technicians 
25 000 000,00 
      17 241,38  
(training, support for research institutions,  
  
  
 capacity building) 
1 450 000,00 
        1 000,00  
Sub-total 
26 450 000,00 
    18 241,38  
Supervision  
  
  
Local Supervisors 
         3 120 000,00          2 151,72  
Sub-total 
       3 120 000,00        2 151,72  
  
  
  
Quality assurance system  
  
  
(data validation, slides cross-check) 
  
  
Sub-total 
       2 300 000,00        1 586,21  
Data management  
  
  
(data entry, data analysis, report writing) 
  
  
Sub-total 
       7 270 500,00        5 014,14  
Laboratory support  
  
  
(genotyping) 
  
  

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
21
Sub-total 
0 
                 -    
Miscellaneous 
  
  
Sub-total 
       2 500 000,00        1 724,14  
  
  
  
 
  
  
 GRAND TOTAL 
  
186,200,500 
  128,414  
 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
22
11. CURRICULUM VITAE OF THE PRINCIPAL INVESTIGATOR  
Mwinyi I. Msellem, CMLT, ADMLS, MSc  
 
Date and place of birth 
14 Dec 1966, Zanzibar 
Nationality 
Civil status 
Tanzanian 
Married with four children 
Address 
P.O.BOX 503  
Zanzibar, Tanzania 
Telephone 
E-mail 
+255 77 743 29 11 and +255 71 543 29 11 
mmwinyi@hotmail.com 
 
Employment 
 
November 2016 to date: Training and Research Officer, Mnazi mmoja hospital, Zanzibar 
Ministry of Health  
Responsible for coordinating researches and trainings to be conducted in Mnazi mmoja 
hospital. Also to make sure eligible staffs are participating in capacity building programmes 
inside and outside of Zanzibar. To work very close with other members of Training and 
Research unit of Mnazi mmoja hospital and of the Ministry of Health to develop training 
plans based on priorities and available resources. To advise the Executive Director and its 
Board on resource mobilization, collaborations and partnership with other organisations 
outside of the hospital for trainings and researches programmes which will improve and 
develop hospital management and its services. 
 
February, 2011 to November 2016: Assistant Program Manager, Zanzibar Malaria Programme 
under the Zanzibar Ministry of Health,  
I was supporting the Program Manager (PM) in coordinating and implementing program 
strategies to increase efficiency, maintain quality, and ensure continuous improvement in 
programme implementation. Assist the PM to review of all grant agreements with 
implementers to ensure that they are fully aligned with the grant agreements signed 
between the ZAMEP Program and the Donors; ensure the program units and implementers  
prepare the  quarterly and annual  programmatic and financial reports; manage staff and 
support functions to promote the effective functioning of the Program, build capacity of 
program staff through training,  supervise line managers and undertake regular monitoring of 
program field activities. To support Zanzibar Malaria Control Program and later Elimination 
Programme in controlling and eliminate malaria as a public health problem and obstacle to 
socio-economic development, through providing technical guidance to local authorities, 
national and international partners. 
 
August, 2001 to February 2011: Head of Diagnostic unit of Zanzibar Malaria Programme under 
the Zanzibar Ministry of Health,  
Leader on technical coordination, convening and facilitating mechanism in the ZAMEP that 
aims to: advise, provide technical support, review, encourage harmonization and pooling of 
efforts for faster uptake and scale up of malaria recommended quality diagnostic techniques 
in Zanzibar. 
 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
23
October, 1992 to August 2001: Laboratory technician in Laboratories of Zanzibar Malaria 
Programme.  
Execution of all laboratory procedures aimed to provide accurate finding of malaria parasites 
detection on patient samples. Participating in all laboratory based operational studies. To 
perform quality control and quality assurance of other laboratories with their respective 
technicians   
 
January 1984 to October, 1992: Entomological aid in Entomology unit of Zanzibar Malaria 
Programme.  
Responsible for collection of mosquitoes using different techniques (human bait, window 
traps, cattle traps, CDC light traps etc). Under guidance of the Programmes and partners 
Entomologists to assist on insecticide susceptibility tests, bioassay tests, dissection of 
mosquitoes for different studies. 
 
Education 
2005 -2007 Licentiate Degree in Karolinska Instituttet, Stockholm –Sweden: Trained in 
Research and training. Defended thesis “Efficacy of artemisinin based combination therapy 
and effectiveness of Rapid Diagnostic Test for management of patients with Plasmodium 
falciparum malaria in Zanzibar” 
 
1998 –2000 Advanced diploma in Medical Laboratory Sciences (Muhimbili University, College 
of Health Sciences, Dar es Salaam – Tanzania). Trained in Parasitology and Medical 
Entomology. Learned and conducted research titled “Factors associated with Plasmodium 
falciparum gametocytomia to the young children aged 5-60 months in Zanzibar Island” 
 
1989 – 1992 Certificate in Medical Laboratory Technology (College Of Health Sciences – 
Zanzibar). Trained in general Medical Laboratory Sciences. 
  
1987 – National Ordinary School Certificate (Lumumba Secondary School).  
 
1983 – School Leaving Certificate ‘O’ level (Haile Sellassie Secondary School) 
 
1973 – 1982 Primary and Secondary School Certificate (Muyuni School) 
 
Trainings and International workshops 
2009- WHO Technical Consultation on Parasitological Confirmation Of Malaria Diagnosis –
Geneva 
2008, 2009 and 2010 Malaria Review and Planning Meetings for East and Southern Africa 
jointly organized by WHO IST, EARN, -Zambia, Namibia and Kenya 
2004 –Participant in East Africa Regional Workshop on Protozoan Pathogens, Focused on 
Pregnant Host Morogoro –Tanzania  
2003 Training of Trainers for Malaria Diagnosis procedures for anglophone countries Ndola -
Zambia  
2002 – Participant in MIM/TDR Workshop on Invitro Drug Susceptibility Testing of 
Plasmodium falciparum to antimalarial drugs, Cotonou –Benin 
2001 Facilitator on Basic Malaria Microscopy to Zanzibar Laboratory Technicians 
 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
24
Other responsibilities 
In 2013 –Member of Proposal Development Task Force: under the guidance of the ZGFCCM, 
main responsibilities was management and coordination of Global Fund proposal 
development and applications for funding in Zanzibar. 
From February, 2011 to October 2016: Clinical researches coordinator in Zanzibar Malaria 
Programme: In collaboration with Programme partners to coordinate and conduct clinical 
based and community based operational researches in different study sites. 
Since 2009 to date: Executive Secretary in Professional non-government Organisation: 
responsible for the management and administration of the Zanzibar Association for Medical 
Laboratory Scientific Officers (ZAMELSO) 
Since 2006 to 2016: National IRS Supervisor in Zanzibar Malaria Programme: organize and 
coordinate day to day Indoor Residual house Spraying (IRS) activities, to conduct supervision, 
monitoring and evaluation of IRS activities, to work with community leadership, district IRS 
technical committee etc (ensure participation and ownership which will lead to the success of 
IRS activities). Participate in the recruitment of spray operators. Ensure proper record 
keeping and documentation of spraying activities. Ensure safe and quality spraying. 
2005 to date: Clinical Trials Coordinator, in the collaborative Institution (Zanzibar Malaria 
Research Unit Karolinska Institute (ZAMRUKI)) between Karolinska University of Sweden and 
Zanzibar Ministry of Health through Malaria Programme. Among other duties I coordinate 
and act as local supervisor to the Medical, Undergraduate and postgraduate students from 
Karolinska Instituttet in all operational researches implemented in Zanzibar as per training 
plans and Malaria Programme Strategic plan.  
 
Consultancies 
In 2009: I contracted by WHO as local consultant for the development of Round 8 Global 
Fund malaria and health systems strengthening proposals for Zanzibar. To assist local 
consultant to identify key gaps and priorities; national level consultation and consensus 
building on key priorities; develop mechanisms for CSO inclusion; lead writer on the proposal 
and budget. 
 
October 2013: Lead on ZAMELSO proposal write up and then project implementation on 
HIV&AIDS prevention, testing and behaviour change communication interventions among 
Intravenous drug users in Unguja Island 
 
From 2008 and 2013: Member of writing team on the formulation of Zanzibar Malaria 
Strategic Plans II and lll (2008, 2013) 
 
August 2014: Team leader on ZAMELSO proposal writing and project implementation titled 
Improve HIV&AIDS prevention, testing, adherence in Care & Treatment Centres and 
rehabilitation support among people with inject drugs in Unguja Island 
 
 
Publications (About 22 publications in international peer reviewed journals) 
1. Using low-cost drones to map malaria vector habitats. Andy Hardy, Makame Makame, 
Dónall Cross, Silas Majambere and Mwinyi Msellem. Parasites & Vectors, DOI: 
10.1186/s13071-017-1973-3. 14 January 2017 
 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
25
2. Influence of Rapid Malaria Diagnostic Tests on Treatment and Health Outcome in 
Fever Patients, Zanzibar—A Crossover Validation Study. Mwinyi I. Msellem, Andreas 
Mårtensson, Guida Rotllant, Achuyt Bhattarai, Johan Strömberg, Elizeus Kahigwa, 
Montse Garcia, Max Petzold, Peter Olumese, Abdullah Ali, Anders Björkman Less. 
PLoS medicine2009. PLoS Medicine, vol 6(4), 27 April 2009.  
 
3. Loop-mediated isothermal amplification (LAMP) for point-of-care detection of 
asymptomatic low-density malaria parasite carriers in Zanzibar. Jackie Cook, Berit 
Aydin-Schmidt, Iveth J González, David Bell, Elin Edlund, Majda H Nassor, Mwinyi 
Msellem, Abdullah Ali, Ali K Abass, Andreas Mårtensson, Anders Björkman. Malaria 
Journal2015 
 
4. The Usefulness of Rapid Diagnostic Tests in the New Context of Low Malaria 
Transmission in Zanzibar. Delér Shakely, Kristina Elfving, Berit Aydin-Schmidt, Mwinyi 
I. Msellem, Ulrika Morris, Rahila Omar, Xu Weiping, Max Petzold, Bryan Greenhouse, 
Kimberly A. Baltzell, Abdullah S. Ali, Anders Björkman, Andreas Mårtensson. PloS 
one2013 
 
5. Field deployment of loop-mediated isothermal amplification for centralized mass-
screening of asymptomatic malaria in Zanzibar: a pre-elimination setting. Ulrika 
Morris, Mwinyi Khamis, Berit Aydin-Schmidt, Ali K Abass, Mwinyi I Msellem, Majda H 
Nassor, Iveth J González, Andreas Mårtensson, Abdullah S Ali, Anders Björkman, 
Jackie Cook. Malaria Journal2015 
 
Languages 
SWAHILI AND ENGLISH 
 
Referees 
PROF. ANDERS BJORKMAN 
MALARIA RESEARCH LABORATORY  
KAROLINSKA INSTITUTE 
STOCKHOLM SWEDENDR.  
 
DR. ALI SALIM ALI 
EXECUTIVE DIRECTOR 
MNAZI MMOJA HOSPITAL 
MINISTRY OF HEALTH 
ZANZIBAR 
 
 
 
MR. ABDULLAH S. ALI 
MANAGER, 
ZANZIBAR 
MALARIA 
ELIMINATION 
PROGRAMME, 
P.O.BOX 407 
ZANZIBAR TANZANIA  
 
 
 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
26
Appendix 1. DEFINITION OF SEVERE FALCIPARUM MALARIA1 
Severe manifestation of P. falciparum malaria in adults and children 
Clinical manifestations 
 
prostration, 
 
impaired consciousness, 
 
respiratory distress (metabolic acidosis), 
 
multiple convulsions, 
 
circulatory collapse, 
 
pulmonary oedema (radiological), 
 
abnormal bleeding, 
 
jaundice, 
 
haemoglobinurea. 
Laboratory findings 
 
severe anaemia (haemoglobin < 5 g/dl, haematocrit < 15%), 
 
hypoglycaemia (blood glucose < 2.2 mmol/l or 40 mg/dl), 
 
acidosis (plasma bicarbonate < 15 mmol/l), 
 
hyperlactataemia (venous lactic acid > 5 mmol/l), 
 
hyperparasitaemia (> 4% in non-immune patients), 
 
renal impairment (serum creatinine above normal range for age). 
Classification of severe malaria in children 
Group 1: children at increased risk for death 
 
prostration 
 
respiratory distress 
Group 2: children at risk for clinical deterioration 
 
haemoglobin < 5 g/dl, haematocrit < 15% 
 
two or more convulsions within 24 h  
Group 3: children with persistent vomiting 
                                                                    
 
 
1  World Health Organization. Severe falciparum malaria. Transactions of the Royal Society of Tropical Medicine and Hygiene, 2000, 
94(Suppl. 1):1–90. 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
27
Appendix 2. MEDICATIONS (WITH ANTIMALARIAL ACTIVITY) THAT SHOULD NOT BE USED 
DURING THE STUDY PERIOD 
 
chloroquine, amodiaquine; 
 
quinine, quinidine; 
 
mefloquine, halofantrine, lumefantrine; 
 
artemisinin and its derivatives (artemether, arteether, artesunate, dihydroartemisinin); 
 
proguanil, chlorproguanil, pyrimethamine; 
 
sulfadoxine, sulfalene, sulfamethoxazole, dapsone; 
 
primaquine;  
 
atovaquone; 
 
antibiotics: 
tetracycline*, 
doxycycline, 
erythromycin, 
azythromycin, 
clindamycin, 
rifampicin, 
trimethoprim; 
 
pentamidine. 
 
* Tetracycline eye ointments can be used. 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
28
Appendix 3. DOSING CHART OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE 
A fixed dose combination of artesunate + amodiaquine (Artesunate Amodiaquine Winthrop®, Sanofi Aventis), 
prequalified by the WHO, will be used as study drug. Tablets containing 25/67.5 mg, 50/135mg and 100/270 
mg, base of artesunate/amodiaquine will be administered according to the dosing chart below: 
 
Body 
weight  
Number of tablets of Artesunate (AS) + Amodiaquine (AQ) 
Day 0 
Day 1 
Day 2 
<10 kg 
1 tab 
(AS 25 mg + AQ 67.5 mg) 
1 tab 
(AS 25 mg + AQ 67.5 mg) 
1 tab 
(AS 25 mg + AQ 67.5 mg) 
10-20 kg 
 
1 tab 
(AS 50 mg + AQ 135 mg) 
1 tab 
(AS 50 mg + AQ 135 mg) 
1 tab 
(AS 50 mg + AQ 135 mg) 
21-30 kg 
 
2 tab 
(AS 50 mg + AQ 135 mg) 
2 tab 
(AS 50 mg + AQ 135 mg) 
2 tab 
(AS 50 mg + AQ 135 mg) 
>30 kg 
 
2 tab 
(AS 100 mg + AQ 270 mg) 
2 tab 
(AS 100 mg + AQ 270 mg) 
2 tab 
(AS 100 mg + AQ 270 mg) 
 
DOSAGE AND ADMINISTRATION OF PRIMAQUINE 
  
WEIGHT 
AGE 
Single low dose [0 hrs] 
1 
5-9 kg 
1-4 yrs 
2.5 mg 
2 
10-20 kg 
5-8 yrs 
5 mg 
3 
20-40 kg 
9-14 yrs 
10 mg 
4 
>40 kg 
15+ yrs 
15 mg 
 
 
Pediatric dosing of SLD primaquine: 
To dissolve tablets in Water:  
a. Based on patients weight dissolve one tablet(s) (15mg) of Primaquine in 5 ml of 
water. 
b. Ensure that the solution is thoroughly mixed. 
c. Measure the volume (cc) of solution to give to the participant based on the 
participant’s weight. The drug will be mixed with equal volume of juice to mask its 
bitter test.  

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
29
 

PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
30
Appendix 4. CLASSIFICATION OF TREATMENT OUTCOMES2 
Early treatment failure  
 
danger signs or severe malaria on day 1, 2 or 3 in the presence of parasitaemia; 
 
parasitaemia on day 2 higher than on day 0, irrespective of axillary temperature; 
 
parasitaemia on day 3 with axillary temperature ≥ 37.5 ºC; 
 
parasitaemia on day 3 ≥ 25% of count on day 0. 
Late treatment failure 
Late clinical failure 
 
danger signs or severe malaria in the presence of parasitaemia on any day between day 4 and day 28 in 
patients who did not previously meet any of the criteria of early treatment failure; 
 
presence of parasitaemia on any day between day 4 and day 28 with axillary temperature  
≥ 37.5 ºC or history of fever in patients who did not previously meet any of the criteria of early 
treatment failure 
Late parasitological failure 
 
presence of parasitaemia on any day between day 7 and day 28 with axillary temperature  
< 37.5 ºC in patients who did not previously meet any of the criteria of early treatment failure or late 
clinical failure 
Adequate clinical and parasitological response 
 
absence of parasitaemia on day 28, irrespective of axillary temperature, in patients who did not 
previously meet any of the criteria of early treatment failure, late clinical failure or late parasitological 
failure 
                                                                    
 
 
2 WHO. Susceptibility of Plasmodium falciparum to antimalarial drugs. Report on global monitoring 1996–2004. Geneva, World Health 
Organization, 2005 (WHO/HTM/MAL/2005.110) (http://www.who.int/malaria/resistance). 

 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
31
Appendix 5. CASE SCREENING FORM 
Case screening form 
Health centre name:       
Study number:        
District:       
Patient screening number:       
Sheiha       
Date of visit (dd-mmm-yyyy):       
Demographic data 
Date of birth (dd-mmm-yyyy):       
or estimated age:       in: 
 months or 
 years 
Height (cm):        
Weight (kg):        
 
Sex: 
 Male 
 Female  
If female, is the patient pregnant? 
 Yes 
 No 
 Unknown 
If pregnant, provide the date of the last menstrual period (dd-mmm-yyyy):       
Pre-treatment temperature 
History of fever in previous 48 h? 
 Yes 
 No 
Axillary temperature:       ºC  
Screening test for presence of P. falciparum with Rapid Diagnostic Test 
RDT result       
 Positive           
 Negative (If negative, patient is not eligible) 
Thick and thin blood smears for estimation of P. falciparum parasite counts 
Species: 
 P. falciparum 
 P. vivax 
 P. ovale 
 P. malariae 
Were species other than P. falciparum present? 
 Yes 
 No (If yes, patient is not eligible). 
Presence of P. falciparum asexual parasites: 
 Yes 
 No (If no, patient is not eligible) 
Presence of P. falciparum gametocytes? 
 Yes 
 No 
Has a blood sample for PCR been collected? 
 Yes 
 No 
Urinary analysis (pregnancy test for female patients) 
Result of pregnancy test: 
 Positive 
 Negative 
 Not done (If positive, patient is not eligible) 
Inclusion criteria 
 
age 3 months and above   
 
mono-infection with P. falciparum detected by microscopy; 
 
presence of P. falciparum malaria asexual parasitaemia;  
 
presence of axillary ≥37.5 °C  or history of fever during the past 24 hours 
 
ability to swallow oral medication; 
 
ability and willingness to comply with the study protocol for the duration of the study and to 
comply with the study visit schedule; and 
 
informed consent from the patient or from a parent or guardian in the case of children. 
 
Does the patient meet all the inclusion criteria? 
 Yes 
 No (If no, patient is not eligible) 
 
 
 

 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
32
Case screening form (page 2) 
Exclusion criteria 
 
presence of general danger signs in children aged under 5 years or signs of severe falciparum malaria according 
to the definitions of WHO (Appendix 1); 
 
mono-infection with a Plasmodium species other than P. falciparum detected by microscopy; 
 
presence of severe malnutrition (defined as a child whose growth standard is below –3 z-score, has 
symmetrical oedema involving at least the feet or has a mid-upper arm circumference < 110 mm); 
 
presence of febrile conditions due to diseases other than malaria (e.g. measles, acute lower respiratory tract 
infection, severe diarrhoea with dehydration) or other known underlying chronic or severe diseases (e.g. 
cardiac, renal and hepatic diseases, HIV/AIDS); 
 
regular medication, which may interfere with antimalarial pharmacokinetics; 
 
history of hypersensitivity reactions or contraindications to any of the study medicines; and 
 
pregnancy  
Does the patient meet any of the exclusion criteria? 
 Yes 
 No (If yes, the patient is not eligible) 
If yes, please specify the reason for exclusion:  
      
      
      
      
      
      
Patient informed consent and assent 
Consent form signed: 
 Yes 
 No 
Patient identity number:       
Date (dd-mmm-yyyy):       
Assent form signed:   
 Yes 
 No 

 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
33
Appendix 6. SCHEDULE OF FOLLOW-UP ACTIVITIES 
 
Day 0 
1 
2 
3 
7 
14 
21 
28 
Any other day 
Procedure 
 
 
 
 
 
 
 
 
 
Clinical assessment 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Temperature 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Blood slide for parasite count 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Urine sample 
(X) 
 
 
 
 
 
 
  (X) 
 
Blood for: 
Genotyping/ molecular markers 
Hb 
 
X 
X         
X 
X 
 
X 
    X 
 
X 
X 
 
X 
X 
 
X 
 
 
X 
   X 
 
X 
             
Treatment 
 
 
 
 
 
 
 
 
 
Artesunate + amodiaquine 
Primaquine 
X 
X 
    X 
 
X 
 
 
 
 
 
 
 
 

 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
34
Day 0 
Screening 
 
clinical assessment, including measurement of weight and height; referral in cases of severe malaria or 
danger signs; 
 
measurement of temperature; 
 
parasitological assessment; 
 
pregnancy test (if necessary); 
 
informed consent. 
Enrolment 
 
treatment, first dose; 
 
blood sampling for genotyping/molecular markers of drug resistance; 
 
haemoglobin  
Day 1 
 
clinical assessment; referral in cases of severe malaria or danger signs; 
 
measurement of axillary temperature; 
 
parasitological assessment  
 
treatment, second dose or alternative treatment in case of early treatment failure. 
Day 2 
 
clinical assessment; referral in cases of severe malaria or danger signs; 
 
measurement of axillary temperature; 
 
parasitological assessment; 
 
treatment, third dose or alternative treatment in case of early treatment failure. 
Day 3, day 7, day 14, day 21, day 28, any other day 
 
clinical assessment; referral in cases of severe malaria or danger signs; 
 
measurement of axillary temperature; 
 
parasitological assessment; 
 
alternative treatment in cases of treatment failure; 
 
pregnancy test at the end of follow-up (if necessary); 
 
blood sampling for genotyping to distinguish between recrudescence and reinfection and molecular 
markers of drug resistance in cases of treatment failure after day 7, 
 
haemoglobin will be routinely assessed at enrolment, day 3, 7, 14 and 28. 

 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
35
Appendix 7. CASE REPORT FORMS 
Case report form: Day of enrolment = day 0 
Health centre name:       
Study number:        
District:       
Patient identity number:       
Sheiha:       
Date of visit (dd-mmm-yyyy):       
Household card identification number:       
Demographic data 
Date of birth (dd-mmm-yyyy):       
or estimated age:       in: 
 months or 
 years 
Height (cm):        
Weight (kg):        
Sex: 
 Male 
 Female 
If female, is the patient pregnant? 
 Yes 
 No 
 Unknown (If yes, patient is not eligible) 
If pregnant, provide the date of the last menstrual period (dd-mmm-yyyy):       
Overnight travel away from home within past month? 
 Yes 
 No 
If yes, please list all places where at least on night was spend: 
Pre-treatment temperature 
History of fever in previous 48 h? 
 Yes 
 No 
Axillary temperature:       ºC  
Thick blood smears for P. falciparum: asexual and gametocyte counts; haemoglobin assessment 
Average number of asexual P. falciparum parasites/l:       
Presence of P. falciparum gametocytes? 
 Yes 
 No 
Were species other than P. falciparum present? 
 Yes 
 No (If yes, patient is not eligible). 
If yes, which species? 
 P. vivax 
 P. ovale 
 P. malariae 
Hemoglobin       
Has blood sample for PCR been collected? 
 Yes 
 No 
Prior medication 
All prior medication, including natural remedies and homeopathic medicines, taken within the previous 14 days 
should be reported in this section. 
Has the patient taken any prior antimalarial medication? 
 Yes 
 No. If yes, please specify below. Either the 
date of stopping or the ‘ongoing’ box should be checked. 
Medicine name 
(generic name) 
Dates 
Ongoing 
(Yes = 
) 
Total daily 
dose and unit 
(e.g. 400 mg) 
Route of 
administration 
Indication for use 
      
Start:       
 
      
      
      
Stop:       
      
Start:       
 
      
      
      
Stop:       
      
Start:       
 
      
      
      
Stop:       
 

 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
36
 
Case report form: Day of enrolment = day 0 (page 2) 
Medication administration 
Name(s) of antimalarial drug(s) 
Time of dose 
(hh:min) 
Number of 
tablets 
Did the patient 
vomit? 
Time of 
vomiting 
(hh:min) 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      
Name(s) of other medicine(s) 
 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      

 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
37
 
Case report form: follow-up day 1 
Study number:        
Patient identity number:       
Date of visit (dd-mmm-yyyy):       
Clinical status 
Presence of danger signs or signs of severe or complicated malaria? 
 Yes 
 No  
Axillary temperature:       ºC  
Thick blood smears for estimation of P. falciparum parasitemia 
Average number of asexual P. falciparum parasites/l:       
Presence of P. falciparum gametocytes? 
 Yes 
 No 
Were species other than P. falciparum present? 
 Yes 
 No 
If yes, which species? 
 P. vivax 
 P. ovale 
 P. malariae 
Adverse events 
Presence of an adverse event? 
 Yes 
 No  
If yes, name the adverse event:      
Is it a serious adverse event? 
 Yes 
 No. If yes, inform the sponsor. 
Medication administration 
Name(s) of antimalarial drug(s) 
Time of dose 
(hh:min) 
Number of 
tablets 
Did the patient 
vomit? 
Time of 
vomiting 
(hh:min) 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      
Name(s) of other medicine(s) 
 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      

 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
38
 
Case report form: follow-up day 2 
Study number:        
Patient identity number:       
Date of visit (dd-mmm-yyyy):       
Clinical status 
Presence of danger signs or signs of severe or complicated malaria? 
 Yes 
 No 
Axillary temperature:       ºC  
Thick blood smears for estimation of P. falciparum parasitemia 
Average number of asexual P. falciparum parasites/l:       
Presence of P. falciparum gametocytes? 
 Yes 
 No 
Were species other than P. falciparum present? 
 Yes 
 No 
If yes, which species? 
 P. vivax 
 P. ovale 
 P. malariae 
Adverse events 
Presence of an adverse event? 
 Yes 
 No  
If yes, name the adverse event:      
Is it a serious adverse event? 
 Yes 
 No. If yes, inform the sponsor. 
Medication administration 
Name(s) of antimalarial drug(s) 
Time of dose 
(hh:min) 
Number of 
tablets 
Did the patient 
vomit? 
Time of 
vomiting 
(hh:min) 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      
Name(s) of other medicine(s) 
 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      

 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
39
 
Case report form: follow-up day 3 
Study number:        
Patient identity number:       
Date of visit (dd-mmm-yyyy):       
Clinical status 
Presence of danger signs or signs of severe or complicated malaria? 
 Yes 
 No 
Axillary temperature:       ºC  
Thick blood smears for estimation of P. falciparum parasitemia; Hemoglobin assessment 
Average number of asexual P. falciparum parasites/l:       
Presence of P. falciparum gametocytes? 
 Yes 
 No 
Were species other than P. falciparum present? 
 Yes 
 No 
If yes, which species? 
 P. vivax 
 P. ovale 
 P. malariae 
Hemoglobin       
Adverse events 
Presence of an adverse event? 
 Yes 
 No  
If yes, name the adverse event:       
Is it a serious adverse event? 
 Yes 
 No. If yes, inform the sponsor. 
Medication administration 
Name(s) of antimalarial drug(s) 
Time of dose 
(hh:min) 
Number of 
tablets 
Did the patient 
vomit? 
Time of 
vomiting 
(hh:min) 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      
Name(s) of other medicine(s) 
 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      

 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
40
 
Case report form: follow-up day 7 
Study number:        
Patient identity number:       
Date of visit (dd-mmm-yyyy):       
Clinical status 
Presence of danger signs or signs of severe or complicated malaria? 
 Yes 
 No 
History of fever within previous 48 h? 
 Yes 
 No 
Axillary temperature:       ºC  
Thick blood smears for estimation of P. falciparum parasitemia; Hemoglobin assessment 
Average number of asexual P. falciparum parasites/l:       
Presence of P. falciparum gametocytes? 
 Yes 
 No 
Were species other than P. falciparum present? 
 Yes 
 No 
If yes, which species? 
 P. vivax 
 P. ovale 
 P. malariae 
Hemoglobin       
Has a blood sample for PCR been collected? 
 Yes 
 No 
Adverse events 
Presence of an adverse event? 
 Yes 
 No  
If yes, name the adverse event:      
Is it a serious adverse event? 
 Yes 
 No. If yes, inform the sponsor. 
Medication administration 
Name(s) of antimalarial drug(s) 
Time of dose 
(hh:min) 
Number of 
tablets 
Did the patient 
vomit? 
Time of 
vomiting 
(hh:min) 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      
Name(s) of other medicine(s) 
 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      

 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
41
 
Case report form: follow-up day 14 
Study number:        
Patient identity number:       
Date of visit (dd-mmm-yyyy):       
Clinical status 
Presence of danger signs or signs of severe or complicated malaria? 
 Yes 
 No 
History of fever within previous 48 h? 
 Yes 
 No 
Axillary temperature:       ºC  
Thick blood smears for estimation of P. falciparum parasitemia; Hemoglobin assessment 
Average number of asexual P. falciparum parasites/l:       
Presence of P. falciparum gametocytes? 
 Yes 
 No 
Were species other than P. falciparum present? 
 Yes 
 No 
If yes, which species? 
 P. vivax 
 P. ovale 
 P. malariae 
Hemoglobin       
Has a blood sample for PCR been collected? 
 Yes 
 No 
Adverse events 
Presence of an adverse event? 
 Yes 
 No  
If yes, name the adverse event:      
Is it a serious adverse event? 
 Yes 
 No. If yes, inform the sponsor. 
Medication administration 
Name(s) of antimalarial drug(s) 
Time of dose 
(hh:min) 
Number of 
tablets 
Did the patient 
vomit? 
Time of 
vomiting 
(hh:min) 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      
Name(s) of other medicine(s) 
 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      

 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
42
 
Case report form: follow-up day 21 
Study number:        
Patient identity number:       
Date of visit (dd-mmm-yyyy):       
Clinical status 
Presence of danger signs or signs of severe or complicated malaria? 
 Yes 
 No 
History of fever within previous 48 h? 
 Yes 
 No 
Axillary temperature:       ºC  
Thick blood smears for estimation of P. falciparum parasitemia 
Average number of asexual P. falciparum parasites/l:       
Presence of P. falciparum gametocytes? 
 Yes 
 No 
Were species other than P. falciparum present? 
 Yes 
 No 
If yes, which species? 
 P. vivax 
 P. ovale 
 P. malariae 
Has a blood sample for PCR been collected? 
 Yes 
 No 
Adverse events 
Presence of an adverse event? 
 Yes 
 No  
If yes, name the adverse event:      
Is it a serious adverse event? 
 Yes 
 No. If yes, inform the sponsor. 
Medication administration 
Name(s) of antimalarial drug(s) 
Time of dose 
(hh:min) 
Number of 
tablets 
Did the patient 
vomit? 
Time of 
vomiting 
(hh:min) 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      
Name(s) of other medicine(s) 
 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      
 
 
 
 
 
 
 
 
 

 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
43
Case report form: follow-up day 28 
Study number:        
Patient identity number:       
Date of visit (dd-mmm-yyyy):       
Clinical status 
Presence of danger signs or signs of severe or complicated malaria? 
 Yes 
 No 
History of fever within previous 48 h? 
 Yes 
 No 
Axillary temperature:       ºC  
Thick blood smears for estimation of P. falciparum parasitemia; Hemoglobin assessment 
Average number of asexual P. falciparum parasites/l:       
Presence of P. falciparum gametocytes? 
 Yes 
 No 
Were species other than P. falciparum present? 
 Yes 
 No 
If yes, which species? 
 P. vivax 
 P. ovale 
 P. malariae 
Hemoglobin       
Has a blood sample for PCR been collected? 
 Yes 
 No 
Adverse events 
Presence of an adverse event? 
 Yes 
 No  
If yes, name the adverse event:      
Is it a serious adverse event? 
 Yes 
 No. If yes, inform the sponsor. 
Medication administration 
Name(s) of antimalarial drug(s) 
Time of dose 
(hh:min) 
Number of 
tablets 
Did the patient 
vomit? 
Time of 
vomiting 
(hh:min) 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      
Name(s) of other medicine(s) 
 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      

 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
44
 
Case report form: day ___(any other day that is not part of regular follow-up) 
Study number:        
Patient identity number:       
Date of visit (dd-mmm-yyyy):       
Clinical status 
Presence of danger signs or signs of severe or complicated malaria? 
 Yes 
 No 
History of fever within previous 48 h? 
 Yes 
 No 
Axillary temperature:       ºC  
Thick blood smears for estimation of P. falciparum parasitemia; Hemoglobin assessment 
Average number of asexual P. falciparum parasites/l:       
Presence of P. falciparum gametocytes? 
 Yes 
 No 
Were species other than P. falciparum present? 
 Yes 
 No 
If yes, which species? 
 P. vivax 
 P. ovale 
 P. malariae 
Hemoglobin       
Has a blood sample for PCR been collected? 
 Yes 
 No 
Adverse events 
Presence of an adverse event? 
 Yes 
 No  
If yes, name the adverse event:      
Is it a serious adverse event? 
 Yes 
 No. If yes, inform the sponsor. 
Medication administration 
Name(s) of antimalarial drug(s) 
Time of dose 
(hh:min) 
Number of 
tablets 
Did the patient 
vomit? 
Time of 
vomiting 
(hh:min) 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      
Name(s) of other medicine(s) 
 
      
      
      
 Yes 
 No 
      
      
      
      
 Yes 
 No 
      

 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
45
 
Case report form: follow-up day 28 (=final day of study) 
Overall assessment 
Outcome:  
 adequate clinical and parasitological response 
 early treatment failure 
 late clinical failure 
 late parasitological failure 
 lost to follow-up 
 withdrawn  
Outcome occurred on follow-up day:      (e.g. 1, 2, 3, 7, 14, 21 and 28) 
PCR:  
 P. falciparum recrudescence 
 P. falciparum reinfection  
 other species 
 mixed with P. falciparum recrudescence 
 mixed with P. falciparum reinfection  
 unknown 
 
PCR corrected results:  
 adequate clinical and parasitological response 
 early treatment failure 
 late clinical failure 
 late parasitological failure 
 lost to follow-up 
 withdrawn 
 
Reason for withdrawal:       
      
      
      
      
      
 
Other comments: 
      
      
      
      
      
      
      
      
 

 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
46
Appendix 8. SERIOUS ADVERSE EVENT REPORT FORM 
Serious adverse event report form 
Health centre name:       
Study number:       
District:       
Patient identity number:       
Sheiha:       
Date of visit (dd-mmm-yyyy):       
 
Follow-up day:    
Demographic data 
Date of birth (dd-mmm-yyyy):       
or estimated age:       in: 
 months or 
 years 
Height (cm):        
Weight (kg):        
 
Sex: 
 Male 
 Female  
If female, is the patient pregnant? 
 Yes 
 No 
 Unknown 
If pregnant, provide the date of the last menstrual period (dd-mmm-yyyy):       
Serious adverse event  
Type of event: 
 Death  
 Life-threatening 
 Hospitalization or prolongation of hospitalization 
 Permanent disability  
 Congenital anomaly or birth defect 
Date of occurrence (dd-mmm-yyyy):       
Describe the serious adverse event (include all relevant laboratory results): 
      
      
      
      
      
      
      
      
      
      
      
Describe how the reaction was treated: 
      
      
      
      
      
      
      
      
      
      

 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
47
 
Serious adverse event report form (page 2) 
Comments (e.g. relevant medical history, drug allergies, previous exposure to similar drugs, other laboratory data, 
whether reaction abated after stopping the drug, whether reaction reappeared after reintroduction): 
      
      
      
      
      
      
      
      
      
      
Outcome 
 Recovered completely  
 Not yet recovered  
 Recovered with long-term consequences 
If patient recovered, provide date of recovery (dd-mmm-yyyy):       
Medicines (list the medicine suspected of causing the serious adverse event as well as all concomitant 
medicines) 
Brand name, batch 
number, manufacturer 
name 
(list suspected medicine 
first) 
Daily 
dose 
Route 
Start date 
End date 
Indications for use 
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
      
Reporting officer 
Name:       
Qualification:       
Address:       
Phone:       
 
Fax:      
 
Email:       
Signature:  
Date:       

 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
48
Appendix 9. GUIDELINES FOR ANALYSIS OF RESULTS 
End-point for day X 
(X = 28 or 42) 
PCR-uncorrected results 
Cumulative success or 
failure rate (Kaplan-Meier 
analysis) 
Proportion 
(per-protocol analysis) 
Adequate clinical and parasitological 
response on day X 
Success 
Success 
Early treatment failure 
Failure 
Failure 
Late clinical failure before day 7 
Failure 
Failure 
Late clinical failure or late parasitological 
failure on or after day 7 
Failure 
Failure 
Other species infection 
Censored day of infection 
Excluded from analysis 
Lost to follow-up 
Censored last day of follow-up 
according to timetable 
Excluded from analysis 
Withdrawal and protocol violation 
Censored last day of follow-up 
according to timetable before 
withdrawal or protocol 
violation 
Excluded from analysis 
 
End-point for day X 
(X = 28 or 42) 
PCR-corrected results 
Cumulative success or failure 
rate (Kaplan-Meier analysis) 
Proportion 
(per-protocol analysis) 
Adequate clinical and parasitological 
response at day X 
Success 
Success 
Early treatment failure 
Failure 
Failure 
Late clinical failure before day 7 
Failure 
Failure 
Late clinical failure or late parasitological 
failure on or after day 7 
 
 
 
falciparum recrudescence* 
Failure 
Failure 
 
falciparum reinfection* 
Censored day of reinfection 
Excluded from analysis 
 
other species mixed with falciparum 
recrudescence 
Failure 
Failure 
 
other species mixed with falciparum 
reinfection 
Censored day of reinfection 
Excluded from analysis 
 
other species infection 
Censored day of infection 
Excluded from analysis 
 
undetermined or missing PCR 
Excluded from analysis 
Excluded from analysis 
Lost to follow-up 
Censored last day of follow-up 
according to timetable 
Excluded from analysis 
Withdrawal and protocol violation 
Censored last day of follow-up 
according to timetable before 
protocol violation or withdrawal 
Excluded from analysis 
* WHO. Methods and techniques for clinical trials on antimalarial drug efficacy: genotyping to identify parasite populations.  
Geneva, World Health Organization, 2008 (http://www.who.int/malaria/resistance).  

 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
49
Appendix 10. CONSENT AND ASSENT FORMS3 
Efficacy and safety of artesunate + amodiaquine combined with a single low dose of primaquine 
(0.25 mg/kg) for the treatment of uncomplicated plasmodium infection in Zanzibar 
Informed consent form for adults  
This informed consent form is for adults 18 years of age and above who attend any of the 20 
primary health care facilities in Zanzibar used as study sites in the above mentioned trial, and 
who have been invited to participate in the study to evaluate the efficacy of artesunate 
+amodiaquine for the treatment of uncomplicated falciparum malaria.  
 
Name of principal investigator: 
Mwinyi I. Msellem 
Name of organization: 
Zanzibar Malaria Elimination Programme 
Name of sponsor: 
The Global Funds against AIDS, Tuberculosis and 
Malaria 
Name of proposal and version: 
Efficacy and safety of artesunate + amodiaquine  combined 
with a single low dose of primaquine (0.25 mg/kg) for the 
treatment of uncomplicated Plasmodium falciparum infection 
in Zanzibar 
 
 
This informed consent form has two parts:  
I. Information sheet (to share information about the study with you) 
II. Certificate of consent (for signatures if you agree to take part) 
You will be given a copy of the full informed consent form. 
Part I. Information sheet 
My name is............................................. I work for the Zanzibar Ministry of Health. We are 
presently doing a study in this primary health care facility on the treatment of malaria. Malaria is 
a dangerous disease; however, it can be treated with medicine. The purpose of this study is to 
confirm that the medicine presently recommended as first-line treatment for malaria in Zanzibar, 
is still effective for curing malaria infection on the Isles.  
 
We have examined your blood and it was found that you have been infected with malaria 
parasites. Therefore, I am going to give you information about our ongoing study and invite you 
to participate in it. Before you decide whether to participate or not, you are free to talk to anyone 
you feel comfortable with about the study. There may be some words that you do not understand. 
                                                                    
 
 
3 http://www.who.int/rpc/research_ethics/en/ 

 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
50
Please ask me to stop as we go through the information, and I will take time to explain. If you 
have questions later, you can ask me, the study doctor or the staff.  
Your participation in this study is entirely voluntary. If you choose not to participate, all the 
service you may need from this clinic will continue as usual. Even if you agree to participate now 
but decide later to change your mind and withdraw your consent, the services you receive at the 
clinic will continue. 
You will receive medicine once daily for 3 days to treat the malaria parasites you have in your 
blood. The medicine we are testing is a fixed dose combination of artesunate + amodiaquine 
combined with a single low doise of primaquine (0.25 mg/kg). This is the recommended first-line 
treatment for uncomplicated malaria infection by the Zanzibar Ministry of Health and Social 
Welfare. The Ministry through the Zanzibar Malaria Elimination Programme regularly conducts 
studies to make sure that the recommended malaria medicines are still working. The malaria 
medicines are known to be very effective, but you should know that some people experience 
minor side-effects from the medicine: weakness, headache, nausea, vomiting, abdominal pain, 
diarrhoea and itching may occur. Primaquine has in rare cases been associated with anemia. 
However, these symptoms are usually transient and of mild or moderate intensity. 
If we find that the medicine is not able to cure the malaria infection that you are infected with, we 
will instead give you what is called ‘rescue medicine’. The rescue medicine is called quinine and 
is given orally at a dose of 10 mg/kg body weight trice daily to complete a total of 21 doses in 7 
days. You should also know that this medicine has some minor side-effects: such as tinnitus, 
muffled hearing, sometimes vertigo or dizziness. In case you develop signs of severe malaria 
infection we will provide in-patient care for you and treat you with quinine given directly into 
your blood using a drip. 
 
In this study we will ask all women aged between 15-49 years about their menstrual history. If 
the last menstrual period is 4 weeks ago or more we will ask oral permission to conduct a urine 
test for pregnancy. Pregnant women will not be enrolled in this study since Artesunate + 
Amodiaquine Winthrop® is not recommended for treatment during the first trimester of the 
pregnancy.  
All patients in this study will be asked to come back to the clinic for review on day 1, 2, 3, 7, 14, 
21 and 28 after enrolment, but also any time if fever persists. At each visit in the study, a small 
amount of blood (equivalent to a few drops) will be taken from your finger. In total blood will be 
taken 8 times during the study, including today’s visit. You may experience a bit of pain or fear 
when your finger is pricked. The pain normally disappears within 1 day. The blood will be 
dropped onto a glass slide and a small piece of paper. The blood sample collected on the glass 
slide will be examined with the use of a microscope to study if the malaria medicine is effective 
in curing the infection and in preventing malaria parasites from coming back into your blood. 
These examinations will be done directly at the clinic during each follow-up visit. The blood 
samples that will be collected on small pieces of paper will be used to study the malaria parasites 
in your blood. The examination of these blood samples will be done after the completion of the 
study in Sweden in collaboration with colleagues at the medical university in Stockholm namely 
Karolinska Institutet. Since these analyses will be done after the study is completed they will not 
be available to guide or evaluate the treatment. Except for the above described analyses no other 
tests will be done with your blood.   

 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
51
The study period for each patient in this study is 28 days. During that time, we would like you to 
come to the health facility, which in total will be 8 visits including today’s visit. Each follow-up 
visit will last for about 1 hour. At each visit, you will be asked a few questions about your health 
condition, including if you have developed any new symptoms since last visit and if you have 
used any other medicines than the study medication. In addition you will also undergo a brief 
physical examination by study clinician at every visit. 
As previously mentioned the medicine can have some unwanted or unexpected effects that we are 
not currently aware of; however, we will follow you closely and keep track of these effects, if 
they arise, and of any other problems. We will give you a telephone number to call if you notice 
anything out of the ordinary or if you have concerns or questions, please see below.. You can also 
come to this health facility at any time and ask to see (......................................give name of nurse, 
doctor). If you experience side-effects, we may use some other medicine, free of charge, which 
will help to reduce the symptoms or reactions, or we may stop the medicine. If this is necessary 
we will discuss it together. You will always be consulted before we move to the next step.  
 
Today, we took a few drops of blood for testing. The first dose of treatment will be given here at 
the facility once when you accept to participate. 
On the 
2nd visit: you will receive the 2nd dose of treatment plus a blood test. 
3rd visit: you will receive the 3rd dose of treatment plus a blood test. 
4th, 5th, 6th, 7th and 8th visit, you will have a blood test taken. 
 
If you decide to participate in this study, any illnesses related to malaria or to the malaria 
treatment will be treated at no charge to you. Your participation will help us to understand if the 
medicine is still effective, and this may benefit the society and future generations. You will be 
reimbursed one thousand (1,000) Tanzania shillings for your travel expenses for every visit and at 
the end (day 28) of study. 
We will not disclose your identity and your participation in the study with anyone. The 
information that we collect from this study will be kept confidential. Any information collected 
about you will have a number on it instead of your name. Only the study team members will 
know what your number is and we will lock that information up.  
We will share the knowledge that we get from this study with you before it is made available to 
the public. Confidential information will not be shared. There will be small meetings in the 
community where members of the study team will inform about the results of the study, and these 
meetings will be announced in advance. Afterwards, we will publish the results and make them 
available so that other interested people may learn from our study.  
This proposal has been reviewed and approved by Zanzibar Medical Research Ethical Committee 
(ZAMREC). The committee has carefully assessed the study in advance to make sure that study 
participants are protected from any harm. If you wish to find about more about the institutional 
review board, you may contact Dr. Jamala Taib, Chairperson of ZAMREC telephone No 077 743 
24 65  

 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
52
If you have any further questions or for any other reason would like to contact the responsible persons for 
the study you are most welcome to do so, please find our contact information below: 
Part II. Certificate of consent  
I ______________________________have been invited to participate in a study of a medicine 
used to treat malaria. 
I have read the above information, or it has been read to me. I have had the opportunity to ask 
questions, and any questions that I have asked have been answered to my satisfaction. I consent 
voluntarily to participate in this study.  
Print name of participant:  
 
Signature of participant: 
 
 
Date: 
 
 
 
 
(dd/mmm/yyyy) 
Witness’ signature: (A witness’ signature and the patient’s thumbprint are required only if the 
patient is illiterate. In this case, a literate witness must sign. If possible, this person should be 
selected by the participant and should have no connection with the study team.)  
I have witnessed the accurate reading of the consent form to the potential participant, who has 
had the opportunity to ask questions. I confirm that the participant has given consent freely.  
Print name of witness: 
 
 
 
and thumbprint of participant: 
Signature of witness: 
 
 
 
 
Date: 
 
 
 
 
 
 
(dd/mmm/yyyy) 
 
 
Investigator’s signature: 
I have accurately read or witnessed the accurate reading of the consent form to the potential 
participant, who has had the opportunity to ask questions. I confirm that the participant has given 
consent freely.  
Print name of investigator:  
 
Signature of investigator: 
 
 
Date: 
 
 
 
 
(dd/mmm/yyyy) 
A copy of this informed consent form has been provided to the participant. _____ (initials of the 
principal investigator or assistant).  
 
 

 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
53
Informed consent form for children or minors  
This informed consent form is for parents or guardians of children aged up to 18 years who attend 
any of the 20 primary health care facilities in Zanzibar used as study sites in the above mentioned 
trial, and who have been invited to participate in the study to evaluate the efficacy of artesunate 
+amodiaquine for the treatment of uncomplicated falciparum malaria. 
Name of principal investigator: 
Mwinyi I. Msellem 
Name of organization: 
Zanzibar Malaria Elimination Programme 
Name of sponsor: 
GFATM: QNB-M-MOH, Karolinska Instituttet 
Name of proposal and version: 
Efficacy and safety of artesunate + amodiaquine  
combined with a single low dose of primaquine 
(0.25 mg/kg) for the treatment of uncomplicated 
Plasmodium falciparum infection in Zanzibar 
 
This informed consent form has two parts:  
I. 
Information sheet (to share information about the study with you) 
II. 
Certificate of consent (for signatures if you agree to take part) 
You will be given a copy of the full informed consent form. 
Part I: Information sheet 
My name …………………………………………., and I work for the Ministry of Health. We are 
doing a study on the treatment of malaria. Malaria is a dangerous disease; however, it can be 
treated with medicine. The purpose of this study is to confirm that the medicine presently 
recommended as first-line treatment for malaria in Zanzibar is still effective for curing malaria 
infection on the Isles. 
We are inviting all adults and children 3 months and above living in this area to take part in this 
study.  
I am going to give you information and invite you to consent to have your child participate in this 
study. Before you decide whether you want your child to participate, you can talk to anyone you 
feel comfortable with. There may be some words that you do not understand. Please ask me to 
stop as we go through the information, and I will take time to explain. If you have questions later, 
you can ask me, the study doctor or the staff.  
Your decision to have your child participate in this study is entirely voluntary. If you choose not 
to consent, all the services your child receives at this clinic will continue as usual. Even if you 
agree now but decide to change your mind and withdraw later, the services your child receives at 
the clinic will continue. 
Your child will receive medicine once a day over 3 days. The malaria medicines are the 
recommended first-line treatment for uncomplicated malaria infection by the Zanzibar Ministry 
of Health and Social Welfare. As the parasites that cause malaria can become resistant to the 
medicine, the Ministry regularly does studies to make sure the medicine is still working. The 
medicines are known to be very effective, but you should know that it has some minor side-

 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
54
effects: weakness, headache, nausea, vomiting, abdominal pain, diarrhoea and itching may occur. 
Primaquine has in rare cases been associated with anemia. However, these symptoms are usually 
transient and of mild or moderate intensity. 
 
If we find that the medicine is not able to cure the malaria infection that you are infected with, we 
will instead give you what is called ‘rescue medicine’. The rescue medicine is called quinine and 
is given orally at a dose of 10mg/kg body weight trice daily to complete a total of 21 doses in 7 
days. You should also know that this medicine has some minor side-effects: such as tinnitus, 
muffled hearing, sometimes vertigo or dizziness. In case you develop signs of severe malaria 
infection we will provide in-patient care for you and treat you with quinine given directly into 
your blood using a drip. 
A small amount of urine will be taken once. It will be tested for the presence of other medicines 
used to treat malaria in your child’s body. During the follow-up, a small amount of blood will be 
taken 7/9 times from your child’s finger or heel. Your child may experience a bit of pain or fear 
when the finger is pricked. The pain should disappear within 1 day. The blood will be dropped 
onto a slide or a small piece of paper. The blood samples will be used to study the malaria in your 
child’s blood. The examination of the blood samples will be done after the study and it will not 
affect the success of the treatment. Nothing else will be done with the blood. 
The study period for each patient in this study is 28 days. During that time, your child will have 
to come to the health facility for 1 hour, which in total will be 8 visits including today’s visit. At 
each visit, you will be asked a few questions about your child's health condition, including if 
he/she have developed any new symptoms since last visit and if he/she was any other medicines 
than the study medication. In addition your child will also undergo a brief physical examination 
by study clinician at every visit. You may stay with your child during each of the visits and 
during the procedures. 
As previously mentioned the medicine can have some unwanted or unexpected effects that we are 
not currently aware of; however, we will follow your child closely and keep track of these 
effects, if they arise, and of any other problems. We will give you a telephone number to call if 
you notice anything out of the ordinary or if you have concerns or questions, please see below. 
You can also come to this health facility at any time and ask to see (give name of nurse, doctor). 
If your child experience side-effects, we may use some other medicine, free of charge, which will 
help to reduce the symptoms or reactions, or we may stop the medicine. If this is necessary we 
will discuss it together. You will always be consulted before we move to the next step.  
Today, we will take few drops of blood for testing. Your child will receive the first dose of 
treatment. 
On the 
 2nd visit, your child will receive the 2nd dose of treatment. 
 3rd visit, your child will receive the 3rd dose of treatment plus a blood test. 
 4th, 5th, 6th, 7th, 8th visits, your child will have a blood test. 
 

 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
55
If you decide that your child will participate in this study, any illnesses related to malaria or to the 
malaria treatment will be treated at no charge to you. Your child’s participation will help us to 
make sure the medicine is still working, and this will benefit society and future generations. You 
will be reimbursed two thousand and five hundred (2,500) Tanzania shillings for your travel 
expenses for every visit and at the end (day 28) of the study. 
 
We will not share the identity of participants in the study with anyone. The information that we 
collect from this study will be kept confidential. Any information collected about your child will 
have a number on it instead of your child’s name. Only the study team members will know what 
the number is, and we will lock that information up.  
We will share the knowledge that we get from this study with you before it is made available to 
the public. Confidential information will not be shared. There will be small meetings in the 
community where members of the study team will inform about the results of the study, and these 
meetings will be announced in advance afterwards, we will publish the results and make them 
available so that other interested people may learn from our study.  
This proposal has been reviewed and approved by Zanzibar Medical Research Ethical Committee 
(ZAMREC). The committee has carefully assessed the study in advance to make sure that study 
participants are protected from any harm. If you wish to find about more about the institutional 
review board, you may contact Dr. Jamala Taib, Chairperson of ZAMREC telephone No 077 743 
24 65  
 
If you have any further questions or for any other reason would like to contact the 
responsible persons for the study you are most welcome to do so, please find our contact 
information below: 
Part II: Certificate of consent  
I have been invited to have my child participate in a study of a medicine used to treat malaria. 
I have read the above information, or it has been read to me. I have had the opportunity to ask 
questions, and any questions that I have asked have been answered to my satisfaction. I consent 
voluntarily to my child’s participation in this study.  
Print name of participant: 
 
Print name of parent or 
guardian:  
 
Signature of parent or 
guardian: 
 
Date: 
 
 
(dd/mmm/yyyy) 
 

 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
56
Witness’ signature: (A witness’ signature and the thumbprint of the participant’s parent or 
guardian are required only if the parent or guardian is illiterate. In this case, a literate witness 
must sign. If possible, this person should be selected by the participant’s parent or guardian and 
should have no connection with the study team.) 
I have witnessed the accurate reading of the consent form to the potential participant’s parent or 
guardian, who has had the opportunity to ask questions. I confirm that the participant’s parent or 
guardian has given consent freely.  
Print name of 
witness: 
 
 
 
and thumbprint of parent/guardian: 
Signature of 
witness: 
 
 
 
 
Date: 
 
 
 
 
 
 
(dd/mmm/yyyy) 
 
 
Investigator’s signature: 
I have accurately read or witnessed the accurate reading of the consent form to the potential 
participant’s parent or guardian, who has had the opportunity to ask questions. I confirm that the 
participant’s parent or guardian has given consent freely.  
Print name of 
investigator: 
 
 
Signature of 
investigator: 
 
 
Date: 
 
 
 
 
(dd/mmm/yyyy) 
A copy of this informed consent form has been provided to participant’s parent or guardian. 
_____ (initials of the principal investigator/assistant).  
Informed assent forms will _____ or will not _____ be completed.  
 

 
 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
57
Example of an informed assent form 
This informed assent form is for children aged 12–17 years who attend any of the 20 primary 
health care facilities in Zanzibar used as study sites in the above mentioned trial, and who have 
been invited to participate in the study to evaluate the efficacy of artesunate +amodiaquine for the 
treatment of uncomplicated falciparum malaria. 
Name of principal investigator: 
Mwinyi I. Msellem 
Name of organization: 
Zanzibar Malaria Elimination Programme 
Name of sponsor: 
GFATM: QNB-M-MOH, Karolinska Instituttet 
Name of proposal and version: 
Efficacy and safety of artesunate + amodiaquine  combined 
with a single low dose of primaquine (0.25 mg/kg) for the 
treatment of uncomplicated Plasmodium falciparum infection 
in Zanzibar 
 
This informed assent form has two parts:  
I. 
Information sheet (to share information about the study with you) 
II. 
Certificate of assent (for signatures if you agree to take part) 
You will be given a copy of the full informed assent form. 
Part I. Information sheet  
My name is .................................................., and I work for the Zanzibar Malaria Elimination 
Programme. We are presently doing a study in this primary health care facility on the treatment 
of malaria. Malaria is a dangerous disease; however, it can be treated with medicine. The purpose 
of this study is to confirm that the medicine presently recommended as first-line treatment for 
malaria in Zanzibar is still effective for curing malaria infection on the Isles.   
We are inviting all adults and children living in this area to take part in this study.  
I am going to give you information and invite you to participate in this study. You can choose 
whether you want to participate. We have discussed this study with your parent(s) or guardian, 
and they know that we are also asking you for your agreement. If you decide to participate in the 
study, your parent(s) or guardian also has to agree. If you do not wish to take part in the study, 
you do not have to, even if your parents have agreed. It is your choice. If you decide not to 
participate, nothing will change; this is still your clinic. Even if you say ‘Yes’ now you can 
change your mind later and it will still be okay. You may discuss anything in this form with your 
parents or friends or anyone else you feel comfortable talking to. There may be some words you 
do not understand or things that you want me to explain more because you are interested or 
concerned. Please ask me to stop at any time, and I will take time to explain. 
Interviewer: I have checked with the child, and he or she understands that participation is 
voluntary. _____ (initials) 
You will receive medicine once a day over 3 days. The medicine is a fixed dose combination of 
artesunate + amodiaquine combined with a single low dose of primaquine (0.25 mg/kg). This is 
the recommended first-line treatment for uncomplicated malaria infection by the Zanzibar 
Ministry of Health and Social Welfare. The Ministry through the Zanzibar Malaria Elimination 

 
 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
58
Programme regularly conducts studies to make sure that the recommended malaria medicines are 
still working. The malaria medicines are known to be very effective, but you should know that 
some people experience minor side-effects from the medicine: weakness, headache, nausea, 
vomiting, abdominal pain, diarrhoea and itching may occur. Primaquine has in rare cases been 
associated with anemia. However, these symptoms are usually transient and of mild or moderate 
intensity. 
 
All patients in this study will be asked to come back to the clinic for review on day 1, 2, 3, 7, 14, 
21 and 28 after enrolment, but also any time if fever persists. At each visit in the study, a small 
amount of blood will be taken from your finger. You may experience a bit of pain or fear when 
your finger is pricked. The pain normally disappears within 1 day. The blood sample collected on 
the slide will be examined with the use of a microscope to study if the malaria medicine is 
effective in curing the infection and in preventing malaria parasites from coming back into your 
blood.  The blood samples that will be collected on small pieces of paper will be used to study the 
malaria parasites in your blood. The examination of these blood samples will be done after the 
completion of the study in Sweden in collaboration with colleagues at the medical university in 
Stockholm namely Karolinska Institutet. Since these analyses will be done after the study is 
completed they will not be available to guide or evaluate the treatment. Except for the above 
described analyses no other tests will be done with your blood. 
The study period for each patient in this study is 28 days. During that time, we would like you to 
come to the health facility, which in total will be 8 visits including today’s visit. Each follow-up 
visit will last for about 1 hour. At each visit, you will be asked a few questions about your health 
condition, including if you have developed any new symptoms since last visit and if you have 
used any other medicines than the study medication. In addition you will also undergo a brief 
physical examination by study clinician at every visit. 
Interviewer: I have checked with the child, and he or she understands the procedures. _____ 
(initials)  
As previously mentioned the medicine can have some unwanted or unexpected effects that we are 
not currently aware of; however, we will follow you closely and keep track of these effects, if 
they arise, or of any other problems. If anything unusual happens to you, we need to know, and 
you should feel free to call us any time with your concerns or questions. If you get sick or have 
concerns or questions between scheduled visits to clinic, you should let me or the staff nurse 
know. You do not have to wait for a scheduled visit. We have also given your parents 
information about what to do if you are hurt or get sick during the study. 
Interviewer: I have checked with the child, and he or she understands the risks and discomforts. 
_____ (initials)  
If you decide to participate in this study, any illnesses related to malaria or to the malaria 
treatment will be treated at no charge to you. Your participation will help us to make sure the 
medicine is still working, and this will benefit society and future generations.  
Interviewer: I have checked with the child, and he or she understands the benefits. _____ 
(initials)  
Because you live quite far from the clinic, we will give your parents or guardian enough money 
to pay for the trip here and back. 

 
 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
59
We will not tell other people that you are participating in this study, and we will not share 
information about you with anyone who does not work in the study. Information about you that 
will be collected from the study will be put away, and no one but the study team will be able to 
see it. Any information about you will have a number on it instead of your name. Only the study 
team will know what your number is, and we will lock that information up.  
When we have finished the research, I will sit down with you and your parent or guardian and tell 
you about what we learnt. Afterwards, we will be telling more people, scientists and others, about 
the study and what we found. We will do this by writing and sharing reports and data and by 
going to meetings with people who are interested in the work we do. 
You can ask me questions now or later. You can ask the nurse questions. I have written a number 
and address where you can reach us or, if you are nearby; you can come and see us. If you want 
to talk to someone else whom you know, like your teacher, doctor or auntie, that is okay too. 
Part II: Certificate of assent  
I have been invited to participate in a study of the efficacy of an antimalarial medicine. I have 
read this information (or had the information read to me), and I understand it. I have had my 
questions answered and know that I can ask questions later if I have them. I agree to take part in 
the study. _____ (initials) or I do not wish to take part in the study and I have not signed the 
assent below. _____ (initials) 
Child’s signature (only if the child assents): 
Print name of child:  
 
Signature of child: 
 
 
Date: 
 
 
 
 
(dd/mmm/yyyy) 
Witness’ signature: (A witness’ signature and the child’s thumbprint are required only if the 
child is illiterate. In this case, a literate witness must sign. If possible, this person should be 
selected by the participant and should have no connection with the study team.) 
I have witnessed the accurate reading of the assent form to the potential participant, who has had 
the opportunity to ask questions. I confirm that the participant has given consent freely.  
Print name of witness:  
 
 
and thumbprint of the child or 
minor: 
Signature of witness: 
 
 
 
 
Date: 
 
 
 
 
 
 
(dd/mmm/yyyy) 
 
 
Investigator’s signature: 
I have accurately read or witnessed the accurate reading of the assent form to the potential 
participant, who has had the opportunity to ask questions. I confirm that the participant has given 
consent freely.  
Print name of investigator:  

 
 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
60
Signature of investigator: 
 
Date: 
 
 
(dd/mmm/yyyy) 
 
A copy of this informed assent form has been provided to the participant. _____ (initials of the 
principal investigator or assistant).

 
 
 
PROTOCOL FOR TERAPEUTIC EFFICACY TRIAL OF ARTESUNATE + AMODIAQUINE AND PRIMAQUINE IN ZNZ  
 
61
REFERENCES 
 
Bhattarai A et al., Impact of artemisinin-based combination therapy and insecticide-treated nets on malaria 
burden in Zanzibar. PLoS Med, 2007. 4(11): p. e309. 
 
Dahlström S et al., Diversity of the sarco/endoplasmic reticulum Ca2+-ATPase orthologue of Plasmodium 
falciparum (PfATP6). Infect Genet Evol. 2008 May; 8 (3):340-5. Epub 2008 Feb 15 
 
Dahlström S et al., Plasmodium falciparum multidrug resistance protein 1 and artemisinin-based 
combination therapy in Africa. J Infect Dis. 2009 Nov 1; 200 (9):1456-64. 
 
Holmgren G et al., Amodiaquine resistant Plasmodium falciparum malaria in vivo is associated with 
selection of pfcrt 76T and pfmdr1 86Y. Infect Genet Evol. 6:309-14, 2006. 
 
Holmgren G et al., Selection of pfmdr1 mutations after amodiaquine monotherapy and amodiaquine plus 
artemisinin combination therapy in East Africa. Infection, Genetics and Evolution 2007; 562–569 
 
Mårtensson and Strömberg et al Efficacy of artesunate plus amodiaquine versus that of artemether-
lumefantrine for the treatment of uncomplicated childhood malaria in Zanzibar, Tanzania. Clin Infect Dis. 
2005 Oct 15;41(8):1079-86 
 
Sisowath C et al., In vivo selection of Plasmodium falciparum pfmdr1 86N coding alleles by artemether-
lumefantrine (Coartem). J Infect Dis. 191:1014-7, 2005. 
 
Sisowath C et al., In vivo selection of Plasmodium falciparum pfmdr1 86N coding alleles by artemether-
lumefantrine (Coartem). J Infect Dis. 191:1014-7, 2005. 
 
Snounou G. Genotyping of Plasmodium spp. Nested PCR. Methods in molecular medicine 2002; 72:103. 
 
WHO. Severe falciparum malaria. Transactions of the Royal Society of Tropical Medicine and Hygiene, 
2000, 94(Suppl. 1):1–90. 
 
WHO. Assessment and monitoring of antimalarial drug efficacy for the treatment of uncomplicated 
falciparum 
malaria. 
Geneva, 
World 
Health 
Organization, 
2003 
(WHO/RBM/HTM/2003.50) 
(http://www.who.int/malaria/resistance). 
 
WHO. Susceptibility of Plasmodium falciparum to antimalarial drugs. Report on global monitoring 1996–
2004. Geneva, World Health Organization, 2005 (WHO/HTM/MAL/2005.110) 
(http://www.who.int/malaria/resistance). 
 
WHO. Methods and techniques for clinical trials on antimalarial drug efficacy: genotyping to identify 
parasite populations. Geneva, World Health Organization, 2008 (http://www.who.int/malaria/resistance). 
 
WHO. Method for surveillance of antimalarial drug efficacy. Geneva, World Health Organization, 2009 
(http://www.who.int/malaria/resistance). 
 
WHO/GMP. Standardized data entry for therapeutic efficacy tests. Geneva, World Health Organization 
(http://www.who.int/malaria/resistance). 
 
Zanzibar Ministry of Health and Social Welfare, National Guidelines for malaria diagnosis and treatment in 
Zanzibar, 2010