Assessing the Effectiveness of Targeted Active Case Detection Among High Risk Populations in Southern Lao PDR
Phase: PHASE4
Conditions: Plasmodium Falciparum Malaria
Sponsor: University of California, San Francisco

 
 
 
 
 
 
 
Protocol 
 
 
 
 
 
Assessing the effectiveness of targeted active case detection  
among high-risk populations in Southern Lao PDR 
 
 
 
 
Partnership of Center for Malariology, Parasitology and Entomology, National 
Institute of Public Health, and University of California, San Francisco 
 
 
 
 
 
 
 
 
Funded by: Bill & Melinda Gates Foundation 
 
Version Number: 4 
November 05, 2017 
 
 

Protocol Amendment – 05 November 2017         
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Principal Investigators 
 
 
Adam Bennett, PhD  
MEI Programmatic Lead 
 
Malaria Elimination 
Initiative, Global Health 
Group 
University of California, San 
Francisco 
Phone: 1-415-476-5590 
Adam.Bennett@ucsf.edu 
 
Rattanaxay Phetsouvanh, MD, MSc 
Director 
 
Department of Communicable 
Disease Control 
Ministry of Health 
Vientiane, Lao PDR 
bphommasack@gmail.com 
 
 
Andrew Lover, MS, MPH, PhD 
GMS Technical Program Coordinator 
 
Malaria Elimination Initiative,  
Global Health Group 
University of California, San 
Francisco 
andrew.lover@ucsf.edu 
 
 
Co-investigators and Key Personnel 
 
 
Emily Dantzer, MHS 
Program Manager 
 
Lao PDR Malaria Elimination 
Research Partnership 
Global Health Group / UCSF Global 
Health Sciences 
Vientiane, Lao PDR 
emily.dantzer@ucsf.edu 
Bouasy Hongvanthong, MD 
Director            
 
Center of Malariology, Parasitology, 
Entomology (CMPE) 
Vientiane, Lao PDR 
cmpelao@gmail.com 
 
Vatthana Nanthana, MBA 
Local Study Coordinator 
 
Lao PDR Malaria Elimination 
Research Partnership 
Global Health Group / UCSF Global 
Health Sciences 
Vientiane, Lao PDR 
vnanthana@gmail.com 
NIOPH: Dr. Souraxay Phrommala, 
DG of NIOPH 
NIOPH: Dr. Khampheng Phongluxa, 
Head of Health Research Outcome 
Division 
Jennifer L Smith, MSc, PhD 
Assistant Professor 
 
Malaria Elimination Initiative,  
Global Health Group 
University of California, San 
Francisco 
Jennifer.Smith@ucsf.edu 
Jimee Hwang MD, MPH 
Medical Epidemiologist 
 
US Center for Disease Control & 
Prevention 
Center for Global Health/DPDM 
Malaria Branch/US President’s 
Malaria Initiative, and 
Malaria Elimination Initiative,  
Global Health Group 
University of California, San 
Francisco 
Sophia Hocini, MPH 
Surveillance Research Analyst 
 
Malaria Elimination Initiative,  
Global Health Group 
University of California, San Francisco 
Sophia.Hocini@ucsf.edu 
Francois Rerolle, MS 
Geospatial specialist; PhD student 
 
Malaria Elimination Initiative,  
Global Health Group 
University of California, San  
Francisco 
Francois.Rerolle@ucsf.edu 

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Jimee.Hwang@ucsf.edu 
Roly Gosling, MD PhD 
Associate Professor 
 
Lead, Malaria Elimination Initiative, 
Global Health Group 
University of California, San 
Francisco 
Roly.gosling@ucsf.edu 
Joshua Yukich, PhD 
Assistant Professor 
 
Tulane University School of Public 
Health and Tropical Medicine 
jyukich@tulane.edu 
Bryan Greenhouse, MD, MA  
Assistant Professor 
Dept. of Medicine / Div. of Infectious 
Diseases 
University of California, San 
Francisco 
bryan.greenhouse@ucsf.edu 
 
Jerry Jacobson 
Independent consultant 
 
jerryojacobson@gmail.com 
 
 
 
 
 

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Table of Contents 
1 
PROTOCOL SUMMARY 
7 
2 
BACKGROUND AND INTRODUCTION 
9 
2.1 
LITERATURE REVIEW 
 
9 
2.1.1 
ACTIVE SURVEILLANCE FOR MALARIA ELIMINATION 
9 
2.1.2 
ACTIVE SURVEILLANCE FOR MALARIA ELIMINATION IN HIGH-RISK POPULATIONS 
9 
2.1.3 
RATIONALE 
10 
2.2 
SIGNIFICANCE 
 
12 
2.3 
PRIMARY AIM 
 
12 
2.4 
PRIMARY RESEARCH QUESTIONS AND HYPOTHESES 
12 
2.5 
STUDY OVERVIEW 
 
13 
2.6 
SUMMARY OF ETHICAL ISSUES 
 
13 
3 
METHODOLOGY 
14 
3.1 
STUDY SITE 
 
14 
3.2 
INTERVENTIONS 
 
16 
3.2.1 
VILLAGE-LEVEL MASS TEST AND TREAT WITH HS-RDTS (MTAT-HS) 
17 
3.2.2 
PEER NAVIGATOR-LED FTAT WITH HS-RDTS 
20 
3.2.3 
ADHERENCE AND SAFETY MONITORING 
22 
3.3 
STUDY EVALUATION METHODS 
 
23 
3.3.1 
OVERVIEW OF EVALUATION ACTIVITIES BY STUDY OBJECTIVES, OUTCOMES, AND DATA COLLECTION ACTIVITIES 
23 
3.3.2 
ACTIVITY 1 - EVALUATION OF TEST AND TREAT USING HS-RDTS 
25 
3.3.3 
ACTIVITY 2 - ASSESSMENT OF HEALTH-SECTOR AND COMMUNITY FEASIBILITY AND ACCEPTABILITY OF THE TEST AND 
TREAT INTERVENTIONS 
35 
3.3.4 
ACTIVITY 3 - ESTIMATING POPULATION SIZE OF FOREST-BASED HRPS 
37 
3.3.5 
ACTIVITY 4 - ASSESS DEMOGRAPHIC AND GEOGRAPHIC PREDICTORS FOR G6PDD TESTING ADHERENCE WITH A 
POSITIVE P. VIVAX RDT 
39 
4 
ETHICAL ISSUES RELATED TO HUMAN SUBJECT RESEARCH 
39 
4.1 
ADEQUACY OF PROTECTION AGAINST RISKS 
39 
4.2 
PROTECTION AGAINST RISKS ASSOCIATED WITH THE ADMINISTRATION OF AL / SLD-PQ 
40 
4.3 
POTENTIAL BENEFITS OF THE PROPOSED RESEARCH TO THE PARTICIPANTS AND OTHERS 
41 
4.4 
ALTERNATIVES TO PARTICIPATION 
41 
4.5 
DATA AND SAFETY MONITORING PLAN 
41 
4.6 
COLLECTION OF SPECIMENS 
 
42 
4.6.1 
RACIAL AND ETHNIC ORIGIN 
42 
4.6.2 
INCLUSION OF VULNERABLE SUBJECTS – CHILDREN AND PREGNANT WOMEN 
42 
4.7 
SUBJECT CONSENT/ASSENT 
 
43 
4.7.1 
PROCESS OF CONSENT 
43 
4.7.2 
SUBJECT CAPACITY 
43 
4.7.3 
SUBJECT/REPRESENTATIVE COMPREHENSION 
43 
4.7.4 
DOCUMENTATION OF CONSENT 
43 
4.7.5 
COSTS TO THE SUBJECT 
43 
4.7.6 
PAYMENT FOR PARTICIPATION 
43 
4.7.7 
FIELD DATA COLLECTOR TRAINING 
43 

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4.7.8 
COMMUNITY SENSITIZATION AND COMMUNICATION 
44 
4.7.9 
STUDY ORGANIZATION AND MANAGEMENT 
44 
5 
POTENTIAL RISKS, LIMITATIONS, DATA QUALITY ASSURANCE, AND DISSEMINATION PLAN 
44 
5.1 
POTENTIAL RISKS FROM PARTICIPATION 
44 
5.2 
LIMITATIONS 
 
44 
5.3 
DATA QUALITY ASSURANCE PLAN  
45 
5.4 
DISSEMINATION PLAN 
 
45 
6 
BUDGET 
46 
7 
TIMELINE 
46 
8 
REFERENCES 
48 
9 
APPENDICES 
53 
9.1 
ANNEX A. DETAILED SCHEMATIC OF STUDY DESIGN 
53 
9.2 
ANNEX B.  STUDY POWER CURVES 
54 
9.3 
ANNEX C. CROSS-SECTIONAL SURVEY INFORMED CONSENT FORM 
56 
9.4 
ANNEX D. BASELINE/END-LINE HOUSEHOLD SURVEY QUESTIONNAIRE 
56 
9.5 
ANNEX E. INDIVIDUAL BLOOD COLLECTION INFORMED CONSENT (CROSS-SECTIONAL SURVEY) 
56 
9.6 
ANNEX F. BLOOD COLLECTION RESULTS FORM (CROSS-SECTIONAL SURVEY) 
56 
9.7 
ANNEX G. MTAT HOUSEHOLD SURVEY INFORMED CONSENT FORM 
56 
9.8 
ANNEX H. MTAT HOUSEHOLD SURVEY QUESTIONNAIRE 
56 
9.9 
ANNEX I. MTAT BLOOD COLLECTION INFORMED CONSENT FORM 
56 
9.10 ANNEX J. FTAT SURVEY AND BLOOD COLLECTION INFORMED CONSENT FORM 
56 
9.11 ANNEX K. FTAT HRP SURVEY QUESTIONNAIRE 
56 
9.12 ANNEX L. G6PD TESTING REFERRAL LETTER 
56 
9.13 ANNEX M. G6PD HEALTH FACILITY REGISTER FORM 
56 
9.14 ANNEX N. ADVERSE EVENT REPORTING FORM 
56 
9.15 ANNEX O. SEVERE ADVERSE EVENT INVESTIGATION FORM 
56 
9.16 ANNEX P. FDG/KII INFORMED CONSENT FORM 
56 
9.17 ANNEX Q. MTAT TEAM FGD GUIDE 
56 
9.18 ANNEX R. PEER NAVIGATOR FGD GUIDE 
56 
9.19 ANNEX S. STUDY TEAM AND DISTRICT KII GUIDE 
56 
9.20 ANNEX T. TREATMENT ADHERENCE FOLLOW-UP FORM 
56 
9.21 ANNEX U. PEER NAVIGATOR FTAT COMPETENCY CHECKLIST 
56 
9.22 ANNEX V. PEER NAVIGATOR INTERVIEW GUIDE 
56 
9.23 ANNEX W. HRP INTERVIEW GUIDE 
56 
 
 
 
 
 
 
 
 

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Acronyms 
 
ACT 
 
Artemisinin-based combination therapy 
AE  
 
Adverse event 
AL  
 
Artemether lumefantrine 
CRCT 
 
Cluster randomized control trial 
CMPE 
 
Center for Malariology, Parasitology, Entomology (Lao PDR) 
DAMNs 
 
District anti-malaria nucleus 
DBS 
 
Dried blood spot 
DHO 
 
District health office 
DSMB  
 
Data safety monitoring board 
FSAT 
 
Focal screen and treat 
FGD 
 
Focus group discussion 
G6PDd 
 
Glucose-6-phosphate dehydrogenase deficiency 
GMS 
 
Greater Mekong Subregion  
HC  
 
Health center 
HCCA 
 
Health center catchment area 
HPA 
 
Health Poverty Action 
HRPs 
 
High-risk populations (for malaria infection) 
HRP 2/3 
 
(Plasmodium falciparum) Histidine-rich protein 2/3 
HS-RDT 
 
Highly sensitive malaria rapid diagnostic test 
HH  
 
Household 
IOM 
 
International Organization for Migration 
IRS  
 
Indoor residual spraying 
KII  
 
Key informant interview 
Lao PDR 
 
Lao People’s Democratic Republic 
LLIN 
 
Long-lasting insecticidal nets 
MSAT  
 
Mass screen and treat 
MTAT 
 
Mass test and treat 
MMPs 
 
Mobile and migrant populations 
MSP 
 
Merozoite surface protein 
NIOPH 
 
National Institute of Public Health (Lao PDR) 
PAMS 
 
Provincial anti-malaria station 
PN  
 
Peer navigator 
PQ  
 
Primaquine 
RDT 
 
Rapid diagnostic test 
PCR  
 
Polymerase chain reaction 
SAE 
 
Serious adverse event 
SLD-PQ 
 
Single low-dose primaquine  
VMW/VMV 
Village malaria worker/volunteer 
VHV 
 
Village health volunteer 
WHO 
 
World Health Organization 
 
 

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1 Protocol summary 
 
Aim 
To determine the effectiveness, cost-effectiveness, acceptability, and feasibility of 
proactive targeted test and treat activities using high-sensitivity malaria rapid 
diagnostic tests (HS-RDTs) for reducing Plasmodium falciparum transmission 
among:  
(1) village residents in Champasak Province, Southern Lao PDR, and  
(2) mobile and migrant populations (MMPs) and other high-risk populations (HRPs) 
in Champasak Province, Southern Lao PDR. 
 
Primary 
research 
questions and 
hypotheses 
Null hypothesis 1:  There is no benefit of three rounds of village-based test and 
treat using HS-RDTs relative to standard of care for reducing P. falciparum parasite 
prevalence and health facility confirmed case incidence over a 12-month period. 
 
Research hypothesis 1: Three rounds of village-based test and treat using HS-RDTs 
will be significantly more effective than standard of care (case management) at 
reducing P. falciparum parasite prevalence and health facility confirmed case 
incidence over a 12-month period. 
 
Null hypothesis 2:  There is no benefit of peer-navigator targeted test and treat 
using HS-RDTs relative to standard of care for reducing P. falciparum parasite 
prevalence and health facility confirmed case incidence over a 12-month period. 
 
Research hypothesis 2: Routine peer-navigator targeted test and treat using HS-
RDTs will be significantly more effective than standard of care at reducing P. 
falciparum parasite prevalence and health facility confirmed case incidence over a 
12-month period. 
 
Null hypothesis 3:  There is no benefit of three rounds of village-based test and 
treat using HS-RDTs and routine peer-navigator targeted test and treat using HS-
RDTs relative to standard of care for reducing P. falciparum parasite prevalence 
and health facility confirmed case incidence over a 12-month period. 
 
Research hypothesis 3: Three rounds of village-based test and treat combined with 
routine peer-navigator targeted test and treat using HS-RDTs will be significantly 
more effective than standard of care at reducing P. falciparum parasite prevalence 
and health facility confirmed case incidence over a 12-month period. 
 
Research 
objectives 
Primary Objective: To evaluate the effectiveness of targeted test and treat 
activities using HS-RDTs compared to control for reducing the health center 
catchment- and village-level prevalence and incidence of P. falciparum within four 
districts in Champasak Province, Southern Lao PDR. 
 
Secondary Objectives:  
1. To determine key risk factors among study populations for malaria 
infection and identify optimal screening and case detection strategies 
addressing characteristics or behaviors that lead to increased risk 

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2. To determine the cost-effectiveness, acceptability, and feasibility of active 
case detection strategies aimed at reducing P. falciparum transmission 
among study populations, including peer navigator targeted test and treat 
among high-risk populations and village-based test and treat using HS-
RDTs 
3. To assess the sensitivity and specificity of HS-RDTs for the detection of P. 
falciparum parasites relative to PCR (baseline and end-line surveys, and 
peer-navigator activities), and compared to standard RDTs (baseline and 
end-line surveys and test and treat activities) 
4. To assess the operational feasibility of malaria HS-RDTs for active case 
detection within the public health sector in Lao PDR 
5. To estimate the size of the MMP/high-risk population in study districts in 
Champasak Province, Southern Lao PDR 
6. To determine the effectiveness of test and treat activities in reducing P. 
vivax prevalence and incidence 
7. To determine factors associated with G6PDd testing adherence after 
referral to district-level facilities for persons with P. vivax positive RDT 
results.  
 
Study site and 
populations 
Total population of approximately 85,000 in 14 health center catchment areas. 
 
Health center catchments and forest-fringe population of four target districts in 
Champasak Province, Southern Lao PDR: Mounlapamook, Panthampone, 
Sanamsaboun, and Soukhuma. 
 
Study design 
Split-plot community-randomized controlled trial, with peer navigator test and 
treat randomized at the health center catchment level, and village-based test and 
treat randomized at the village level within health center catchment areas.  
 
Primary 
outcome 
measures 
1. PCR-based P. falciparum parasite prevalence in sampled villages 
2. HS-RDT-based test positivity rate in village-level and HRP populations 
3. Village-based population coverage of test and treat interventions 
4. Village-based confirmed case incidence in sampled villages 
Data collection 
and sampling 
period 
12 months from start date (planned November 2017 – October 2018) 
Sample sizes 
1) Household surveys: 5,600 persons aged > 18 months at baseline; 8,400 persons 
aged >18 months at end-line (total 14,000 persons during household surveys) 
2) Village-based test and treat: approximately 22,000 persons per round 
3) High-risk population test and treat: approximately 2,000 persons over 10-month 
period 
4) Confirmed case incidence across 14 health center catchment areas: population 
of approximately 85,000 
 
Statistical and 
analytical plan 
Rapid reporting of RDT and HS-RDT positivity will be analyzed as interventions are 
implemented (or shortly thereafter) to provide preliminary assessment of 
interventions. Generalized linear mixed effects models will be used to test the 

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effect of each intervention independently (main effects) relative to standard of 
care and additionally the combined interventions relative to standard of care 
(interaction term).   
2 Background and introduction 
2.1 Literature review 
2.1.1 Active surveillance for malaria elimination 
Malaria control programs traditionally use passive surveillance systems, which are based on symptomatic 
cases presenting to health facilities or community-based workers, to monitor disease burden. In 
elimination settings, where symptomatic case numbers are much lower, the World Health Organization 
(WHO) recommends incorporating active surveillance methods such as case investigation followed by 
active case detection in order to identify asymptomatic cases that may cluster around index cases in space 
and time.  
 
Active case detection approaches are differentiated based upon whether they are conducted in response 
to an index case (reactive) or at regular intervals in locations known to have transmission, but not in 
response to a specific individual case (proactive). Reactive case detection (RACD) is commonly practiced 
by malaria elimination programs, and involves screening households in close geographic proximity to 
passively-detected index cases. Proactive case detection approaches can be conducted on community-
wide scales (mass screen and treat (MSAT) or mass test and treat (MTAT)) or in small geographic areas 
(focal screen and treat (FSAT) or focal test and treat (FTAT)).  
 
When employing standard RDTs, however, none of these strategies have been shown to have a sustained 
significant impact on malaria transmission due to limited sensitivity being insufficient to detect many 
persons with asymptomatic parasitemia [1–3]. In the Greater Mekong Subregion (GMS) specifically, few 
studies have been undertaken to assess the impact of active case detection, and in line with global findings, 
all have failed to demonstrate impact on community-level prevalence using standard RDTs [4,5].  While 
PCR-based strategies have shown potential impacts in the region [6], this methodology is not field 
deployable, and follow-up of cases may be difficult due to delays in reporting of results. A number of 
studies are currently exploring targeted mass drug administration (MDA) approaches, but due to concerns 
about large-scale MDA approaches in the GMS resulting from widespread artemisinin resistance, 
identifying optimal screen or test and treat activities is critical for accelerating progress to elimination in 
the region.  
2.1.2 Active surveillance for malaria elimination in high-risk populations 
In many pre-elimination and elimination settings, there is increasing evidence that the epidemiology of 
malaria is rapidly changing, with a greater proportion of transmission occurring outside of formal 
households, and in younger adult males [7]. This is especially true in the GMS including Lao People’s 
Democratic Republic (Lao PDR), where forest-based activities are a major contributor to the overall 
economy in many areas. Forest-goers may have higher risk of malaria infection, and are likely linked by 
specific characteristics that increase their exposure to outdoor-biting and/or forest-dwelling mosquitoes. 
These shared characteristics may be social (people who socialize together), behavioral (people who sleep 
outside at night), related to travel (groups of people who go into the forest together) or occupational 
(people who work in or near the forest, on plantations, or at industry/development project sites). Despite 
a growing consensus that high-risk groups are often strongly linked by behavioral characteristics [8,9], 

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little evidence exists to help guide decision-making around which case detection strategies are most 
effective and how best to implement these strategies to target high-risk populations. 
In the GMS, mobile and migrant populations (MMPs) are considered at highest risk for malaria due to 
their occupational environments (forest, forest fringe, plantations, and others) and commonly a lack of 
access or motivation to seek formal health care. While the tendency exists to refer to MMPs as a single 
homogenous group, the composition, exposures, and mobility patterns – and thus risk profiles, of these 
populations are thought to be highly heterogeneous.  
 
Additionally, the proportion of reported malaria cases among males aged five years and older increased 
from 46 percent in 2009 to 86 percent in 2014, suggesting an association between malaria infections and 
occupational exposures, particularly among forest workers and migrant laborers [10]. Despite a growing 
emphasis on targeting MMPs, specific regional data on these subpopulations particularly in Lao PDR are 
limited. Furthermore, the relative contribution to transmission from forest-based work, compared to 
village-based risk factors, remains unclear. 
 
MMPs and other forest-goers (hereafter, ‘high-risk populations’ or HRPs) constitute a barrier to malaria 
elimination and artemisinin-resistance control efforts in the GMS and beyond. As a result of these groups’ 
movement patterns, HRPs have the potential to introduce malaria parasites and perpetuate the spread 
of artemisinin resistance to new areas. Moreover, foreign MMPs pose a further challenge to national 
elimination efforts, as these populations may be less likely to seek formal care, and are therefore less 
likely to be captured through national reporting systems. Finally, the isolated, ambiguous, and overlapping 
composition of MMP subgroups defies simple classification for targeting and tailoring of interventions. To 
date there have been limited studies actively targeting highest-risk populations; one successful study 
targeted a set of border crossings in Southern Lao PDR and found high prevalence of parasitemia [11], but 
there has been limited success with social network-based approaches such as respondent-driven sampling 
in HRPs [12,13]. 
 
The Lao Ministry of Health defines MMPs as any workers or their family members who migrate for 
economic or labor-related reasons within the country or across national borders [10]. The majority of 
MMPs are thought to be comprised of adult men and some women engaged in logging, agriculture, forest 
foraging activities, and industrial/development projects [9,14]. A recent Lao government decree (enacted 
in May 2016) implemented stringent regulations on all logging, resulting in rapid shifts in the livelihood 
activities of local populations. However, many other demographics aside from loggers spend time 
overnight in forest areas or forest-fringe farm sites, and may be contributing to ongoing malaria 
transmission. A formative assessment carried out by UCSF in these populations in 2016 found that small-
scale spatial movements by local rice farmers who generally migrate from their home villages seasonally 
may be an important contributor to overall transmission (UCSF, 2016, unpublished report). 
2.1.3 Rationale 
While there has been limited impact of MSAT/FSAT with standard RDTs, major investments in improved 
RDTs have led to the next generation of histidine-rich protein 2 (HRP-2) RDTs for P. falciparum, with an 
expected ~10-fold greater sensitivity. The new highly sensitive Alere Malaria Ag P.f Ultra Sensitive RDT 
(http://www.alere.com/en/home/product-details/alere-malaria-ag-pf.html) 
(HS-RDT) 
has 
recently 
become commercially available, with a primary intended use being active case detection for individuals 
with low parasitemia. The increased sensitivity (approaching PCR-based testing) in a user-friendly and 
field-deployable diagnostic will address gaps in active surveillance and allow direct targeting of the 
asymptomatic reservoir, with the potential to dramatically change the malaria surveillance landscape in 
the GMS and beyond. This HS-RDT has not yet been tested in an active case detection setting. 

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The standard first-line treatment for confirmed uncomplicated P. falciparum malaria cases in Lao PDR is 
artemether-lumefantrine (AL); single low-dose primaquine (SLD-PQ) has recently been added to this 
regimen. While AL is effective at clearing the asexual form of the parasite, it does not clear the sexual 
form gametocytes, which are still produced for a short period following treatment with AL (median of 72 
hours) [15], contributing to onward transmission. SLD-PQ has recently been shown to be safe and effective 
for rapidly clearing sexual stage parasites [16], and modeling work suggests a marginal benefit on 
transmission when added to AL in low transmission settings [17]. The clearance of P. falciparum 
gametocytes by addition of SLD-PQ to standard AL treatment has the potential to increase the impact of 
active case detection interventions in the GMS [18]; however this has yet to be tested in a controlled field 
setting.  
 
Formative work by UCSF, Health Poverty Action (HPA), International Organization for Migration (IOM), 
and others in 2015-2017 suggests that many ‘forest-goers’ in Southern Lao PDR may be permanent 
residents of nearby villages, who may spend only a limited interval (2-5 days) in forest or forest fringe 
areas before returning to their home villages. While being village-based provides a probable entry point 
for health services, many infections may be asymptomatic and therefore unlikely to seek care through 
village malaria workers (VMWs) or with health centers. This formative work also suggests that village-
based populations in Southern Lao PDR are highly accepting of household-based active case detection, 
and that utilizing these new HS-RDTs in this setting is unlikely to be met with opposition.  
  
However, active outreach in other high-risk subpopulations by public sector health staff is challenging due 
to the illegal/semi-legal nature of some activities in forested areas, as well as socio-cultural barriers that 
may exist if Lao is not the primary language of target groups. Additional formative work suggests there 
are currently few congregation sites suitable for venue-based surveillance within the target areas, and 
moreover, worksites are few, small in scale, and temporary. Together these circumstances suggest that 
novel methods will be required to access HRPs for testing with HS-RDTs. 
 
One promising technique to address similar challenges in sampling hard-to-reach groups that has been 
widely used in other disease areas (especially HIV/AIDS) is that of ‘peer-navigators’ (PNs) who are simply 
peer-group members who are directly supported to seek out any persons like themselves for testing and 
treatment, and to provide linkages to health services [19,20]. These positions have several important 
differences from other outreach methods. Specifically, PNs are full-time paid positions, who need to have 
shared socioeconomic level, racial/ethnic identity, common language(s), and should have shared “lived 
experience” as target groups [20]. Finally, their sole responsibility is active case finding and direct 
community outreach in target subpopulations. 
 
HPA’s studies in 2015 found that some HRPs (true mobile and migrant groups) may also travel with their 
extended families to forest-based worksites. These family members generally stayed in temporary 
dwellings within forests, but some may also transit from forested areas to nearby villages and visit small 
shops for supplies [21]. However, the schedules and frequency of these visits is unknown, and the total 
number of such HRPs has not been estimated. Finally, the ratio of these forest-based HRPs to village-
based groups is currently unknown, but a deeper understanding would allow for prioritizing interventions 
towards the Lao National Strategic Plan 2016-2020 goals. 
 
In combination with novel strategies for accessing HRPs, we hypothesize that active case detection using 
the next generation of HRP-2 RDTs can help bridge gaps in identification of high-risk asymptomatic 

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individuals with low density parasitemia, allowing for targeting of this reservoir and thereby reducing 
transmission. 
2.2 Significance 
In direct support of the Lao National Strategic Plan, robust comparisons of the effectiveness and cost-
effectiveness of targeted parasite detection strategies are needed to prioritize inherently limited 
resources. Towards these goals, this study will assess the role of HS-RDTs in active case detection at both 
the village-level and in forest-based HRPs for decreasing prevalence and incidence of P. falciparum in 
target areas. The effectiveness of these interventions will be compared independently and in combination 
against areas with no study interventions (standard of care case management). The findings of this study 
will provide the Center for Malariology, Parasitology, and Entomology (CMPE) and partners with practical 
and direct guidance on the effectiveness of active case detection for village and forest-based HRPs with 
HS-RDTs and artemether lumefantrine plus primaquine (AL-PQ) to further shrink the parasite reservoir in 
Southern Lao PDR towards the 2030 elimination goals within the context of current malaria program 
interventions. 
2.3 Primary aim 
In Southern Lao PDR a range of partners are supporting CMPE to reduce the parasite reservoir through 
scale-up of ITNs and support for prompt care-seeking behaviors, which have had major impacts on 
incidence within the last 2-3 years. This protocol plans to evaluate a novel platform for targeted P. 
falciparum parasite detection in the highest risk populations, many of whom may become infected due 
to forest-based work. A community-randomized controlled trial will be used to assess the impact of active 
case detection using HS-RDTs in village-based populations though test and treat campaigns, and in forest-
based HRPs through routine active case detection by peer navigators operating in selected health center 
catchment areas. Specifically, the primary aim of this study is to quantify the impact of village-based and 
peer navigator active case detection with HS-RDTs in HRPs against the standard of care using prevalence 
(primary outcome) and incidence (secondary outcome) of P. falciparum in selected health center 
catchment areas and villages. 
2.4 Primary research questions and hypotheses 
Within the context of CMPE’s standard interventions in Southern Lao PDR, this project will specifically aim 
to answer the following primary evaluation research questions and hypotheses: 
 
In target areas, are three rounds of test and treat using HS-RDTs in villages and routine test and treat using 
HS-RDTs in HRP sites more effective than no test and treat (standard of care) in reducing P. falciparum 
incidence and prevalence over a 12-month intervention period? 
 
Null hypothesis 1:  There is no benefit of three rounds of village-based test and treat using HS-RDTs over 
standard of care for reducing P. falciparum parasite prevalence and health facility confirmed case 
incidence over a 12-month period. 
 
Research hypothesis 1: Three rounds of village-based test and treat using HS-RDTs will be significantly 
more effective than standard of care at reducing P. falciparum parasite prevalence and health facility 
confirmed case incidence over a 12-month period. 
 
Null hypothesis 2:  There is no benefit of peer-navigator targeted test and treat using HS-RDTs over 
standard of care for reducing P. falciparum parasite prevalence and health facility confirmed case 
incidence over a 12-month period. 

Protocol Amendment – 05 November 2017         
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Research hypothesis 2: Three rounds of peer-navigator targeted test and treat using HS-RDTs will be 
significantly more effective than standard of care at reducing P. falciparum parasite prevalence and health 
facility confirmed case incidence over a 12-month period. 
 
Null hypothesis 3:  There is no benefit of three rounds of village-based test and treat using HS-RDTs and 
peer-navigator targeted test and treat using HS-RDTs relative to standard of care for reducing P. 
falciparum parasite prevalence and health facility confirmed case incidence over a 12-month period. 
 
Research hypothesis 3: Three rounds of village-based test and treat combined with peer-navigator 
targeted test and treat using HS-RDTs will be significantly more effective than standard of care at reducing 
P. falciparum parasite prevalence and health facility confirmed case incidence over a 12-month period. 
2.5 Study overview 
To test these hypotheses, this study will employ a split-plot community-randomized trial design for the 
two main interventions: MTAT using HS-RDTs in village-based populations, and PN-led FTAT using HS-RDTs 
in forest-based HRPs. The primary outcomes include: PCR-based P. falciparum prevalence at end-line; HS-
RDT test positivity rate in village and HRP populations; and village-based population coverage of test and 
treat interventions. The trial will be implemented between November 2017 and October 2018 in 
Champasak Province, Lao PDR. The interventions will consist of three rounds of MTAT spaced throughout 
the year, and continuous FTAT by PNs in forest and forest-fringe HRPs. The primary evaluation will be 
conducted through an end-line cross-sectional survey in October 2018. A baseline cross-sectional survey 
will be conducted in November 2017 to gather baseline information and assist with study randomization. 
2.6 Summary of ethical issues 
All project activities will be approved prior to implementation by the institutional review boards in Lao 
PDR (NIOPH/MOH) and at UCSF.  
 
Artemether-lumefantrine (AL) is the standard first-line drug for uncomplicated P. falciparum malaria in 
Lao PDR, and will be used to treat all positive cases detected during study interventions. Single-low dose 
primaquine (SLD-PQ) has recently been approved for use for uncomplicated P. falciparum malaria 
infection and in addition to AL constitutes the first-line drug regimen of policy.  
 
The use of SLD-PQ for P. falciparum has been shown to have no clinically significant impacts on 
hematological indexes in populations with severe glucose-6-phosphate dehydrogenase deficiencies 
(G6PDd) in the GMS [22]. SLD-PQ is currently recommended by WHO without prior G6PD testing, and no 
serious adverse events (SAEs) are expected from SLD-PQ. 
 
In all settings (village and forest-based), individuals with malaria infections identified by RDTs/HS-RDTs 
will benefit directly from treatment with AL-PQ. Furthermore, non-infected individuals within households 
and communities will benefit from population-level clearance of parasites including gametocytes. While 
the HS-RDTs specifically target the low-density infection P. falciparum reservoir, standard RDTs will likely 
identify P. vivax infections. Individuals with a confirmed P. vivax infection will benefit from treatment with 
AL (standard treatment) and will be referred to the nearest district hospital for G6PD testing and follow-
up treatment with primaquine. It is also possible that some individuals with a low-density P. falciparum 
infection also have a low-density P. vivax infection. These individuals and their communities may benefit 
from clearance of blood-stage P. vivax parasites.   
 

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Household members and parents/guardians of children will be verbally informed of the general purpose 
of the test and treat interventions, the study, and the possible risks and potential benefits associated with 
participation in the research and intervention. All informed consent procedures will be conducted in the 
appropriate local languages. Participation in either the research or the intervention is voluntary. For 
children <6 years old, malaria testing will be based on consent from the parent or guardian; for children 
aged 6 to <18 years of age the child’s assent will also be required.  
 
The monitoring and evaluation of the interventions includes: a short survey at the time of the intervention 
documenting insecticide-treated mosquito net possession and use, any history of fever in the past two 
weeks, and any history of forest- or rice field-related work in the past month; routinely collected malaria 
incidence data from health facilities; cross-sectional household surveys with finger sticks for malaria 
parasitemia; and qualitative data collection with forest goers (open-ended questions) during 
implementation, and study team members (MTAT teams, PNs) and district health staff (focus group 
discussions and key informant interviews) at end-line. Participation in any of the research is voluntary, 
and will not affect an individual’s ability to participate in the intervention. There is minimal risk from the 
evaluation measures. 
 
3 Methodology 
3.1 Study site 
After years of declines, Southern Lao PDR experienced a resurgence of malaria incidence in 2013-2015, 
and incidence rates in Champasak Province remain among the highest in the country. The study will be 
carried out in selected health center catchments areas (HCCA) in four districts in Champasak Province 
(Mounlapamook, Panthampone, Sanamsaboun, and Soukhuma), targeting the highest-burden HCCAs 
(Figure 1) which include those that were part of the previous formative studies by UCSF in 2016. The 
study area population, number of villages, total health facilities, and P. falciparum and P. vivax annual 
parasite indices (API) for 2015 by district can be found in Table 1. 
 
Figure 1. Overview of project districts, Champasak Province, Lao PDR, showing all-species API (2015) 
 

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Table 1. Study area population and confirmed case incidence, Champasak Province, Lao PDR 
 
District 
Total 
villages 
Total population 
(2015 census) 
Total health 
facilities 
Pf cases 2015 
(API) 
Pv cases 2015 
(API) 
Total cases 2015 
(API) 
Mounlapamook 
50 
38,800 
8 
944 (24.3) 
1558 (40.2) 
2593 (66.8) 
Panthamphone 
93 
61,252 
9 
2529 (41.3) 
2381 (38.9) 
5082 (83.0) 
Sanamsaboun 
86 
69,338 
10 
268 (3.9) 
1564 (22.6) 
1856 (26.8) 
Soukhuma 
62 
58,445 
5 
639 (10.9) 
788 (13.5) 
1459 (25.0) 
 
Currently, CMPE’s standard-of-care interventions include periodic mass distribution of ITNs, health facility 
level testing with RDTs, community case management by VMWs in high-burden areas, and IEC/BCC work 
through village malaria/health workers. In some high-burden areas, malaria posts and mobile malaria 
teams have been implemented on a pilot-scale, but maintaining momentum in light of other competing 
priorities within the health sector has been challenging. There are currently no indoor residual spraying 
(IRS) activities, and case investigation and follow-up occur only in outbreak scenarios. The current first-
line treatment for uncomplicated P. falciparum malaria is AL with SLD-PQ, however the use of SLD-PQ is 
a new policy that has not yet been widely implemented. 
 
Multiple other partners are currently working in districts in Champasak. Clinton Health Access Initiative 
(CHAI) has been supporting supply chain management from national to district level through the mSupply 
system, and this is expected to expand to cover all districts in Champasak during the coming year. In 
addition, CHAI plans to place support staff at the provincial level in Southern Lao PDR to provide day-to-
day support and technical assistance to strengthen the capacity of provincial and district staff, including 
in the four target districts in this study. 
 
PSI recently launched a public-private mix (PPM) intervention project at selected private-sector facilities 
in five southern provinces in Lao PDR, including Champasak. This project provides financial, technical, and 

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managerial support to PPM network sites using a passive case detection strategy with real-time 
smartphone or tablet-based reporting of malaria cases. Scale-up is underway to potentially cover all clinics 
and pharmacies in this study’s project districts. 
 
A malaria post initiative funded by the Regional Artemisinin-resistance Initiative – Inter-country 
Component (RAI-ICC) and implemented by HPA was designed to pilot early diagnosis and treatment 
(EDAT) and enhanced surveillance in known malaria hotspots along the Lao PDR-Cambodia and Lao PDR-
Thailand borders in Champasak. Included in this package of work is the establishment of malaria posts in 
hard-to-access forest areas (which otherwise lack access to formal healthcare); the distribution of forest 
survival kits to forest-goers and military personnel; EDAT training for malaria post volunteers (MPVs) and 
military nurses; and the provision of mobile phones to improve surveillance and commodity stock-out 
reporting. These forest kits include RDTs, AL drug treatments, mosquito repellant, flashlight/torch, 
paracetamol, bandages, gloves, and oral rehydration solution (ORS), among other supplies; however no 
mosquito nets are provided. While ICC ends in June 2017, continuation of these same activities has been 
requested in the latest Global Fund application and activities will resume, if approved, in early 2018. Only 
a subset of the 48 functioning malaria posts currently distribute the forest kits, but there are plans to 
expand this intervention in early 2018 to all 48 posts if the Global Fund approves the funding request.  
 
HPA’s other activities in Champasak include training, mobilization, and provision of incentives for VMWs; 
intensified active case detection in remote areas and development project sites; international border 
screening points; efforts to increase cross-border coordination; and malaria education campaigns in 
schools and through the Lao Women’s Union. 
 
Two qualitative studies have recently been completed in Southern Lao PDR to explore malaria-related 
knowledge and behavior in HRPs. A mixed-methods study was implemented in three provinces (Attapeu, 
Champasak, and Sekong) in Southern Lao PDR in 2015 [21] by HPA with assistance from UCSF and CHAI. 
A total of 189 HRPs were interviewed; of which two-thirds were of Lao origin, 31% were Vietnamese, with 
smaller numbers of Chinese, Cambodians, and Thais [21]. HRPs in these areas were found to be 
contactable, had diverse occupations and origins both within and outside of Lao PDR, and were highly 
welcoming of any health-based interventions due to reported limited access to services. 
 
Subsequent formative studies through a partnership of UCSF, HPA, and CMPE in late 2016 expanded on 
these findings, and suggest a dynamic situation in Southern Lao PDR. Specifically, forest-going lifestyles 
have been impacted by depletion of hardwood and wildlife within forests due to widespread logging and 
hunting, as well as the recent government ban on logging. Villagers generally stated that free testing was 
a sufficient incentive for participation in test and treat activities, but health staff reported needing 
incentives to conduct active case detection activities. These studies also suggest that people with fever, 
whether coming from the forest, village, or field, know that malaria testing is readily available in both the 
government and private sectors. The findings from these assessments have been used to inform and fine-
tune the sampling approaches, study population, eligibility criteria, logistical operations, and potential 
population entry points for this study. 
3.2 Interventions 
Previous work in Lao PDR suggests that the highest-risk populations generally have exposure to forest 
sites or forest-fringe farms, yet there are currently limited mechanisms within national guidelines to 
actively target these HRPs for screening and/or malaria testing.  
 

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The aim of this study is to assess the impact of two active case detection interventions using HS-RDTs: 
MTAT amongst village populations, and peer navigator-directed FTAT to target forest- and non-village 
based HRPs. Together these interventions aim to target the entire P. falciparum reservoir.  
3.2.1 Village-level mass test and treat with HS-RDTs (MTAT-HS) 
The village-level test and treat intervention will be implemented in three rounds during the period January 
2018-October 2018. The three rounds will be conducted with at least one month separation between 
rounds, and not conducted during months with traditionally heavy rains, or during major crop harvesting 
periods, when large numbers of individuals may not be available during household visits. The preliminary 
timing for this three-round schedule is January, May, and August 2018.  
 
Communities will be notified of the scheduled test and treat activities in advance to promote high levels 
of participation. In selected villages, all households will be visited by a MTAT team comprised of local 
district, health center, and village malaria staff, who will administer a short demographic and malaria risk 
factor survey to the head of household, and invite all household members aged >18 months to participate 
in RDT and HS-RDT testing. The survey responses will be used to assess whether any household members 
may be at higher risk for malaria, and may be developed in future MTAT rounds to serve as a screening 
form. 
 
Testing strategy and operations: village-based MTAT-HS 
At three time points during the year, MTAT teams comprised of local district, health center, and VMW 
staff will conduct test and treat activities in all intervention villages within a single calendar month. The 
sample frame will consist of all permanent households within villages; study teams will meet with village 
authorities before each intervention round to update all village-level household registers.  
 
Teams will attempt to visit 100% of households in intervention villages during each round for testing and 
treatment of any positive cases. If based upon HS-RDT results and survey findings from the first two rounds, 
it is determined that the bulk of infected individuals have specific risk factors, a screening and treatment 
approach may be adopted whereby in the third round, individuals are initially screened and only those 
reporting specific risk factors are tested.  
 
Individual consent will be obtained at each household and for each blood sample collected for testing. A 
finger stick blood sample will be collected for each consenting individual for testing with the HS-RDT, 
standard SD Bioline Pf/Pv RDT, and four blood spots on filter paper (baseline, end-line surveys and one 
MTAT round). Household members and parents/guardians of children will be verbally informed of the 
general purpose of the intervention and the study, and the possible risks and potential benefits associated 
with participation. All informed consent procedures will be conducted in the appropriate local language, 
and participants will be provided with a copy of the consent form with study contact information. 
Participation in either the surveys or the intervention rounds is voluntary. For children <6 years old, 
malaria testing will be based on consent from the parent or guardian. For children 6 to <18 years of age, 
the child’s oral assent will also be required.  
 
In the event that household members are not present at the time of testing, the MTAT team will ask if any 
absent household member has been ill with fever during the previous two weeks. If any absent household 
members are reported as having recent fever history or if any other household members test positive for 
malaria, the VMW will schedule a time to revisit the household. At this time, the VMW will administer the 
informed consent form to any previously absent household members and then test these individuals (and 

Protocol Amendment – 05 November 2017         
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treat positive cases). All individuals testing positive during the initial household visit will receive immediate 
treatment, as detailed below. 
 
All individuals with suspected severe malaria or other severe illness as assessed by the MTAT team 
(including those with symptoms of severe anemia, prostration, impaired consciousness, respiratory 
distress, convulsions, circulatory collapse, abnormal bleeding, jaundice or passing dark urine) will be 
referred to the nearest health facility for clinical assessment and treatment.  
 
All individuals who have provided informed consent, test positive by either HS-RDT or standard RDT, are 
≥18 months old, are not pregnant or breastfeeding (see below), and who do not have symptoms 
associated with severe malaria or another severe illness, will be offered an age-appropriate course of AL 
(age-specific blister packages) and SLD-PQ according to national treatment guidelines [23]. 
 
Table 4. National guidelines for AL treatment 
 
 
Age group 
 
 
Body weight 
(kg) 
 
 
Dose given daily  
for 3 days 
 
6 months – 5 years 
5 to < 15 
 1 tablet 2x per day 
6 – 11 years 
15 to < 25 
 2 tablets 2x per day 
12 – 14 years 
25 to < 35 
 3 tablets 2x per day 
15 years and over 
35 and over 
 4 tablets 2x per day 
Note: all tablets are standardized at 20 mg artemether + 120 mg lumefantrine in age-specific blister packs. 
 
All women with a positive HS-RDT or RDT test who are unsure of their pregnancy status will be offered a 
human chorionic gonadotropin (hCG) rapid pregnancy test. Women meeting any of the following criteria 
will be assumed to be in the first trimester and referred to the closest health center for treatment 
according to the national treatment guidelines (Table 5) [23]:  
 
• 
Any woman declaring that she is in her first trimester of pregnancy, or who requests to 
receive quinine instead of AL; 
• 
Any woman reporting that she is pregnant (or established by a positive rapid pregnancy 
test) of less than 3 months; 
• 
Any woman reporting that she is pregnant (or established by a positive rapid pregnancy 
test) and reports no quickening. 
 
Use of SLD-PQ is contraindicated for all women who may be pregnant or who are breastfeeding. 
Consequently, all women of reproductive age with a positive HS-RDT or RDT for P. falciparum will be 
offered an hCG rapid pregnancy test by study staff. All women with a positive hCG test or who choose not 
to be tested will not be given SLD-PQ, but treated with only AL as per national guidelines. It will be 
emphasized during all field team trainings that SLD-PQ can only be given to women of reproductive age 
with a confirmed negative hCG test. 
 
Table 5. National treatment guidelines for pregnant women in Lao PDR 
 
 
P. falciparum only 
P. vivax only  
Mixed P. falciparum/P. vivax 

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First trimester 
Quinine 30 kg/mg/day 
for 7 days 
Chloroquine 25 mg/kg/day  
(divided in 3 days) 
 
- Day 1: 10 mg (base)/kg/day, 
once a day  
- Day 2: 10 mg (base)/kg/day, 
once a day 
- Day 3: 5 mg (base)/kg/day, 
once a day 
Quinine 30 kg/mg/day   
for 7 days 
Second or  
third trimester 
AL for 3 days 
AL for 3 days 
AL for 3 days 
 
Age and weight dosing regimens for national SLD-PQ treatment guidelines have not yet been finalized by 
CMPE/MOH, but are expected to follow standard WHO recommendations based on body weight [24]; 
age-based dosing has also been developed for use in Cambodia [25] but this has yet to be endorsed by 
the WHO. Measurement of lower doses is challenging due to the physical size of 15-mg tablets, and 
therefore SLD-PQ will not be administered to children weighing less than 10 kg. MTAT teams will be 
provided with scales to weigh all eligible participants in order to determine the correct SLD-PQ treatment 
dose.  
 
 
 
 
Table 6. Single low-dose primaquine dosing guidelines 
 
Body weight (kg)  
(WHO [24]) 
SLD-PQ dose (mg)  
(as base) 
Age (years) 
(Ref [25]) 
SLD-PQ dose (mg)  
(as base) 
< 10 kg 
No treatment 
0.5 – 4 
2.5 
10 to < 25 
3.75 
5-9 
5 
25 to < 50 
7.5 
10-14 
7.5 
50 to 100 
15 
≥ 15 
15 
 
A treatment guide based upon HS-RDT and RDT results for all individuals excluding pregnant and 
breastfeeding women and children <18 months is shown in Table 7. 
 
Table 7. Treatment decision guide for RDT and HS-RDT results 
 
RDT       
Pf / Pv  
HS-RDT 
results 
Action 
(+ +)    
(+) 
Treatment aligned with national guidelines for mixed species infections:                         
ACT (AL) with referral to district hospital for G6PDd testing  
(+ -)    
(+) 
Treatment as per national guidelines for P. falciparum infections:                                       
ACT (AL) including SLD-PQ 
(- -)    
(+) 
Treatment aligned with national guidelines for P. falciparum infections:                           
ACT (AL) including SLD-PQ  
(- +)    
(+) 
Treatment aligned with national guidelines for mixed species infections:                         
ACT (AL) with referral to district hospital for G6PDd testing 

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(- +)   
(-) 
Treatment aligned with national guidelines for P. vivax infections:                                          
ACT (AL) with referral to district hospital for G6PDd testing 
(+ +)   
(-) 
Treatment aligned with national guidelines for mixed species infections:                          
ACT (AL) with referral to district hospital for G6PDd testing. 
(+ -)   
(-) 
Treatment as per national guidelines for P. falciparum infections:                                      
ACT (AL) including SLD-PQ 
(- -)    
(-) 
No treatment 
3.2.2 Peer navigator-led FTAT with HS-RDTs 
In Lao PDR, several types of health workers may also be forest-goers. Specifically, some VMWs/VHVs, and 
many malaria post volunteers, fulfill criteria for working as peer navigators (PNs), and have been trained 
by the national program to perform RDT-based testing. These health staff may be directly recruited or 
may be twinned with other forest-goers for the PN activities. Efforts will be made to recruit PNs fluent in 
Lao, Khmer, local languages, and potentially Vietnamese, wherever possible. 
 
PN inclusion criteria include: 
• 
At least 18 years of age 
• 
Has resided in health center catchment area for at least the past six months 
• 
Shared socioeconomic level and racial/ethnic identity with target HRPs 
• 
Fluent in Lao and preferred proficiency in second local language (minority, Khmer, Vietnamese) 
• 
Currently engaged in forest or field-based livelihood activities in target districts 
• 
Literate and capable of administering informed consent 
• 
Available for full-time employment as a PN and ability to travel via motorbike  
• 
Highly familiar with health center catchment area geography and mobility/access routes 
• 
Previous experience with malaria testing and treatment preferred, or interest and willingness to 
learn and undergo training by CMPE 
 
The number of PNs recruited per HCCA will depend on the overall population size of the catchment, the 
malaria incidence, proximity to forest fringe and plantations including rice fields, and the estimated level 
of HRP activity in the area. On average, two teams each consisting of two PNs will be recruited for each 
intervention catchment area, totaling 28 PNs across the 7 intervention HCCAs. The 28 PNs will be allocated 
to HCCAs based on a combination of forest area and population to have roughly equivalent intervention 
effort per forest-going population in each HCCA. 
 
PNs will be recruited for a 10-month period and provided with an initial comprehensive training followed 
by ongoing refresher courses throughout the implementation period. Training topics will cover proper 
informed consent procedures, data collection, ethical issues related to marginalized populations, the 
handling and use of RDTs, collection and storage of blood samples, provision of treatment to positive P. 
falciparum and P. vivax cases, referral of P. vivax cases for G6PD testing, and recognition of severe 
symptoms of illness or any adverse effects. 
 
PNs will actively seek non-village based HRPs in forested areas, rice fields and plantations, and any other 
non-permanent settlements within target HCCAs, and conduct FTAT among all consenting individuals. By 
conducting continuous FTAT, IEC/BCC, and providing direct linkages between the target population and 
the formal public health sector, PNs aim to improve local HRPs’ access to malaria testing, treatment, and 
information. 
 

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Specifically, PN responsibilities are expected to include the following (however tasks may be refined over 
time as opportunities and capacities are better understood): 
 
• 
Identify potential HRPs in non-village sites in designated HCCAs on a continuous basis and obtain 
informed consent for the FTAT intervention  
• 
As part of the FTAT intervention, administer a demographic and risk factor survey to the HRP 
participant to capture information on occupations and related exposures, travel history, 
intervention coverage, treatment-seeking behaviors, and acceptability and perceptions of FTAT 
• 
Measure axillary temperature and perform standard RDT and HS-RDT on all consenting 
individuals; dried blood spots (DBS) will also be collected on all HRPs where feasible 
• 
Administer treatment to any HRP testing positive by RDT or HS-RDT in accordance with 
guidelines outlined in Table 7 
• 
Refer all P. vivax cases to the nearest district hospital for G6PDd testing and follow-up treatment 
• 
Refer individuals with any severe symptoms or danger signs to nearest health facility for clinical 
assessment and treatment (PNs to undergo training on recognition of severe symptoms) 
• 
Query all HRPs on estimated HRP population size (‘wisdom of the crowds’ method - whereby, in 
aggregate, individuals can estimate the total number of people like themselves) 
• 
Provide identified HRPs with a study ID card for identification across arms and at health facilities 
• 
At the consent of surveyed HRPs, geo-locate locations where FTAT activities take place 
• 
Use a GPS logger to track where and when peer navigators conduct FTAT activities  
• 
Invite a subset of forest-goer HRPs (especially those who are RDT-positive) to carry a GPS logger 
to track their spatial and temporal movement patterns; Facilitate retrieval of loggers through 
follow-up with participating HRPs 
• 
Use IEC/BCC materials to provide malaria and general health information to all HRPs, and 
pinpoint nearest health facilities based on FTAT location for future care-seeking or treatment 
• 
Provide personal contact information card with mobile phone number to all HRPs and 
encourage outreach if any questions or support for navigation/linkage to care is needed 
• 
Invite HRPs (particularly those testing positive) to provide their contact information and that of 
their peers to allow for follow-up and exchange of information on potential sites for FTAT 
activities 
• 
Work with HC workers to follow up on any of these social contacts who may be at higher risk for 
malaria infection 
• 
Provide HRPs with a small token of appreciation for their participation (e.g., rechargeable torch) 
 
Targeting strategy and operations: forest-based FTAT 
PNs will target HRPs in forested and forest fringe areas, rice field regions, plantations, and in any informal 
settlements through three general mechanisms: 
 
i. 
Study health staff will first work with PNs in each HCCA to map out the boundaries of their 
assigned HCCA using specific natural boundaries and other landmarks to define the area within 
which they are working. 
ii. 
As piloted by HPA during formative studies, PNs will inquire about any potential HRP informal 
settlement locations or travel routes in study areas from all health staff, including HCs and 
village malaria posts. PN teams will then travel to these sites and assess any persons in these 
areas for inclusion, plus will gather any knowledge of other informal settlements or work sites in 
close proximity. Additionally, as optimal overnight sites in forest areas may be reused by 

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different forest-based groups, local knowledge will be used to target these areas for visits by PN 
teams. 
iii. 
Prior to project implementation, HC staff and VMWs will be retrained to ensure capture of 
relevant data from any non-village based persons presenting for malaria testing; while detailed 
locations or coordinates will not be possible, any geographic location should be captured.  
iv. 
On a biweekly basis during the study period, PN supervisors will contact HCs in target areas to 
review facility listings for any HRPs from potential non-village settings. Within health centers, all 
fever cases will be asked if they have spent any nights in the forest or rice fields in the past 
month. Cases who report recent forest or rice field travel will be asked to provide contact 
information for any persons they travelled or worked with. 
v. 
PN supervisors will arrange weekly mobile phone calls to support the PNs, address any urgent 
issues, and relay any up-to-date HRP information collected from HC staff. Every two weeks, the 
PNs will have a face-to-face meeting with their supervisors to rest, assess coverage and intensity 
of field activities to address any potential issues, map any forest sites, and plan the ensuing 
testing activities. This period will also allow for collection of any DBS samples collected and 
replenishment of field supplies. PNs will be incentivized through a monthly stipend, but per-
capture payments or quotas will not be utilized to minimize potential biases in data collection. 
GPS loggers will be carried by PNs to track their movements, and periodically reviewed by field 
staff to ensure adherence to HCCA boundaries and comprehensive coverage of target area.  
vi. 
Throughout the study period, PNs will conduct forest-based testing and treating on a semi-
continual basis, staying at field sites and forest encampments whenever possible.  
vii. 
If geographic overlap is evident between the two teams operating in the same HCCA, study staff 
will work with PNs to ensure comprehensive coverage of the HCCA area. 
viii. 
All HRPs contacted and enrolled will also be asked if they are willing to provide contact 
information for any other forest-goers related or known to them (especially those they have 
travelled with recently) for active follow-up by PNs. 
 
At all of the sites visited, PNs will actively seek out any groups of persons like themselves (to be carefully 
defined during pilot testing) within defined and specific HCCAs, using GPS loggers to minimize spillover to 
adjacent areas (defined buffer zones will be delineated based upon HCCA mapping activities). The eligible 
study population will include all persons aged 15 years and older approached at any non-village sites 
within the defined HCCAs who spent at least one night outside a formal village in the past one month, 
including individuals traveling into the HCCA who are willing and sufficiently able to communicate with 
PNs to assess their eligibility. Treatment regimens will follow those under protocol section 3.2.1. 
 
While the intensity and weekly schedules of FTAT activities will likely vary depending on seasonal patterns 
of crop harvesting and forest-going, PNs will be encouraged to continuously rotate throughout their 
designated HCCA in search of HRPs, drawing on information generated by HCs, VMWs, MTAT surveys, and 
previously-surveyed HRPs. The generation of unique personal identifiers using a combination of 
participant mobile phone numbers, age or date of birth, home village, and initials will allow for 
identification of any persons retested throughout the study period. When residents of villages within the 
HCCA are identified by PNs, PNs will identify the name of the home village and if possible obtain a GPS 
location for the individual’s home.  
3.2.3 Adherence and safety monitoring 
Employing directly observed therapy on day 0 for both intervention arms will aim to maximize adherence 
with treatment. On day 0 of the household visits for the village MTAT intervention, and on day 0 for peer-
navigator identified individuals, treatment with AL-PQ will be provided for all eligible individuals testing 

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positive by HS-RDT or RDT, and directly observed by the field team. Adherence to the full 3-day treatment 
course will be assessed for one round of village MTAT, whereby a list of all HS-RDT/RDT positive individuals 
administered treatment will be created and all individuals visited to assess completion of treatment and 
any side effects. Trained study staff will visit treated participants within 3-8 days of receiving the first 
treatment dose, and ask a series of questions to determine adherence with each dose, number of 
remaining tablets, and reasons for non-adherence or treatment refusal (Appendix T). Throughout the 
study period, any potential adverse events (AEs) will be referred to the nearest health center and 
documented as per 4.2 below.  
3.3 Study evaluation methods 
3.3.1 Overview of evaluation activities by study objectives, outcomes, and data collection 
activities 
 
The study evaluation activities are linked to specific research objectives, outcomes, and data collection 
activities, as summarized in Table 8 below. 
 
 
 
 
 
 
Table 8: Overview of study outcomes and data collection activities 
 
Study 
Research objective 
Primary outcome 
Data collection activity 
Activity 1: Impact 
evaluation of test 
and treat 
interventions using 
HS-RDTs 
1. 
Evaluate the relative 
effectiveness of 3 rounds 
of MTAT-HS in village-
based populations using-
AL-PQ, as compared to 
control, and the 
combination of MTAT-HS 
in villages and 
continuous FTAT in 
forest-based HRPs 
compared to control 
P. falciparum prevalence in all 
persons aged >18 months 
Cross-sectional parasite 
surveys (November 2017 
and October 2018) 
Total and confirmed outpatient 
(OPD) P. falciparum malaria case 
incidence among all ages, matched 
to village by name 
Routine malaria data from 
all reporting sites in districts 
(health centers, PPM sites, 
and district hospitals) 
HS-RDT and RDT test positivity 
rate 
HS-RDT and RDT positivity 
data from village based 
MTAT-HS  
2. 
Evaluate the relative 
effectiveness of routine 
continuous FTAT in 
forest-based HRPs using-
AL-PQ, as compared to 
standard of care 
Total and confirmed outpatient 
(OPD) P. falciparum malaria case 
incidence among all ages at the 
health facility level 
Routine malaria data from 
reporting sites in districts 
(health centers, PPM sites, 
and district hospitals) 
HS-RDT and RDT test positivity 
rate 
HS-RDT and RDT positivity 
data from FTAT in 
forest/rice-field based HRPs 
3. 
Assess and compare cost 
and cost-effectiveness of 
village-based and peer-
navigator based case 
detection activities  
Cost using standard procedures for 
costing methods and cost-
effectiveness [27] and will be 
based on a health-sector 
(provider) perspective. 
Program data on cost 
combined with estimates of 
program effectiveness 

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4. 
Assess sensitivity and 
specificity of HS-RDTs 
relative to standard RDTs 
and to PCR-based 
parasite detection 
P. falciparum prevalence by each 
testing methodology 
Cross-sectional parasite 
surveys November 2017 and 
October 2018 (PCR, HS-RDTs 
and RDTs); village MTAT and 
forest-based FTAT surveys 
(HS-RDTs and RDTs) 
5. 
To determine the 
effectiveness of test and 
treat activities on 
reducing P. vivax 
prevalence and incidence 
 
P. vivax prevalence in all persons 
aged >18 months 
Cross-sectional parasite 
surveys (November 2017 
and October 2018) 
Total and confirmed outpatient 
(OPD) P. vivax malaria case 
incidence among all ages, matched 
to village by name 
Routine malaria data from 
all reporting sites in districts 
(health centers, PPM sites, 
and district hospitals) 
Activity 2: 
Assessment of the 
feasibility and 
acceptability of 
MTAT and FTAT 
interventions as 
perceived by the 
health-sector, 
communities, HRPs, 
peer navigators, and 
study staff 
1. 
Assess the acceptability, 
feasibility, support for, 
and participation in the 
MTAT/FTAT interventions  
Proportion of survey respondents 
who strongly disagree, disagree, 
are ambivalent, agree and strongly 
agree on the importance and 
acceptability of community-based 
MTAT 
Cross-sectional surveys and 
qualitative studies at end-
line with health sector staff 
including VMWs and study 
staff 
Proportion of HRP survey 
respondents who strongly 
disagree, disagree, are ambivalent, 
agree and strongly agree on the 
importance and acceptability of 
peer navigator-based FTAT 
Peer navigator directed 
FTAT surveys; interviews 
with participating HRPs 
 
Proportion of peer navigators who 
rate conducting the FTAT 
intervention as very easy, 
somewhat easy, somewhat 
difficult, and very difficult, and 
changes in proportions over time 
Entrance, mid-FTAT, and exit 
interviews with peer 
navigators; focus group 
discussion with peer 
navigators at end-line 
2. 
Assess the capacity of 
peer navigators to 
conduct FTAT, and their 
confidence in ability to 
perform FTAT functions 
 
Proportion of peer navigators 
receiving a ‘pass’ score on 
competency checklist during FTAT 
observation by supervisor, and 
change in proportion of ‘pass’ 
scores over time; 
 
Supervisor observation of 
peer navigators conducting 
FTAT and scoring of 
competencies using 
checklist; FTAT survey data 
including peer navigator 
adherence to diagnosis, 
treatment, and referral 
guidelines 
Proportion of peer navigators 
rating their confidence in 
conducting the FTAT intervention 
as very low, low, moderate 
(confident), and high, and changes 
in proportions over time 
Entrance, mid-FTAT, and exit 
interviews with peer 
navigators; focus group 
discussion with peer 
navigators at end-line 
Activity 3: Estimate 
population size of 
forest-based HRPs 
1. 
Estimate the total forest-
based HRP population in 
targeted health center 
catchments 
 
Total population size estimates 
triangulated through three 
separate estimations (‘wisdom of 
the crowds’, single-source 
capture-recapture, and double-list 
capture-recapture.) 
Peer navigator directed 
FTAT surveys. 

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Activity 4: Explore 
demographic and 
geographic 
predictors for G6PDd 
testing referral 
adherence among 
positive P. vivax RDT 
cases 
2. 
Determine risk factors for 
non-adherence for 
G6PDd testing at district 
hospital sites after 
referral 
Proportion of symptomatic and 
asymptomatic referred cases 
presenting at district hospital for 
G6PDd testing. 
Village-based MTAT surveys; 
peer navigator directed 
FTAT surveys; district 
hospital facility records. 
 
3.3.2 Activity 1 - Evaluation of test and treat using HS-RDTs 
3.3.2.1 Study design 
To meet the overall aim and objectives, this study will employ a cluster-randomized control trial (CRCT) 
and randomize the interventions in two separate stages in a split-plot design (Figure 2 and Table 9). 
 
Figure 2. Schematic of split-plot study design 
 
 
 
A split-plot design [28–30] allows for randomization at two different scales, allowing one set of 
treatment/control (‘sub-plot’) areas to be nested within the second set of treatment/control areas (‘whole 
plot’). In this design, the first level, or ‘whole plot’ is often an intervention that is difficult operationally to 
conduct at a lower level. Randomization at two different spatial scales is necessary within this study, as 
PNs will be operating in areas between villages, so randomization at the village level will not be feasible. 
Conversely, the test and treat campaigns will be organized at the village level to maximize the number of 
units available for randomization to ensure adequate study power. The split-plot design allows for greater 
power to detect differences in sub-plot effect sizes as well as the interaction between sub-plot and whole 
plot. 
3.3.2.1.1 Randomization 
 
Randomization 1: Health center selection and randomization 

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A total of 14 HCCAs will be selected for inclusion based upon HCCA-level API and distance between HCCAs. 
HCCAs with higher API will be prioritized to improve power; where possible, directly neighboring HCCAs 
will not both be included to reduce contamination. Restricted randomization of the 14 HCCAs into either 
PN or control arms will be conducted, whereby HCCAs will first be matched into strata based upon HCCA-
level API, population size, amount of forest cover, and non-contiguity of opposite arms. Within matched 
strata, the random allocation rule will be used to assign 7 HCCAs each to the PN or control group. 
Restricted randomization in this way will ensure balance across intervention and control groups on 
potential confounding factors. The ‘sample’ command in Stata v14 (StataCorp, College Station, TX) will be 
used to implement randomization. 
 
Randomization 2: Village selection and randomization 
All villages within selected HCCAs will be mapped and restricted randomization conducted for 28 villages 
from among each of the two HCCA arms from randomization 1 (PN FTAT or control). Randomization 2 will 
randomize the 56 total study villages to either MTAT or control (no MTAT intervention). 
 
For each arm of randomization 1, suites of 28 villages that maximize distances between villages and/or 
include non-study buffer villages will be generated. From amongst these sets, a single set of 28 villages 
will be randomly selected for each arm of randomization 1.  
 
A baseline survey will be performed approximately one month prior to implementation of interventions 
(described below). As baseline demographics and parasitemia are expected to vary widely across the 
study area, these survey data will be used to provide a well-balanced set of clusters. Restricted 
randomization of the 28 villages within each arm to either MTAT or control will be conducted, whereby 
villages will first be matched into strata based upon population size, distance to nearest forest, distance 
to health facility, parasite prevalence, intervention coverage, and other key covariates. The ‘sample’ 
command in Stata v14 (Stata Corp, College Station, TX) will be used to implement randomization. 
 
Table 9: Split-plot community randomized controlled trial design 
 
Study arm 
Treatment 
group 
Intervention description  
Number of 
HCCAs 
Number of 
villages/village 
clusters per arm 
In health center catchments without peer navigators (total of 7 HCCAs) 
1A 
Village-based 
test and treat 
All members of target household population will be 
offered RDT-based testing with standard and HS-
RDTs, with anyone testing positive for malaria with 
any RDT offered treatment with AL + SLD-PQ for 
clearing asexual and sexual stage parasites*  
 
 
 
 
7 
14 
1B 
Control 
Standard of care 
 
 
 
14 
In health center catchments with peer navigators (total of 7 HCCAs) 
2A 
Village-based  
test and treat 
All members of target household population will be 
offered RDT-based testing with standard and HS-
RDTs, with anyone testing positive for malaria with 
any RDT offered treatment with AL + SLD-PQ for 
clearing asexual and sexual stage parasites,* overlaid 
with peer navigator-based test and treat. 
 
7 
 
14 

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2B 
Control 
Standard of care, overlaid on peer navigator-based 
test and treat. 
 
 
 
14 
 
* Excluding children <18 months and women who are pregnant, who believe they may be pregnant, or who are breastfeeding. 
 
If possible, a public event will be held during which village elders randomize the units for full transparency 
of intervention allocation [31]. 
 
Allocation concealment 
After allocation, the specified interventions will be implemented in HCCAs and villages, but assignments 
will not be blinded to participants or investigators due to the nature of the interventions. However, all 
efforts will be made to ensure data collection teams will be blinded to these allocations for the end-line 
cross-sectional survey. For analysis of all primary outcomes the study assignment arm will be blinded by 
use of concealed codes within the final dataset. 
3.3.2.2 Primary outcome measures 
 
1. Community-level PCR-based P. falciparum parasite prevalence in sampled villages: defined as 
the proportion of individuals >18 months old with P. falciparum infection (detected by PCR) out 
of all individuals >18 months tested within the 2017 and 2018 surveys. 
2. HS-RDT-based test positivity rate in village-based and forest-based samples: defined as the 
proportion of all individuals tested by HS-RDT at each round of the MTAT interventions or during 
routine FTAT, with a positive HS-RDT, among the population older than 18 months. 
3. Village-based population coverage of test and treat interventions: this indicator will be 
measured in two ways for each round of village MTAT. Operational program coverage is defined 
as the proportion of individuals ≥18 months old and households visited and offered the MTAT 
interventions within the target areas. Effective program coverage is defined as the proportion of 
individuals (≥18 months old) that agreed to participate in the MTAT intervention among all 
individuals ≥18 months old eligible to participate in the intervention in the target population.  
4. Community-level confirmed P. falciparum malaria parasite incidence: defined as the number of 
OPD malaria confirmed and suspected cases per person per year for each village, as ascertained 
from the health facility registers, utilizing village population size estimates for the exposure 
denominator. 
3.3.2.3 Sample size 
The study design is constrained by the number of villages and HCCAs available for randomization. The 
maximum number of health center catchments available is roughly 28, as other health center catchments 
currently have multiple partners implementing. Within these 28 HCCAs, there are a total of roughly 230 
villages (5-10 villages per HCCA). Within the 14 highest API HCCAs to be randomized at the first stage, 
there are 121 villages, of which 56 will be randomized. 
 
The primary outcome will be based on comparing differences in parasite prevalence between intervention 
and control areas; while confirmed incidence will be a secondary outcome, it will not be used to determine 
sample sizes, as there are limitations with case diagnosis and reporting within the Lao public health sector. 

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3.3.2.3.1 Community-level malaria parasite prevalence 
The number of village clusters and size needed for valid statistical comparisons was calculated using a 
simulation-based approach, as direct analytical methods have not been developed for a split-plot cluster-
randomized trial [32]. Simulations were performed using R software [33] and the sim.glmm- package [34]. 
Power calculations for varying numbers of health facilities, villages, and sample sizes per village are shown 
in Appendix I.  
 
Sample size for the primary evaluation at the end-line survey was determined based on the power to 
detect a difference between MTAT and control, as well as between MTAT combined with PN FTAT and 
control, assuming a 30% reduction in prevalence in PN areas compared to control. With an assumption of 
4% P. falciparum prevalence via standard PCR (or uPCR – to be determined following baseline survey) and 
a between facility and village variance of 0.10, in order to detect a 50% difference in the prevalence of P. 
falciparum between MTAT and control, with 80% power at a 5% significance level, a total of 14 village 
clusters per arm (for a total of 56 villages across all arms) with 150 persons sampled per cluster (30 HH, 
average HH size of 5) are required, amounting to a minimum total sample size of 8,400 persons, or 1,680 
households for the end-line survey. To account for potential non-response rates of 10% at the HH-level, a 
total of 1,848 households, or 33 per village, will be sampled.  
 
This total sample size will permit an independent comparison between the village-level test and treat 
intervention and control, as well as the comparison between the combined village and PN test and treat 
interventions and control. These power calculations assumed a realistic 30% reduction in prevalence 
based upon the PN intervention independently; while the trial will not have adequate power to detect 
this level of difference, a reduction of 50% is detectable.  
 
Sample size for the baseline survey is based on the precision for comparisons of primary outcomes by arm 
at baseline. Using the 56 selected villages, a total of 20 households will be sampled per cluster (100 
individuals, average HH size of 5), amounting to a minimum total sample size of 1,120 households and 
5,600 persons for the baseline survey. To account for potential non-response rates of 10%, a total of 1,232 
households and 6,160 persons will be sampled. With an assumed P. falciparum prevalence of 4.0%, and 
3,080 sampled per arm, this sample size will provide precision of 4.0% (95% CI: 3.3-4.7%; binomial exact) 
in each arm. 
3.3.2.3.2 HS-RDT test positivity during interventions 
Test positivity by HS-RDT will be monitored for all rounds throughout the intervention period. There is no 
formal sample size calculation for this outcome, as all residents of selected villages will be enrolled. Per 
round, an estimated 22,000 individuals will be tested. 
 
There are currently no estimates of the total number of non-village-based HRPs in Lao PDR. However, 
assuming that parasitemia in these high-risk individuals will be approximately 5% by any RDT (assuming 
consistent numbers with previous data from higher transmission periods of 11.5% by PCR; and 8% by 
standard RDT [11]), with a target to enroll a minimum of 2,000 forest-working HRPs over the course of 
the study, this will provide an estimate of 5% (95% CI: 4.1 – 6.0%; binomial exact) for parasite positivity 
by RDT over the course of the study. These values will help to quantify the relative burden of parasitemia 
in HRPs compared to the village populations for better targeting of interventions.   
3.3.2.3.3 Community-level confirmed P. falciparum malaria parasite incidence 
The confirmed parasite incidence from all reporting units (including HCs, district hospitals, VMWs with 
RDTs, and PPM sites) will be captured throughout the study with support from study staff. In the months 

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prior to the start of study activities, all villages will be mapped, and trainings conducted with health facility 
staff to systematize the collection of village names at health facilities for confirmed malaria cases. Routine 
supervision of health facility staff will be conducted to ensure accurate recording of village names in health 
facility registers throughout the trial.  
 
Using simulation-based sample size calculations with Poisson-distributed annual case counts per village, 
an expected baseline P. falciparum-specific API of 6 per 1,000, with 14 HCCAs, a between village 
coefficient of variation of 0.004, a between facility variation of 0.003 (Lao stratification database, variance 
of API across all included HCCA  = 0.0039), and an average village population size of 750 (750 person-years 
of follow-up), the study will be adequately powered at 0.90 to detect a 50% reduction in P. falciparum 
incidence for the test and treat intervention, and at 0.80 to detect a combined 50% reduction due to 
village-based test and treat, and a 30% reduction due to PN test and treat. 
3.3.2.4 Data collection 
3.3.2.4.1 Cross-sectional surveys 
At the baseline and end-line, cross-sectional surveys will be conducted to obtain an unbiased estimate of 
P. falciparum malaria parasite prevalence in each study arm (November 2017 and October 2018). The 
baseline survey will be used to obtain baseline demographics, intervention coverage, and both standard 
and HS-RDT-based parasite prevalence to inform restricted randomization of study villages, and to assess 
the prevalence of any HRP2/3 deletions. The end-line survey will also test with both RDTs, but will be 
focused on the primary outcome for the overall study using PCR-based testing. 
 
Sampling frame and sampling strategy 
Within each of the 56 villages selected for study inclusion, survey staff will work with village authorities 
to update household ledgers, and then all households within each village will be enumerated and a GPS 
point captured. All households will be given a study ID card and household sticker with a unique barcode, 
which will be used throughout the study to identify repeat visits at each household, as well as for 
individuals to present at health facilities if they report for care. 
 
In order to reduce potential contamination due to proximity to intervention areas (for the control arm), 
households within 2 km of a neighboring study village will be removed from the sampling frame. For each 
of the 56 villages, households will be selected via simple random sampling from the remaining HH lists.    
 
Questionnaires and human specimen collection 
During each survey, selected households will be visited and the head of household interviewed by a study 
staff member using a tablet or paper form. To capture any household members not present at time of 
survey, study staff will plan for an overnight stay whenever feasible to schedule visits for early morning 
or late evening, but will have a maximum of four visits to each HH. The survey questionnaire used for 
interviewing will be developed in English with input from local health staff. This will then be translated to 
Lao, and back-translated by a fluent bilingual health expert prior to field testing.  
 
The survey questionnaire will capture household-level demographics, and assess potential risk factors for 
malaria infection. Information collected will include age, gender, pregnancy, nationality, ethnicity, 
occupation, socioeconomic status, travel history, history of malaria, treatment seeking for fever in the 
past two weeks, individual and household use of vector control measures, housing structure type, 
proximity to forest and forest-fringe, and frequency of overnight sleeping in forest or forest-fringe areas.  
 

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All household members (residents and temporary visitors) aged 18 months and older will be invited to 
participate in an RDT and blood collection component. Informed consent will be obtained from all 
participants, including parental consent for any participant younger than 18 years of age. After consenting, 
the study team will capture axillary temperature, and test each individual using both a standard RDT 
(CareStart Ag Pf/Pv, SD Bioline Cat #05FK80) and HS-RDT (SD Bioline Malaria Ag P.f High Sensitive Cat# 
05FK140), followed by collection of four DBS on filter paper. 
  
If found positive by RDT or HS-RDT, treatment will be administered as in Table 7; women of reproductive 
age will be assessed for treatment as in section 3.2.1. 
3.3.2.4.2 Test and treat data collection 
The test and treat campaigns will consist of two independent intervention activities. The first will be three 
rounds of village-based test and treat (MTAT) of all selected villages, and the other activity will be peer-
navigator directed test and treat (FTAT) in forest- and field-based populations captured in areas outside 
of formal settlements in selected HCCAs. Data collection during village-based MTAT campaign rounds and 
PN FTAT is described below.  
 
Questionnaires and human specimen collection: village-based MTAT-HS 
For all households in intervention villages, after obtaining informed consent, a short demographic and 
malaria risk factor survey will be conducted to obtain information on household members’ occupations, 
recent forest work or travel, ITN usage, and recent care-seeking behavior for fever.  
 
All household members (residents and temporary visitors) aged 18 months and older will be invited to 
participate in RDTs (all rounds) and blood collection component (one round only, as below). Informed 
consent will be obtained from all participants, including parental consent for any participant younger than 
18 years of age. After consenting, the MTAT team will capture axillary temperature, and test each 
individual using both a standard RDT (CareStart Ag Pf/Pv, SD Bioline Cat #05FK80) and HS-RDT (SD Bioline 
Malaria Ag P.f High Sensitive Cat# 05FK140).  
 
If found positive by RDT or HS-RDT, treatment will be administered as in Table 7; women of reproductive 
age will be assessed as in section 3.2.1. 
 
All patients with a P. vivax positive RDT (both febrile and asymptomatic) will be given a coded and signed 
informational letter directing them to the nearest district hospital for G6PDd testing and follow-up 
treatment. 
 
For one of the MTAT rounds, DBS will also be collected from a randomized 25% subset of all households 
(approximately 6,800 samples) for subsequent PCR-testing to assess any factors related to overall impact 
of the intervention. 
 
Questionnaires and human specimen collection: PN FTAT 
For all individuals identified by PNs in intervention HCCAs, after obtaining informed consent, a short 
demographic and malaria risk factor survey will be conducted to obtain information on the respondent’s 
occupations, recent forest work or travel, ITN usage and recent care-seeking behavior for fever.  
 
All individuals will be invited to participate in RDT-based testing (standard RDT and HS-RDT) and a blood 
collection. Informed consent will be obtained from all participants. After consenting, the PNs will capture 
axillary temperature, and test each individual using both a standard RDT (CareStart Ag Pf/Pv, SD Bioline 

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Cat #05FK80) and HS-RDT (SD Bioline Alere Malaria Ag Pf High Sensitive Cat #05FK140), followed by 
collection of four DBS on filter paper.  
 
If found positive by RDT or HS-RDT, treatment will be administered as in Table 7, and women of 
reproductive age will be tested and treated as in section 3.2.1. 
 
All patients with a P. vivax positive RDT (both febrile and asymptomatic) will be given a coded and signed 
informational letter directing them to the nearest district hospital for G6PDd testing and follow-up 
treatment. 
 
PNs will provide participants with a small gift for participation (e.g., torch or topical repellant). Sites where 
interviews occur will be geo-located if all parties agree. PNs may also obtain contact information from 
consenting persons to allow for follow-up on positive cases and potential creation of support networks 
for other HRPs. 
 
A subset of forest-goers (all RDT-positives and a subset of RDT-negatives) will be invited to carry global 
positioning system (GPS) loggers (Figure 3) to capture their movement patterns in time and space. As 
these units require data to be downloaded, study staff will facilitate subsequent retrieval of units from 
HRPs using small incentives (e.g., phone top-up cards), and will use these contact events to enroll other 
HRPs whenever possible.  
Figure 3. “I-GotU” personal GPS data logger 
 
             
 
3.3.2.4.3 Costing data collection 
Itemized expenditure data will be collected during household test and treat and peer-navigator led 
activities (Table 10). This will allow calculation and comparison of the cost-per-case identified using both 
types of test and treat approaches. 
 
Table 10. Types and potential sources of expenditures for per-case 
costings from focal test and treat activities 
 
Expenditure 
category: 
 
Types of expenditure data required 
Potential information sources 
Personnel 
All human resource expenditures and time contributions, 
including: 
·   Salary/wage payments 
·   Volunteer labor/per diems 
·   Annual program budgets for 
salaries and benefits 
·   Work logs or weekly reports 
from health staff, VMWs, and 
PNs 
 

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Commodities 
and Services 
All supplies and services used toward test and treat 
activities: 
·   In-kind donations 
·   Purchased commodities (e.g., acquisition costs, duty fees) 
·   Travel/transit costs: fuel, transit fees and services, airfare 
·   Reproduction costs, postage 
·   Staff trainings: per diem payments, trainer fees, 
consultants 
·   Warehouse space 
·   Printing, shipment receipts 
·   Training budgets and 
receipts 
·   Vehicle travel logs, fuel 
receipts 
·   Utility bills 
·   Consultant invoices 
  
 
3.3.2.4.4 Laboratory procedures and analysis including PCR 
The laboratory procedures described below will be followed for all laboratory-based activities conducted 
during this project. The laboratories performing these tests include the Pasteur Institutes in Phnom Penh 
and Paris, and UCSF. 
 
RDTs will be performed in health facilities and during field activities using quality-assured lots. Dried blood 
spots (DBS) will be regularly transported to the district or provincial offices for refrigerated storage prior 
to bulk transport to Vientiane, and shipment to designated laboratories. DNA from DBS will be extracted 
using the Chelex method [35], and tested by RT-PCR with subsequent speciation for all samples found to 
be Plasmodium-positive. 
 
Serology, a test of past infection as assessed by the presence of antimalarial antibodies, will be used to 
improve the identification of hotspots and estimate current and historical transmission intensities [36]. 
Using DBS, ELISA assays will be performed using previously described methods. Briefly, antibodies will be 
eluted from DBS and assayed to detect antibodies against the P. falciparum blood stage antigens including 
merozoite surface protein-1 (MSP-1) and apical membrane antigen-1 (AMA-1), both biomarkers of P. 
falciparum exposure [37]. Markers for P. vivax exposure will include Pvmsp-1 and Pvcsp [38]. Other 
antigens that are sensitive and specific for recent exposure (currently undergoing evaluation) for P. 
falciparum and P. vivax may also be used. ELISA assays will be performed in duplicate and optical densities 
recorded with an ELISA reader. Other serological and antigenic platforms (bead array, protein microarray) 
may be used to analyze responses to multiple antigens/antibodies, if available. 
 
Genotyping of P. falciparum will consist of a panel of microsatellites located throughout the genome. 
Briefly, DNA samples will be amplified in a multiplex pre-amplification step followed by amplification of 
microsatellites in individual reactions using fluorescently tagged primers, and sized using denaturing 
capillary electrophoresis. Multilocus genotypes from mixed infections will be reconstructed, where 
possible, by quantifying alleles at each locus. Genotyping of additional loci including for HRP2 deletion will 
be performed as needed. 
 
Individual microsatellite amplifications will be undertaken using single round or nested PCR assays with 
fluorescently labeled primers, and the amplicons sized by denaturing capillary electrophoresis with 
internal size standards. Allele-calling will be undertaken with the aid of the GeneMapper v4.0 software. 
The potential for effective multilocus haplotype reconstruction in polyclonal infections will be explored. 
Additional informative SNP markers identified in whole genome sequencing efforts may also be 
genotyped as necessary to improve sample fingerprinting. 
 
Genotyping for markers of drug resistance will include PCR and/or sequencing to identify markers of 
resistance to artemisinin-based combination therapies (ACTs), in particular artemether-lumefantrine, 

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artesunate-amodiaquine, dihydroartemisinin-piperaquine (including K13), and the antifolate combination 
sulfadoxine-pyrimethamine (SP). 
 
Human DNA may be used in the future to screen for genetic risk factors for malaria, such as inherited 
blood disorders, e.g., G6PD status. This information may be used to assess the prevalence of G6PD 
deficiency in study areas to support CMPE’s national-scale implementation of primaquine for P. vivax (full-
course) and P. falciparum (single low-dose).   
3.3.2.4.5 Sample storage and transfer 
DBS sample cards consisting of four individual spots of blood will be collected by finger prick from all 
persons screened in the baseline and end-line surveys, from 25% of households for one round of MTAT, 
and PN FTAT activities when feasible. These DBS cards will be left to air-dry before storage in Ziploc bags 
containing desiccant to limit build-up of moisture. DBS cards will be stored at 4˚C within one week, and at 
-20˚C within one month; extracted DNA will also be stored at -20˚C. Samples will be kept securely in 
Vientiane and/or Phnom Penh and/or San Francisco for current and future studies. Transfer of samples 
outside of Lao PDR will be at the specific request of CMPE. 
3.3.2.5 Analytic plan 
Data will be collected via ODK-based tablet application with internal range checks or paper-based with 
subsequent double-entry, and will be stored in Microsoft Excel or Access. The number of malaria cases, 
based on RDT and PCR results, will be mapped by village or sub-village and compared between surveys.  
 
Where possible, environmental covariates including forest cover will also be utilized; and geostatistical 
analyses will be conducted to produce risk maps for the study districts. 
 
Primary outcomes 
 
Outcome 1: Community-level PCR-based P. falciparum parasite prevalence in sampled villages 
The effectiveness of the interventions will be assessed as P. falciparum prevalence via PCR at end-line 
(post only) using generalized linear mixed effects models with separate random intercepts to allow for 
clustering within villages and health center catchments. The binomial distribution will be used to analyze 
prevalence outcomes (logistic regression). All main analyses will be analyzed as intention-to-treat, and all 
survey clusters will be analyzed within the intervention group assigned at randomization, regardless of 
adherence. The primary effect estimate will be evaluated using the fixed effects for village MTAT 
intervention, PN FTAT intervention, and an interaction term for the combined interventions. Secondary 
analyses will include adjustment for age, sex, health center-catchment and village-level baseline 
prevalence of P. falciparum parasitemia by PCR, and other potential confounders, and a per-protocol 
analysis of the primary effect estimate.  
 
Outcome 2: HS-RDT-based test positivity rate in village-based and forest-based samples 
The HS-RDT and RDT test positivity rate will be estimated for the MTAT villages during each intervention 
round. This will be done as soon as data on HS-RDT results are available, which would be expected to be 
one month following each round. Differences in prevalence measures at each round will be assessed using 
a χ2 test, as well as logistic regression models to account for potential confounding factors.  
 
Outcome 3: Village-based population coverage of test and treat interventions 
The operational coverage will be estimated at the individual and household level as the percent of the 
population that received a visit from the intervention teams to offer the MTAT interventions, among those 

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eligible for inclusion. This will be obtained from a combination of MTAT program data and enumeration 
data. Additionally, the proportion of individuals accepting the MTAT interventions ≥18 months, among 
those eligible for inclusion in the intervention, will be estimated, providing an estimate of the effect 
coverage of each program. Data for the denominator of individuals and households targeted for the 
intervention will be ascertained from the household enumeration for the sampling frame. Additionally, to 
validate the enumeration, attempts will be made to use remote sensing data, and/or Google Earth, to 
enumerate household structures. To the extent possible, individual, household and community level 
factors associated with coverage will be assessed using mixed effects logistic regression.  
 
Outcome 4: Community-level confirmed P. falciparum malaria parasite incidence 
Data pertaining to this outcome will be analyzed on an intention-to-treat basis. Monthly counts of 
confirmed malaria cases from the health facility registers will be linked to villages and analyzed in a time 
series Poisson or negative binomial model with random intercepts at the health center catchment and 
village levels. The models will include a fixed effect for each study arm, an interaction term for the 
combination of MTAT and FTAT, and a fixed effect for time period (pre- and post-intervention). The 
interaction between these two terms will be the primary effect measure (also known as the difference-
in-differences estimator). Pre/post-intervention will be determined as all time periods before the start 
date of the intervention in the areas considered as being pre-intervention and all time periods after (and 
including the start date of the intervention in the area considered as being post-treatment). In addition 
to a post-intervention analysis of confirmed malaria case incidence from routine health information data, 
the health facility data will be reviewed monthly to allow near real-time analysis of confirmed and total 
case outpatient incidence as the three rounds of the MTAT interventions are rolled out across the study 
areas. 
 
Secondary outcomes 
 
Serology 
Seropositivity to a panel of standard malaria parasite antigens for P. falciparum and P. vivax (including 
species-specific MSP, AMA, CSP antigens) will be used to examine both recent and medium-term 
exposures. These data will also be mapped using captured GPS coordinates to examine serological 
hotspots. Finally, novel antigens will also be used to further explore any differences in parasite exposure 
between study arms. Vector exposure may also be explored using antigens to anopheline salivary proteins. 
 
Risk factors for malaria parasite infection in HRPs 
Survey data, RDT results, and PCR-results will be used to examine economic, demographic, occupational 
and spatial risk factors for malaria parasite positivity, and identification of specific high-risk sub-
populations for interventions. The primary outcomes will be all-species parasite prevalence via RDTs, HS-
RDTs (all field testing) plus PCR (cross-sectional surveys, one MTAT round only, and FTAT), combined with 
surveyed risk factors. Logistic regression will be used to determine risk factors for 1) RDT-based test 
positivity 2) HS-RDT-based test positivity and 3) PCR-based positivity (cross-sectional surveys, one MTAT 
round only, and FTAT). Analyses will also be performed for P. falciparum and P. vivax separately, with 
appropriate corrections for multiple testing. Models for panel data will be used for cross-sectional surveys 
(if resample from the same household lists), and for all households with repeat visits during MTAT events. 
Models will also incorporate robust errors and survey correction factors to address non-independence of 
observations. 
 
Cost and cost-effectiveness 

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For the costing portion of the study, the cost per case investigation conducted, cost per additional positive 
case identified using MTAT in village-based populations and FTAT in forest-based HRPs, and the cost per 
case actively detected per person tested during test and treat. The cost-effectiveness of test and treat will 
also be compared between village-based activities and peer-navigator led testing. Costing and analysis 
methods will follow principles of costing for health care programs [27] and analysis and presentation of 
results will follow the CHEERS guidelines [39]. Costing will be conducted from the health-sector (provider) 
perspective and will utilize key informant interview and focus group data collection methods. 
 
Sensitivity and specificity of HS-RDTs 
The P. falciparum prevalence from all individuals tested with HS-RDTs will be compared with parallel 
results from standard RDTs (all field testing activities) and to subsequent PCR-based testing (cross-
sectional surveys only). In the latter case, the PCR-based result will serve as the gold standard for all 
comparisons. Sensitivity and specificity and ROC analyses will be conducted to assess the performance of 
the HS-RDTs in field situations, and in the presence of mixed-species infections.  
3.3.3 Activity 2 - Assessment of health-sector and community feasibility and acceptability of 
the test and treat interventions 
3.3.3.1 Implementation procedures 
Several methods for assessing the feasibility and acceptability of MTAT and FTAT interventions as 
perceived by communities, HRPs, health sector staff, peer navigators, and study staff will be implemented 
over the course of the study. Peer navigators, while widely employed in other public health domains (e.g., 
HIV/AIDS, substance abuse, cancer), have yet to be deployed on any scale in the malaria sector. In these 
settings, peer navigators have successfully engaged hard-to-reach populations, improved health 
outcomes, and offset cumulative healthcare costs. Given the novel use of peer navigators in a malaria 
setting, a more in-depth and focused evaluation will be conducted to assess the capacity, feasibility, and 
acceptability of peer navigators to implement the FTAT intervention. Activity 2 methods are summarized 
in Table 11 below, and include FGDs, KIIs, PN observations and interviews, and HRP interviews. 
 
Table 11. Methods to assess the feasibility and acceptability of MTAT and FTAT 
 
S/N 
Method 
Sample Size 
Tools/Sources 
Sample Data 
Timeframe 
1 
FGDs and 
KIIs 
- 2 FGDs with PNs 
- 2 FGDs with MTAT  
  team members 
(8 participants/FGD) 
- 2 KIIs per district 
(8 total KIIs) 
FGD and KII 
interview guides 
(Annex Q, R, S) 
- Perceived MTAT and FTAT 
feasibility and acceptability 
- MTAT/FTAT barriers and benefits 
- Study experience (staff and PNs) 
- Perceived challenges to malaria 
elimination in Lao PDR 
Study end-line  
2 
Cross-
sectional 
household 
surveys 
- Baseline: 1,120 
head of households 
- End-line: 1,680 
head of households 
Form 2 (Annex D) 
Likert scales (quantitative): 
- Willingness to participate in MTAT 
- Benefit of MTAT for household 
- Benefit of MTAT for community 
- Baseline survey 
- End-line survey 
3 
Observation 
of PNs by 
supervisors 
Random subset of 
12 PNs  
PN competency 
checklist based on 
FTAT SOP  
(Annex U) 
FTAT competencies, including: 
- Adherence to RDT, HS-RDT, and    
  DBS procedures     
- Adherence to diagnosis, 
  treatment, and referral guidelines 
2 observations/PN: 
1. First month FTAT 
2. Final month FTAT 
4 
PN 
interviews  
6 PNs per round 
(random subset) 
PN interview 
guide (Annex V) 
PN perceptions over time: 
- FTAT challenges and barriers 
- FTAT benefits and facilitators  
- Performance and self-efficacy 
- Motivations 
3 rounds of interviews: 
1. FTAT launch 
(entrance interview) 
2. Midpoint FTAT 

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- FTAT enabling environment 
(support and supervision) 
3. Final month FTAT 
(exit interview) 
5 
HRP 
interviews 
by PN 
supervisors 
Subset of 6-8 HRPs 
per round 
HRP interview 
guide (Annex W) 
 
- Acceptability of PNs and FTAT 
- Confidence and trust in PNs 
- Perceived benefits of FTAT 
- Perceived burden/risk of malaria 
1. First month FTAT 
2. Final month FTAT 
(HRP interviews timed 
with PN observations) 
6 
FTAT HRP 
surveys 
2,000 HRP target 
Form 9 FTAT 
Survey (Annex K) 
Likert scales (quantitative): 
- Willingness to participate in FTAT 
- Benefit of FTAT participation 
Continuous during FTAT 
implementation 
7 
Analysis of 
process and 
output 
indicators  
N/A 
Study data and 
records: 
- FTAT/MTAT 
survey data 
- Inventory 
records 
- PN call logs/ 
diaries 
- Lab reports 
 
- # of HRPs surveyed, RDTs, DBS 
- % HRPs properly treated and  
  referred (compared to MTAT) 
- PN data completeness and  
  quality (compared MTAT teams) 
- Supply waste rate (inventory) 
- # of peer contacts made by PNs 
- # HRP follow-up calls received 
- Proportion of collected DBS that 
can be analyzed by laboratory 
Continuous during study 
implementation 
8 
Review of 
PN meeting 
agendas 
and 
minutes 
N/A 
 
PN meeting 
agendas and 
minutes 
- FTAT progress  
- Challenges and solutions 
- Refresher training topics 
- Complaints 
- PN meeting attendance 
- Support and supervision 
Bimonthly meetings 
continuous during FTAT 
implementation  
 
Notes: PN = peer navigator; HRP = high-risk population; FGD = focus group discussion; KII = key informant interview 
3.3.3.2 Primary outcomes 
Proportion of village-based survey respondents who strongly disagree, disagree, are ambivalent, agree 
and strongly agree on the importance and acceptability of community-based MTAT; proportion of 
surveyed HRPs who strongly disagree, disagree, are ambivalent, agree and strongly agree on the 
importance and acceptability of FTAT; proportion of peer navigators who rate conducting the FTAT 
intervention as very easy, somewhat easy, somewhat difficult, and very difficult; proportion of peer 
navigators receiving a ‘pass’ score on FTAT competency checklist completed by supervisor during FTAT 
observation; proportion of peer navigators rating their confidence in conducting the FTAT intervention as 
very low, low, moderate (confident), and high.  
3.3.3.3 Sample size 
Focus group discussion (FGD) and key informant interview (KII) activities will aim to reach saturation and 
be comprehensive. There will be a total of 4 FGDs (2 for PNs, and 2 for MTAT team members), and 2 KIIs 
per district with district or study staff (8 KIIs total). PN supervisors will observe and complete a FTAT 
competency checklist (Annex U) on a random subset of 12 PNs at two different time points: within the 
first month of FTAT launch, and within the final month of FTAT (allowing for pre/post comparison of PN 
capacity to conduct FTAT and related study interventions). During these two rounds of PN observations, 
PN supervisors will also interview a subset of 6-8 HRPs (12-16 HRPs total) on the acceptability of PN-FTAT, 
including confidence and trust in peer navigators, and perceived benefits of FTAT. A random subset of 6 
PNs will be interviewed during each round of entrance, mid-FTAT, and exit interviews (18 interviews total) 
to understand perceived FTAT challenges, facilitators, performance, and self-efficacy. Sample sizes for 
quantitative (Likert scale) MTAT/FTAT acceptability data derived from cross-sectional and HRP surveys will 
be based on activity sample sizes: 1,120 households interviewed during baseline, 1,680 households 
interviewed during end-line, and 2,000 HRPs targeted throughout FTAT implementation. 

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3.3.3.4 Data collection 
Depending on the method, data collection may occur continuously throughout the study, at specific time 
points, or at end-line only. Standardized tools including interview/discussion guides and a competency 
checklist will be developed using best practices in qualitative research [40], and translated and back-
translated prior to implementation. Study staff and an independent FGD/KII moderator will be trained on 
the appropriate tools, and all interviews will be conducted in the local language. The end-line FGDs and 
KIIs will explore constraints and any issues related to all the topics identified from the quantitative survey, 
field experience implementing the FTAT and MTAT interventions, and barriers to implementation of 
malaria control efforts. Informed consent will be obtained from all FGD, KII, and HRP participants in the 
local language prior to any data collection. FGDs and KIIs will be audio-recorded, transcribed, and the 
transcripts translated into English.  
3.3.3.5 Analytic plan 
Quantitative analysis will consist of comparison of the proportions of different study respondents having 
a favorable view of MTAT and FTAT interventions, and identification of any socio-demographic or 
occupational groups that have significantly different distributions of responses from the overall study 
population.  
 
Grounded theory will be used to inform data coding [40], which will be performed by a study analyst(s) 
using dedicated qualitative analysis software (NVivo, ATLAS.ti, or TAMS Analyzer). The grounded theory 
method relies on a constant comparative approach to generate theories about human behavior. Interview 
transcripts or detailed notes are coded into concepts reflecting the objectives of the assessment, and 
identified concepts are grouped into categories, which are then organized into broader themes. 
Relationships among analytic categories or themes are used to interpret the data and generate 
explanations about human actions and behaviors. Analysis of the study data will focus on identification of 
any practical or intervenable barriers to FTAT or MTAT implementation and uptake to inform future 
practice and policy. 
3.3.4 Activity 3 - Estimating population size of forest-based HRPs 
3.3.4.1 Implementation procedures 
During all PN-led FTAT activities, all persons who provide informed consent will be asked several survey 
questions to help estimate the population size of HRPs in the HCCA area. 
 
1. After identification of possible HRPs at any non-village sites, PNs will assess their eligibility, and 
proceed through the informed consent process. 
2. Several questions will ask the respondents to estimate the total number of persons like 
themselves (using sex, plus linguistic, social, and occupation-based criteria) within the 
immediate area (5-10 km radius). 
 
For the second type of population estimation, data collected at each HRP contact event (mobile phone 
numbers, age or date of birth, home village, and initials) will allow for generation of a unique and 
reproducible personal identifier. At the end of the study period, the unique personal identifier codes will 
be used to estimate the HRP population size using single-source capture-recapture methods [41], 
complemented with double-list capture recapture methods. 

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3.3.4.2 Primary outcomes 
The primary outcome will be three separate population size estimates with appropriate confidence 
intervals. 
3.3.4.3 Sample size 
There are no formal sample size calculations for “wisdom of the crowds” methods [42] as this method is 
based on the assumption that taken in aggregate, members of a target population can plausibly estimate 
the total number of persons like themselves.  
 
The sample size for the single source capture-recapture uses simulations from a Poisson distribution to 
ensure useful limits for the confidence intervals in the population size estimates. With an assumed total 
HRP population of 5,000 persons, if 750 are enrolled in the study, 95% confidence interval for the 
population size estimate will be 2,300 to 7,700; larger sample sizes will have correspondingly narrower 
CIs. 
 
For the double-source capture recapture using lists generated by the PN teams working in the same HCCA, 
with an assumption of 2,000 persons surveyed and with a 4% recapture rate (and therefore approximately 
145 per HCCA), the confidence interval for the population size per HCCA will be sufficiently narrow at 213 
(95% CI: 198 to 231), or 2,982 (95% CI: 2,772 - to 2,982) for the pooled HCCAs. 
3.3.4.4 Data collection 
Data collection for sample size estimates will occur during all peer-navigator led FTAT activities. Essential 
demographics will be collected on all persons identified as forest-goers by PNs during their routine 
activities, allowing for generation of a unique and reproducible personal identifier for all HRPs.  
3.3.4.5 Analytic plan 
Three separate estimates for the total HRP population in the target areas will be produced and compared. 
Standard methods for “wisdom of the crowds” [42] and two-source capture recapture [43] will be utilized. 
The methods estimating population size from a single-source capture recapture list will use truncated 
Poisson and related models with inclusion of relevant covariates [42,43] where maximum likelihood fit 
distribution are used to infer the hidden ‘zero’ capture population size.  
 
The second capture-recapture analysis will be performed by comparing lists between the two different 
PN teams that have been operating in the same HCCA using standard multiple-list methods for multiple-
observer surveys [43,46]. As the transient nature of many HRPs may violate a key assumption of capture-
recapture studies (no in or out migration of the study population) data will be analyzed by individual study 
month to minimize this bias. As a sensitivity analysis, the full annual data will also be analyzed using 
alternative models which allow for moderate migrations to be assessed [47,48]. 
 
A third capture-recapture analysis will use the unique identifiers captured during PN activities and 
numbers of those individuals reporting living in a nearby village, compared with proportions of all 
household members reporting forest-going or forest-fringe farming activities during baseline and MTAT 
surveys, to estimate the total size of the HRP population (and sub-populations wherever feasible). 

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3.3.5 Activity 4 - Assess demographic and geographic predictors for G6PDd testing 
adherence with a positive P. vivax RDT 
3.3.5.1 Implementation procedures 
During all MTAT and FTAT RDT testing activities, all patients with a P. vivax positive RDT (both febrile and 
asymptomatic) will be given a different coded and signed informational letter directing them to the 
nearest district hospital for G6PDd testing and possible radical cure depending on results.  Study contact 
information will also be included if the participants present at other health facilities. 
3.3.5.2 Primary outcomes 
The primary outcome will be the proportion of referred patients who present to district hospitals for 
G6PDd testing. 
3.3.5.3 Sample size 
In 2016, there were about 100 confirmed P. vivax cases per district per month in Champasak. If 30% of 
referred patients present for testing, then the study will be adequately powered (80%; at 5% significance 
level) to examine 10 risk factors if at least 500 persons are referred [49]. 
3.3.5.4 Data collection 
As part of the normal data collection activities for MTAT and FTAT, all patients with an RDT positive for P. 
vivax mono- or mixed infection will receive an individually coded letter directing them to the nearest 
district hospital for G6PD testing. 
 
The study staff will meet with district hospital staff (monthly) from all study area district hospitals and all 
nearby district hospitals to collect these forms, with small incentives for health staff to report receiving a 
referral letter (phone top-up card, etc.) to maximize data completeness.  
3.3.5.5 Analytic plan 
At the conclusion of the study, data captured from the total distributed and returned G6PD testing referral 
letters will be linked to individual records from household or forest-based surveys. 
 
Logistic regression will be used to examine risk factors for non-adherence to testing with ‘presented for 
G6PDd testing’ as the outcome. Covariates to be included include distance from the village to district 
hospital, fever status, occupational factors, and demographic characteristics. These models will be used 
to explore the factors associated with adherence for GDPD testing referral among both asymptomatic and 
febrile patients.  
 
4 Ethical issues related to human subject research 
4.1 Adequacy of protection against risks  
We will administer an informed consent form both verbally and in writing to all participants in the local 
language for participation in the cross-sectional surveys, MTAT interventions, and FTAT activities. These 
forms will be read or will be given to participants to read themselves and will include a full description 
of voluntary participation, the right to withdraw from the study at any time, and the right to not answer 
any question or participate in any component of the research.  
 
These forms will also address the risks, benefits, and purpose of the study and what we hope to learn, 
with a specific focus on the potential risks associated with the administration of SLD-PQ. We will train 

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all interviewers extensively on the consent procedure, and each form will be co-signed by a team 
member to ensure all participants have consented. Checks in the field by the PI and project leaders will 
further ensure the consent process is followed in all cases. Data collection team members will provide 
the contact information for study coordinators who can be contacted for any further information on the 
topics brought up in the interview, or for additional treatment if necessary. The confidentiality 
procedures are designed to meet all contingencies to ensure the confidentiality of participant data and 
the privacy of the participants is preserved. 
 
Our proposed strategies to reduce risks to privacy or of disclosure of confidential information include: 
 
1. Identifying information will be recorded only in secure database software on password 
protected computers, and data collectors will only have access to the data that they 
themselves directly collect which will be cleared from their devices after all follow-up visits are 
completed. All data will be stored only in password-protected files on password-protected 
computers in locked offices.   
2. Prior to analysis, data will be de-identified with the exception of geo-location codes, which are 
necessary for specific per-protocol analyses. The absence of individual identifying information 
will protect subject confidentiality.  
3. All paper records will be stored in a locked location. 
4.2 Protection against risks associated with the administration of AL / SLD-PQ 
Artemether lumefantrine (AL) is standard of care for uncomplicated malaria in Lao PDR. The use of SLD-
PQ for P. falciparum [16] has been shown to have no clinically significant impacts on hematological 
indexes in populations with severe G6PD deficiencies in the GMS [22], and no SAEs are expected from 
SLD-PQ. 
 
The key to managing side effects and any potential adverse events (AEs) or serious AEs (SAEs) is thorough 
training of VMWs/VHVs, health facility staff and supervisors, and intensive sensitization of the 
community. HC workers and VMWs/VHVs will passively monitor their respective communities for AEs 
and refer any potential SAEs to designated health facilities. Health workers at these facilities will be 
informed of the project and potential side effects, and undergo training on completion of AE reporting 
forms (Appendix N). Cases that cannot be treated at health centers will be referred to district or 
provincial hospitals.  
 
All participants receiving study drug will be provided with an informational sheet listing potential side 
effects and instruction to seek care at the nearest health center should they experience any of the 
defined symptoms or other adverse events. Community sensitization events and targeted IEC/BCC 
materials will also help increase community awareness of potential adverse events and encourage early 
care-seeking if events arise.  
 
A passive case detection system will be employed in both intervention and control villages to help detect 
and refer any potential SAEs; VMWs/VHVs will be oriented on potential drug side effects and asked to 
passively monitor their communities and refer any potentially serious or unexpected AEs. All public 
health facilities in the four target districts will be trained on AE reporting procedures prior to 
implementation of any study activities. A data safety monitoring board (DSMB) will be established to 
oversee and report on any SAEs that are potentially linked to the administration of AL or SLD-PQ, as 
outlined in further detail in Section 4.5. The following steps will be taken for all AEs: 
 

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The health facility will complete an AE reporting form (Appendix N). The completed form will then be 
submitted to the field manager (a medical doctor), who with the support of the UCSF project manager 
will assess if the event is an SAE or unexpected AE based upon specific criteria determined by the DSMB. 
If determined to be an SAE or unexpected AE, the UCSF project manager will submit the AE reporting 
form and any accompanying documentation (clinical records, laboratory reports) to the DSMB and the 
UCSF PI within 48 hours from the identification of the potential SAE.  
 
Upon receipt of the AE reporting form, the DSMB will complete an AE investigation form (Appendix O) 
within 24 hours to a) confirm if the event is an SAE, and 2) to determine if the SAE was caused by the 
administration of AL with SLD-PQ as part of this study. If the event is confirmed to meet the criteria of 
an SAE, the DSMB will submit the completed AE investigation form to the PI, who will submit to the 
research ethics committees (RECs) at UCSF and NIOPH within 24 hours of receipt from the DSMB.  
4.3 Potential benefits of the proposed research to the participants and others 
The proposed research may benefit patients in direct and indirect ways. Participants will directly benefit 
from detection of low-level parasitemia, and the curative effects of AL administration on existing P. 
falciparum infections in both the cross-sectional, MTAT, and FTAT interventions. Furthermore, patients 
may directly benefit due to community-wide reductions in malaria transmission that are expected to 
occur after the application of the interventions. Finally, entire target village populations will benefit from 
SLD-PQ, which targets the parasite sexual stages thereby decreasing overall transmission. 
 
Participants may also indirectly benefit, as the information gained from this research will be used to help 
establish the safety and efficacy of a new malaria control intervention in Lao PDR. The research will 
benefit the scientific and malaria control communities more generally by expanding the evidence base 
on MTAT, FTAT, and addition of gametocytocidal drugs to treatment regimens in the GMS.   
4.4 Alternatives to participation 
Participation in the research study is voluntary. Individuals electing not to participate in the research 
study may still receive testing and treatment as part of the interventions. Individuals who do not wish 
to receive testing and treatment during the intervention campaigns may visit local health facilities for 
malaria testing and treatment.   
4.5 Data and safety monitoring plan 
The project will follow US National Institutes of Health (NIH) guidelines for establishing a data safety 
monitoring board (DSMB). The DSMB will be established prior to any data collection as part of this study. 
The members of the DSMB will serve in an individual capacity and provide their expertise and 
recommendations. The primary responsibilities of the DSMB will be to periodically review and evaluate 
the accumulated study data for participant safety, study conduct and progress, and, when appropriate, 
efficacy, and 2) make recommendations to investigators concerning the continuation, modification, or 
termination of the trial. DSMB will consider study-specific data as well as relevant background 
knowledge about malaria, adverse events from AL and SLD-PQ, drug resistance, and the participant 
population under study. 
 
Membership of the DSMB will consist of five independent experts in malaria control, diagnosis, case 
management and epidemiology, and one member of the research team to advise and clarify study 
activities for the independent experts. No independent member of the DSMB shall have any conflict of 
interest with the study team, the organizations funding or conducting the research, or the results of the 

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study. The DSMB will be comprised of experts in the following areas, with an emphasis on local Lao 
expert participation: 
 
• 
The study population in Southern Lao PDR (Lao representative) 
• 
Malaria diagnosis and case management 
• 
Malaria epidemiology 
• 
Biostatistics 
• 
Conduct of clinical trials 
• 
Malaria drug resistance 
 
No data on futility or benefit of the intervention will be estimable during the course of the trial as the 
timing of outcome data collection precludes developing stopping rules based on outcome data collected 
during implementation. Safety concerns associated with the wide-scale use of AL + SLD-PQ, although 
unexpected, will form the basis of development of a stopping rule. The stopping rules for this trial will 
be based on detection of a significantly higher rate of mortality, hospitalization for possible drug-related 
events, or any other SAE in the MTAT villages versus rates recorded at health facilities for the control 
(non-MTAT) villages. Further, any investigated SAE that results in death that is found to be due to the 
administration of AL + SLD-PQ will be grounds for stoppage. 
4.6 Collection of specimens 
RDT kits for malaria using finger prick blood samples will be collected during the research and 
intervention. These samples and their byproducts will be collected for disposal according to local 
disposal standards for biohazard and sharps waste at the nearest health facility (generally incineration). 
DBS will also be collected for PCR analysis of malaria parasite infection. These blood spots will be 
disposed of after the research and not stored for future use. The research period will be defined by the 
approval dates for the local research ethics committee, the UCSF, and CMPE, and blood samples will not 
be stored for any longer than three years past the date the research study end. The informed consent 
documents will specify the uses and storage plans for dried blood specimens. Patient identifying 
information will be replaced with an unrelated unique identifier on each filter paper. All appropriate 
universal and site-specific safety precautions will be used in handling sharps, RDTs, microscopy slides, 
and filter paper blood spots. All survey workers will be trained in the proper storage and handling of 
blood samples prior to fieldwork. 
4.6.1 Racial and ethnic origin 
A diverse range of ethnic groups will be included in the study, including several marginalized ethnic 
minorities. Our study will be conducted outside of the U.S., and no racial/ethnic group will be excluded. 
We do not expect to find race/ethnicity differences in the intervention effect, but refusal rates may differ. 
4.6.2 Inclusion of vulnerable subjects – children and pregnant women 
All age groups will be included in this study, except for those < 18 months. All children that participate 
must have the consent of the parent or guardian. Children older than 6 years and less than 18 must also 
provide oral assent before participation. All women who are pregnant or believe they may be pregnant 
will be assessed as in section 3.2.1. 

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4.7 Subject consent/assent 
4.7.1 Process of consent 
Informed, written consent will be sought from all participants in the study. Individuals 18 years of age 
and older will provide individual consent. For individuals >18 months and less than 18 years of age, 
consent will be sought from the head of household or parent/household guardian at least 18 years of 
age. For children greater than 6 years and less than 18, oral assent will be sought from the child.  
4.7.2 Subject capacity 
For individuals who do not have the capacity to provide consent for testing and treatment, consent will 
be sought from the head of household or parent/guardian. If either is absent during the household visit, 
the subject without capacity to provide individual consent will be excluded. If individuals are unable to 
sign consent forms, they may make a thumbprint mark to indicate consent.  
4.7.3 Subject/representative comprehension 
All consent forms will be read in local languages to individuals in the study areas, and provided in Lao in 
written form.  
4.7.4 Documentation of consent 
Written consent will be obtained from all participants as described above in 4.1 and maintained in 
Vientiane. 
4.7.5 Costs to the subject 
There are no costs to the subject for participation in any project activities.  
4.7.6 Payment for participation 
No payment for participation will be provided to participants. Households for the cross-sectional surveys 
will receive a small gift for participation (e.g., soap bars), and forest-based HRPs will receive a torch or 
other small token of appreciation. 
4.7.7 Field data collector training 
All VMWs/VHVs and health professionals recruited from CMPE and NIOPH to implement the study 
interventions will receive standardized training on the process of informed consent, the protection of 
the privacy of study subjects, the protection of the confidentiality of data pertaining to study subjects, 
and in safe and proper methods for conduct of finger sticks for malaria parasite testing. Every effort will 
be made to prevent secondary infection from the finger stick by using new, sterile lancets for each 
individual tested and by cleaning the finger with an alcohol swab prior to conducting the finger stick. HC 
workers and VMWs/VHVs will be provided with sufficient supplies for this throughout the fieldwork. In 
addition, the field staff will be provided with and will wear a fresh pair of latex gloves for each individual 
receiving a finger stick. The first drop of blood will be wiped from the finger; the second-third drops will 
be used for RDT-based tests, and where applicable, the four-seventh collected on filter paper for later 
analysis. 
 
Health staff throughout the project area will also receive dedicated training on best practices in facility-
level data collection, and regular supportive supervision to ensure data quality and completeness 
throughout the study period by district project coordinators. These trainings will also include use of SOPs 
for the reporting of any AEs or SAEs from within the catchment areas. 

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4.7.8 Community sensitization and communication 
To prepare communities for intervention roll-out and survey data collection, community sensitization 
and engagement activities will be implemented. Prior work in the GMS has highlighted the critical role 
of these activities in successful implementation of drug-based approaches at the community level [50]. 
Specifically, the need for local health staff and community leaders to be the primary conveyors of study 
information (as opposed to study staff) is a critical component of high levels of community participation.  
 
Included in this package will be a general informational letter and accompanying flyer for districts and 
local communities. These documents will include information about the purpose, procedures, and the 
importance of household participation. Meetings will be coordinated with the local DAMNs and among 
local community leaders in advance of the training and campaign activities, and in addition to the 
meetings with health facility and community health workers. 
4.7.9 Study organization and management 
The study will be under the overall management of CMPE with oversight being provided by the MOH. 
Implementation and general management of the various activities will be done by CMPE and NIOPH, 
with UCSF providing programmatic and technical support. Administratively, health services are 
decentralized in Lao PDR and therefore the DAMNs in Champasak Province will provide supervisory 
oversight at district level. 
 
5 Potential risks, limitations, data quality assurance, and dissemination plan 
5.1 Potential risks from participation 
Detailed discussion of potential AEs related to drug regimens is discussed above in section 4.2. Finger 
pricks for RDTs and DBS are associated with small risks of bleeding, hematoma, and infection. To minimize 
these risks, the skin will be cleaned with alcohol prior to puncture, and sterile unused lancets will always 
be used, and pressure will be placed on the puncture site after removal of the lancet using sterile gauze. 
Although the quantity of blood drawn would not lead to any ill effects on the participants’ health, some 
adults and rarely children feel faint from the blood during the finger prick. The risks will be minimized by 
having trained health staff perform all procedures, and all untoward effects will evaluated by health center 
staff. 
5.2 Limitations 
Several limitations have the potential to compromise study outcomes. 
 
Malaria declines 
There may be large-scale changes in malaria incidence and prevalence throughout the study area over 
the course of the 12-month implementation period, which could compromise study power.  
 
Malaria increases 
Any large increases in malaria burden or other diseases (e.g., dengue) in target districts could increase 
overall caseloads at health centers, potentially impacting availability of VMWs/VHVs or other staff to 
support test and treat campaigns, especially in areas with ethnic minorities where their expertise is 
crucial. 
 
Widespread HRP2/3 deletions 
There have been no surveys for P. falciparum HRP2/3 deletions in Lao PDR, and only limited data from 
other settings in the GMS: in China and Myanmar deletions were detected in 4/87 samples (unpublished 

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data WHO MPAC, 2017). If these deletions are common in the study sites [51], the impact of HRP2-based 
test and treat could be severely compromised. P. falciparum positive DBS from the baseline cross-
sectional survey will be rapidly analyzed to assess the level of HRP2/3 deletions in Southern Lao PDR. 
 
Changes in forest-going activity patterns 
The Lao government decree (May 2016) is believed to have had a major impact on the total number of 
illegal and semi-legal forest-goers. However, the future status is unknown; if there are changes to the 
decree itself or to its enforcement, the PNs could potentially be overwhelmed with interviews or 
sampling sites to target. 
 
Mobility of target populations 
The fluxional nature of HRPs targeted in this intervention and the mobility inherent in forest-based 
economic activities has the potential to contaminate the HCCA-level randomization. While HRPs may 
freely transit between intervention and non-intervention arms, and thereby ‘carry-over’ PN-led 
interventions, the use of unique IDs will allow the impact of these movements to be assessed and 
adjusted for in exploratory analyses. 
 
Other partners’ interventions impact study outcomes 
The implementation of diverse programs by other partners across the study area has the potential to 
impact study outcomes if implementation is differential across the study arms. The nature of the 
randomization should minimize biases from partner activities, and a detailed matrix of other project 
activities will be created, and used to assess and adjust outcomes for exploratory analyses.  
5.3 Data quality assurance plan 
 
Data quality and management 
Data collection will occur in multiple locations, and differences in data collection systems may exist at 
different locations, which could potentially bias results. However, study teams and regular health staff 
will receive comprehensive training, as well as ongoing evaluation, supervision, and supplementary 
capacity building as necessary to ensure data quality and completeness. 
 
Procedures to minimize biases 
A survey instrument based on the formative work (carried out in December 2016) will be developed in 
English with input from collaborators at CMPE. This will then be translated to Lao and back-translated 
by a fluent bilingual health expert before field testing. Any ethnic minority language interviews will be 
conducted in the appropriate language, and translated into Lao. Formative work will assess the feasibility 
of using tablets for data entry versus paper questionnaires. A pilot study will test the utility of the survey 
instruments; these data will then be discarded if significant changes are made to the survey instrument. 
Study coordinators will be responsible for monitoring data quality to ensure that questionnaires are 
completed and entered correctly. 
 
Potential changes to this protocol based on the piloting of tools and methods  
The organization and supervision of the peer navigators may be changed based on initial feasibility 
studies during field-testing of survey instruments. 
5.4 Dissemination Plan 
The finalized protocol will be filed at http://www.clinicaltrials.gov/ prior to implementation, and will 
conform to CONSORT recommendations for cluster randomized trials [52]. 

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The results of the baseline survey, as well ‘hotspots’ identified during village-level MTAT and peer-
navigator led FTAT activities will be shared on a real-time basis with national, provincial, district and 
village-level partners as well as other key stakeholders (i.e., WHO, CHAI, PSI) throughout implementation 
to ensure that the most up-to-date information about malaria is available in the target districts.  
 
6 Budget 
 
No. 
Description 
 Total  
A 
START-UP OPERATIONS 
  
1 IRB Application 
 2,000,000  
2 Pilot testing (early August 2017) 
 18,571,429  
SUBTOTAL START-UP OPERATIONS 
 20,571,429  
B 
TRAININGS AND PROJECT ORIENTATION 
  
1 Core study team training (3 days in Vientiane) 
 11,350,000  
2 Project orientation (1 day in Pakse) 
 41,548,571  
3 Cross-sectional survey training - (3 days in Pakse following orientation - 
November 2017) 
 28,364,000  
4 Health facility staff training on A3 and AE reporting, G6PD (2 days in Pakse 
following cross-sectional training) 
 55,660,000  
5 PN training (4 days in Pakse - December 2017) 
 71,194,286  
6 MTAT training (4 days in Pakse - January 2017) 
 67,610,286  
SUBTOTAL TRAININGS AND PROJECT ORIENTATION 
 275,727,143  
C 
CROSS-SECTIONAL SURVEYS AND INTERVENTIONS 
  
1 Baseline survey (HH survey, RDT, HS-RDT, and DBS/PCR) 
 105,900,000  
2 Endline survey (HH survey, RDT, HS-RDT, DBS/PCR, and qualitative FGDs/KIIs) 
 105,900,000  
3 MTAT staff (3 rounds x 30 days/round = 90 days) 
 379,400,000  
SUBTOTAL CROSS-SECTIONAL SURVEY AND INTERVENTIONS  
 591,200,000  
D 
EQUIPMENT AND SUPPLIES 
  
1 Vehicle, equipment, and supplies 
 28,000,000  
2 Communications, community sensitization and IEC/BCC materials 
 42,720,000  
SUBTOTAL EQUIPMENT AND SUPPLIES 
 70,720,000  
E 
SUPERVISION AND MONITORING   
  
1 Supervision and monitoring visit by MoH (DCDC, CMPE and NIOPH) 
 67,771,429  
SUBTOTAL SUPERVISION AND MONITORING 
 67,771,429  
Grand total 
 1,025,990,000  
 
 
7 Timeline 
 
Table 9. Preliminary timeline for project activities 
 

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8 References 
 
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9 Appendices 
9.1 Annex A. Detailed schematic of study design 
 
Figure A1. Detailed schematic of villages within split-plot randomized design 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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9.2 Annex B.  Study power curves 
 
Figure A2. Power curves for study designs with 12 HCCA 
Note: Minimum power at 80%, with total number to be sampled per village 
 
 
 
 
 
 
 

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Figure A3. Power curves for study designs with 14 HCCA 
Note: Minimum power at 80%, with total number to be sampled per village 
 
 
 
 
 
 
 
 

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9.3 Annex C. Cross-sectional survey informed consent form 
9.4 Annex D. Baseline/end-line household survey questionnaire 
9.5 Annex E. Individual blood collection informed consent (cross-sectional survey) 
9.6 Annex F. Blood collection results form (cross-sectional survey) 
9.7 Annex G. MTAT household survey informed consent form 
9.8 Annex H. MTAT household survey questionnaire 
9.9 Annex I. MTAT blood collection informed consent form 
9.10 Annex J. FTAT survey and blood collection informed consent form 
9.11 Annex K. FTAT HRP survey questionnaire  
9.12 Annex L. G6PD testing referral letter 
9.13 Annex M. G6PD health facility register form 
9.14 Annex N. Adverse event reporting form 
9.15 Annex O. Severe adverse event investigation form 
9.16 Annex P. FDG/KII informed consent form 
9.17 Annex Q. MTAT team FGD guide 
9.18 Annex R. Peer navigator FGD guide 
9.19 Annex S. Study team and district KII guide 
9.20 Annex T. Treatment adherence follow-up form 
9.21 Annex U. Peer navigator FTAT competency checklist 
9.22 Annex V. Peer navigator interview guide 
9.23 Annex W. HRP interview guide