Clinical trial NCT01955382
Conditions: Malaria Severe Malaria
Keywords: Parasite Clearance Rate Parasite Half Life Actidose Aqua Severe Malaria
Sponsor: National Institute of Allergy and Infectious Diseases (NIAID)
Start date: 2013-09-01; Completion date: 2015-07-01
Enrollment: 70 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
Background:

\- Malaria is caused by small parasites carried by some mosquitoes. People can get malaria if an infected mosquito bites them. Malaria destroys red blood cells. Most malaria is mild, but some children develop severe malaria, which kills about 660,000 people annually. About 9 in 10 who die of malaria are Sub-Saharan African children, most under 5 years old. Scientists can save many lives if they find out how to prevent or relieve severe malaria.

Objective:

\- To know if a common medicine called activated charcoal can reduce severe malaria symptoms.

Eligibility:

\- Children 2 to 11 years old with mild malaria who live in Kenieroba, Mali.

Design:

* For the first 2 days and nights, participants will stay in the hospital.
* They will have their medical history taken, and a physical exam.
* Blood will be drawn from a thin tube inserted in their hand or forearm. This will be done 3 times overall. A drop of blood will be taken from a finger prick 12 times overall.
* An antimalarial drug will be injected into the tube in the arm 4 times. Each time the drug is given, participants will drink a small cup of either water or activated charcoal.
* For the following 3 days, participants will take an antimalarial pill.
* On day 7, participants will visit the hospital. A drop of blood from a finger prick will be tested for malaria parasites.

Detailed description:
While the incidence of Plasmodium falciparum malaria declines (1) the proportion of cases with severe malaria (SM) may increase (2). The mortality associated with SM in endemic countries remains high despite the use of artesunate (AS) (3). Safe, cheap, and effective adjunct therapies preventing the development of, or reducing the mortality from, SM could have considerable and rapid public health impact. We discovered that oral administration of activated charcoal (oAC), a safe treatment for acute poisoning (4), protects mice from experimental cerebral malaria and demonstrated in a randomized controlled trial (RCT) in African adults that oAC is safe and does not interfere with the pharmacokinetics of AS (5). Here, we propose the next step to evaluate the efficacy of adjunct treatment with oAC in Malian children and to explore its mode of action. Before testing adjunct treatment with oAC in children with SM, we will perform an open-label RCT in children with uncomplicated malaria (UM) to demonstrate non-inferiority of intravenous (IV) AS plus adjunct oAC vs. IV AS alone with regards to parasite clearance rate. This study will be conducted in African children, because they are the primary target population for such an intervention. Although the adequate standard-of-care treatment for UM is oral (PO) administration of an artemisinin-based combination therapy (ACT), we will treat participants with IV AS. Like ACT treatment of UM, AS is the WHO-recommended first-line treatment for SM (1). In order for the data obtained from UM cases to be meaningful for our future studies in children with SM, we will administer AS to the UM cases in this trial via the same IV route that is used to administer AS to SM cases. Exploratory objectives include: (i) to compare the kinetics of plasma cytokines in both groups, and (ii) to preserve RNA for gene transcription analysis for future studies into the mode of action of oAC. The study will be nested within an NIAID-funded study (Principal Investigators Drs. Fairhurst, Diakite) that assesses parasite clearance rates in response to AS treatment in Kenieroba (6). Children aged 2-10 years with UM and initial parasite densities 10,000 70,000 parasites per micro L will be enrolled. Parasite clearance rates will be expressed as the parasite half-life (Ph), estimated from parasite clearance curves using a formula that has been validated in this cohort (7). Children will be randomized 1:1 to receive IV AS+oAC or IV AS only, respectively, until complete specimen and data sets for 35 children per group are obtained. oAC will be administered as Actidose Aqua\[registered\] at 0, 6, 12, and 18 hours. AS will be administered IV following WHO recommendations for use of AS in SM (8), followed by 3 daily doses of amodiaquine (AQ). Subsequently and in a separate study, we plan a proof-of-concept RCT to determine whether adjunct oAC reduces disease severity and morbidity (assessed by scoring systems (9)) in hospitalized children with SM and to define the mode of action of oAC. Since oAC is a licensed, inexpensive drug without sophisticated storage requirements, which has an extremely long shelf life at room temperature and can be given orally or via nasogastric tube at high doses without major side effects (4, 10), this drug has an ideal profile for use at the primary health-care level to reduce mortality from SM, or even prevent the development of SM.

Arms: arm 1: All children will receive Artesunate (AS) 2.4 mg/kg IV at 0 and 12 h, 24 h, and 48 h. Children in the AS+oAC group will be given weight-based doses of oAC (Actidose Aqua) (Table 1) at 0, 6, 12, and 18 h. All children will then receive amodiaquine. arm 2: Children in the AS only group will receive a weight-based volume of clean water (Bottled Water) to drink rather than the oAC.
Interventions: intervention 1: Actidose Aqua intervention 2: Artesunate intervention 3: Amodiaquine
Intervention descriptions: intervention 1: Actidose Aqua (oAC) (Paddock Laboratories is sold over the counter in the United States in bottles containing 25 g/120 mL (NDC # 0574-0121-04) or 50 g/240 mL (NDC # 0574-0121-08). oAC is stable at room temperature. intervention 2: Artesunate (AS) obtained from Guilin Pharma (Shanghai), the only pharmaceutical company GMP pre-qualified by the WHO. The product artesunate for injection + 5% sodium carbonate inj + 0.9% sodium chloride inj will be delivered in vials of 30 mg and 60- mg vials, respectively, and will be dosed at 2.4 mg/kg as recommended for SM treatment by the WHO intervention 3: Amodiaquine obtained from Pfizer (Dakar), is provided as 200-mg tablets or syrup (50 10 mg/mL), and will be provided as age-based doses per the manufacturer's directions.

Protocol documents:
Prot_SAP_000.pdf: 
National Institute of Allergy and Infectious Diseases (NIAID) 
National Institutes of Health (NIH) 
 
PROTOCOL FACE SHEET 
 
NIH Principal Investigator: 
Institute/Branch: 
Address: 
Phone: 
           Email: 
Rick M. Fairhurst, MD, PhD 
NIAID/LMVR 
Room 3E-10A, 12735 Twinbrook Pkwy, Rockville, MD 20852 
301-402-7393 
rfairhurst@niaid.nih.gov 
NIH Co-Principal Investigator: 
Institute/Branch: 
Address: 
Phone: 
           Email: 
Michael Walther, MD, PhD 
NIAID/LMIV 
12441 Parklawn Drive, Rockville, MD 20852 
301-827-4732 
michael.walther@nih.gov 
Protocol Number: 
13-I-N209 
Version Description:  
Version 1.0 
Version Date:  
September 4, 2013 
Protocol Title: 
Effect of Oral Activated Charcoal on Parasite Clearance Rates 
in Response to Intravenous Artesunate in Malian Children with 
Uncomplicated Plasmodium falciparum Malaria 
Abbreviated Title: 
Oral Activated Charcoal in Uncomplicated Malaria 
IRB Name:  
NIAID 
Institute Name:  
NIAID 
Proposed Dates: 
August-December, 2013 
Total Subjects to be Accrued: 200 maximum (to enroll 70 children from whom complete 
sample and data sets are collected) 
Ionizing Radiation Use:  
None 
Is Tissue Being Collected for 
Research Purposes? 
Yes (whole blood only) 
Location of the Study 
Kenieroba, Mali 
Research Contact: 
Address: 
Phone: 
Email: 
Prof. Mahamadou Diakite 
BP 1805, Point G, Bamako, Mali 
(223) 76 23 11 91 
mdiakite@icermali.org 
Medically Advisory 
Investigator:  
None (Dr. Fairhurst is a member of the NIH Clinical Center 
Junior Credentialed Medical Staff; Dr. Walther is a member of 
the NIH Clinical Center Senior Credentialed Medical Staff) 


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Oral Activated Charcoal in Uncomplicated Malaria  
STUDY STAFF ROSTER 
 
Name, Degree Professional 
Designation 
Organization 
(Institute/Branch) 
Phone # Protocol Role Medical 
Decision 
Maker 
Informed 
Consent 
Mahamadou 
Diakite, 
PharmD, DPhil 
Assistant 
Professor 
Faculte de 
Pharmacie, USTTB, 
Mali 
(223) 76 
23 11 91 
Co-Principal 
Investigator 
No 
Yes 
Saibou 
Doumbia, MD 
Study 
Clinician 
Faculte de 
Pharmacie, USTTB, 
Mali 
(223) 76 
47 93 87 
Associate 
Investigator 
Yes 
Yes 
Carole A. Long, 
PhD 
Section Head LMVR/NIAID/NIH 
301-496-
3655 
Associate 
Investigator 
No 
No 
Jennifer M. 
Anderson, PhD 
Staff Scientist LMVR/NIAID/NIH 
301-435-
3587 
Associate 
Investigator 
No 
No 
 
 
Multi-site Collaboration: Foreign Sites Only 
 
Organization Name 
Country 
City/State 
Assurance Type/Number 
Faculte de Pharmacie, 
Universite des Sciences, 
Techniques et Technologies 
de Bamako (USTTB), Mali 
Mali 
Bamako 
FWA #1769, IRB #1983 
Expires 12/14/2013 
 
 
 


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Oral Activated Charcoal in Uncomplicated Malaria  
TABLE OF CONTENTS 
 
STUDY STAFF ROSTER ................................................................................................ 2 
TABLE OF CONTENTS .................................................................................................. 3 
ABBREVIATIONS........................................................................................................... 5 
PRECIS ........................................................................................................................... 6 
1 INTRODUCTION ....................................................................................................... 7 
1.1 
Background .................................................................................................................... 7 
2 STUDY OBJECTIVES ............................................................................................... 9 
2.1 
Primary Objective ........................................................................................................... 9 
2.2 
Exploratory Objectives .................................................................................................... 9 
3 STUDY DESIGN AND METHODS .......................................................................... 10 
3.1 
Study Sites ................................................................................................................... 10 
3.2 
Study Procedures ......................................................................................................... 10 
4 STUDY POPULATION ............................................................................................ 11 
4.1 
Rationale for Subject Selection ..................................................................................... 11 
4.2 
Recruitment Plans and Procedures .............................................................................. 11 
4.3 
Description of the Consent Process .............................................................................. 12 
4.4 
Subject Inclusion/Exclusion Criteria .............................................................................. 12 
4.4.1 
Inclusion Criteria .................................................................................................... 12 
4.4.2 
Exclusion Criteria ................................................................................................... 12 
4.5 
Criteria for Withdrawal of Subjects from the Study ........................................................ 12 
4.6 
Plan for Maintaining Privacy and Confidentiality of Subject Records ............................ 13 
5 STUDY AGENT ....................................................................................................... 13 
5.1 
Study Agent, Storage, and Stability .............................................................................. 13 
5.2 
Preparation, Administration, and Dosage ..................................................................... 14 
6 ANALYSIS OF THE STUDY ................................................................................... 15 
6.1 
Sample Size and Power Calculations ........................................................................... 15 
6.2 
Analysis plan ................................................................................................................ 16 
6.3 
Primary and Secondary Outcomes ............................................................................... 17 
6.3.1 
Primary Outcome ................................................................................................... 17 
6.3.2 
Secondary Outcomes ............................................................................................ 17 
7 STUDY PROCEDURES AND EVALUATION ......................................................... 17 
7.1 
Detailed Study Procedure Schedule ............................................................................. 17 
7.2 
Clinical Evaluation ........................................................................................................ 22 
7.3 
Laboratory Evaluation................................................................................................... 22 


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8 POTENTIAL RISKS AND BENEFITS ..................................................................... 22 
8.1 
Potential Risks.............................................................................................................. 22 
8.2 
Potential Benefits ......................................................................................................... 23 
9 ASSESSMENT OF SAFETY AND ADVERSE EVENT REPORTING PLAN .......... 23 
9.1 
Definitions .................................................................................................................... 23 
9.2 
Recording/Documentation ............................................................................................ 24 
9.3 
Reporting Procedures................................................................................................... 24 
9.3.1 
Expedited Reporting .............................................................................................. 24 
9.3.2 
Annual Reporting ................................................................................................... 24 
10 DATA AND SAFETY MONITORING PLAN .......................................................... 24 
11 DATA MANAGEMENT PLAN ............................................................................... 24 
12 PROTOCOL MONITORING PLAN ....................................................................... 25 
13 RESEARCH USE OF STORED HUMAN SAMPLES, SPECIMENS, OR DATA ... 25 
14 RECORD RETENTION ......................................................................................... 26 
15 REMUNERATION PLAN FOR SUBJECTS .......................................................... 26 
SCIENTIFIC REFERENCES ......................................................................................... 27 
Appendix 1:  oAC treatment of mice with P. berghei ANKA (PbA) infection affects T 
cell cytokine production. ............................................................................................ 31 
Appendix 2:  Gene expression profiling of AC-treated PbA-infected mice ............. 31 
Appendix 3:  Actidose Aqua ® package insert (see separate pdf) ................................ 33 
Appendix 4:  Actidose Aqua ® safety data sheet (see separate pdf) ............................ 33 
Appendix 5:  Grading of local reactogenicity at IV catheter site .................................... 33 
 
 


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ABBREVIATIONS 
 
AE 
adverse event 
AQ 
Amodiaquine 
AS 
Artesunate 
AUC 
area under the curve 
BSI 
Biological Sample Inventory 
CBC 
complete blood count 
CM 
cerebral malaria 
Cmax 
maximum drug concentration 
CRF 
case report form 
DCA 
Dichloroacetate 
DHA 
Dihydroartemisinin 
ECM 
experimental cerebral malaria 
FWA 
Federal-wide Assurance 
GCP 
Good Clinical Practice 
h 
Hour 
ICF 
informed consent form 
IRB 
Institutional Review Board 
IV 
Intravenously 
LMIV 
Laboratory of Malaria Immunology and Vaccinology 
LMVR 
Laboratory of Malaria and Vector Research 
NIAID 
National Institute of Allergy and Infectious Diseases 
NIH 
National Institutes of Health 
oAC 
oral activated charcoal 
OHRP 
Office for Human Research Protections 
PbA 
Plasmodium berghei ANKA 
Ph 
parasite half-life  
pi 
post infection 
PI 
principal investigator 
PO 
Orally 
RBC 
red blood cell 
RCHSPB 
Regulatory Compliance and Human Subjects Protection Branch 
SAE 
serious adverse event 
sec 
Second 
SM 
severe malaria 
t1/2 
drug clearance half-life 
tmax 
time to maximum drug concentration 
UM 
uncomplicated malaria 
UPnonAE 
unanticipated problem that is not an adverse event 
USTTB 
Universite des Sciences, Techniques, et Technologies de Bamako 
 
 
 


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Oral Activated Charcoal in Uncomplicated Malaria  
PRECIS 
 
While the incidence of Plasmodium falciparum malaria declines (1) the proportion of cases with 
severe malaria (SM) may increase (2). The mortality associated with SM in endemic countries 
remains high despite the use of artesunate (AS) (3). Safe, cheap, and effective adjunct 
therapies preventing the development of, or reducing the mortality from, SM could have 
considerable and rapid public health impact. We discovered that oral administration of activated 
charcoal (oAC), a safe treatment for acute poisoning (4), protects mice from experimental 
cerebral malaria and demonstrated in a randomized controlled trial (RCT) in African adults that 
oAC is safe and does not interfere with the pharmacokinetics of AS (5). Here, we propose the 
next step to evaluate the efficacy of adjunct treatment with oAC in Malian children and to 
explore its mode of action. Before testing adjunct treatment with oAC in children with SM, we 
will perform an open-label RCT in children with uncomplicated malaria (UM) to demonstrate 
non-inferiority of intravenous (IV) AS plus adjunct oAC vs. IV AS alone with regards to parasite 
clearance rate. This study will be conducted in African children, because they are the primary 
target population for such an intervention. Although the adequate standard-of-care treatment for 
UM is oral (PO) administration of an artemisinin-based combination therapy (ACT), we will treat 
participants with IV AS. Like ACT treatment of UM, AS is the WHO-recommended first-line 
treatment for SM (1). In order for the data obtained from UM cases to be meaningful for our 
future studies in children with SM, we will administer AS to the UM cases in this trial via the 
same IV route that is used to administer AS to SM cases. Exploratory objectives include: (i) to 
compare the kinetics of plasma cytokines in both groups, and (ii) to preserve RNA for gene 
transcription analysis for future studies into the mode of action of oAC. The study will be nested 
within an NIAID-funded study (Principal Investigators Drs. Fairhurst, Diakite) that assesses 
parasite clearance rates in response to AS treatment in Kenieroba (6). Children aged 2-10 years 
with UM and initial parasite densities 10,000–70,000 parasites per µL will be enrolled. Parasite 
clearance rates will be expressed as the parasite half-life (Ph), estimated from parasite 
clearance curves using a formula that has been validated in this cohort (7). Children will be 
randomized 1:1 to receive IV AS+oAC or IV AS only, respectively, until complete specimen and 
data sets for 35 children per group are obtained. oAC will be administered as Actidose Aqua® at 
0, 6, 12, and 18 hours. AS will be administered IV following WHO recommendations for use of 
AS in SM (8), followed by 3 daily doses of amodiaquine (AQ). Subsequently and in a separate 
study, we plan a proof-of-concept RCT to determine whether adjunct oAC reduces disease 
severity and morbidity (assessed by scoring systems (9)) in hospitalized children with SM and to 
define the mode of action of oAC. Since oAC is a licensed, inexpensive drug without 
sophisticated storage requirements, which has an extremely long shelf life at room temperature 
and can be given orally or via nasogastric tube at high doses without major side effects (4, 10), 
this drug has an ideal profile for use at the primary health-care level to reduce mortality from 
SM, or even prevent the development of SM. 
 
 


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1 INTRODUCTION  
1.1 Background 
The fight against malaria has received considerable attention recently, with major funding 
organizations even proposing eradication (2, 3). However, despite documented declines in 
clinical malaria in sub-Saharan Africa over the last decade (4-6), coinciding with substantial 
reductions in overall mortality in children <5 years old, malaria-attributable mortality remained 
stable in West Africa, and even increased in East and South Africa throughout this period (7, 8). 
Estimates of case-fatality rates from severe malaria (SM) still range from 10% to 50% (9, 10) 
and have recently been reported as 15% and 8.5% in Southeast Asia (11) and Africa (12), even 
when using parenteral artesunate (AS) under optimized study conditions. New tools to prevent 
the development of, or reduce mortality from, SM are thus urgently required. 
Over several decades, dexamethasone, low-molecular-weight dextrans, osmotic agents, 
heparin, adrenaline, cyclosporine A, prostacyclin, pentoxifylline, hyperimmune globulin, 
desferrioxamine, prophylactic anticonvulsants, and monoclonal anti-TNF antibodies have all 
been investigated as adjunct treatments for SM without success (13). While dichloroacetate 
(DCA) was evaluated (14-17) and shown to reduce hyper-lactatemia in patients with SM, no 
published studies have assessed mortality. Volume expansion with saline or albumin suggested 
some benefit (18), but a recent multi-center study in African children showed that any fluid bolus 
is associated with a significantly increased risk of dying (19). Levamisole was found to impair 
the sequestration of infected red blood cells (RBCs) in patients with uncomplicated malaria (UM) 
(20), while exploitation of N-acetylcysteine’s anti-oxidant properties failed (21). Rosiglitazone, an 
oral anti-diabetic drug, enhanced parasite clearance and reduced inflammatory responses in 
UM (22), and improved outcome in mice with experimental cerebral malaria (ECM) (23). Case 
reports suggest benefits from drotrecogin alfa in patients with cerebral malaria (CM) and 
disseminated intravascular coagulation (24). The compatibility of levamisole, DCA, and 
rosiglitazone with AS is not yet established. Due to parenteral administration, the use of DCA 
remains limited to the clinic setting. The efficacy of levamisole and rosiglitazone in SM is not yet 
established, and the use of the latter in resource-poor settings is limited by current pricing and 
the need to monitor for hepatotoxicity. Penet et al. recently proposed pantethine as adjunct 
therapy, though multiple parenteral doses from 1 day post-infection (pi) was required for efficacy 
in mice (25). Human recombinant erythropoietin prevents death in mice with ECM (26, 27) and 
will soon enter clinical trials (28, 29), but its price will limit its use to developed countries. 
 
Oral activated charcoal (oAC) is a licensed, orally-administered drug that is widely used to treat 
acute poisoning (30), and more recently to treat some inflammatory diseases (31). oAC 
provides excellent levels of protection against ECM, following infection of C57BL/6 mice with 104 
Plasmodium berghei ANKA (PbA)-infected RBCs (32), a model acknowledged to share many 
characteristics with human CM (33). As shown in Figure 1, only 21.7% (5/23) of untreated PbA-
infected mice survived past Day 7 and 0% (0/23) survived past Day 9. In contrast, mice 
administered oAC (Actidose-Aqua®) by oral gavage on Days 3 and 5 pi were highly resistant to 
developing ECM, with 87.1% (27/31) surviving past Day 7 and 54.8% (17/31) surviving past Day 
9. As no antimalarial drugs were administered, oAC-treated mice eventually developed 
hyperparasitemia and died. Nevertheless, oAC significantly prolonged overall survival time 
(2=37.8, p<0.0001; hazard ratio 16.4, 95%CI 6.73-40.1). 
 
 


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Oral Activated Charcoal in Uncomplicated Malaria  
 
 
A separately-sourced stock of oAC (Aktivkohle®) was also highly effective in preventing ECM 
(40% protection, p<0.002) and also had no impact on parasitemia (not shown). There was no 
difference in ECM protection between mice receiving oAC on Days 4, 5, and 6 pi and those 
receiving oAC on Days 3 and 5 pi (p=0.54). Most importantly, mice receiving only one dose of 
oAC on Day 6 pi (at the onset of clinical symptoms) were also protected against ECM (100% vs. 
40% survival at Day 7 for oAC-treated and untreated PbA-infected mice), but ultimately died 
from the disease. 
 
We conclude that oAC given shortly prior to the onset of severe illness is highly efficient in 
preventing ECM, and that repeated administration of oAC maximizes benefit. Even when oAC 
was given at the onset of ECM symptoms, it clearly postponed death from ECM, suggesting that 
repeated dosing even at this stage – which is readily feasible in humans, but technically 
challenging in mice – has the potential to reduce mortality from SM.  
 
While the precise mode of action of oAC in preventing ECM is unknown, its efficiency in 
reducing the progression of chronic kidney disease (31) – an essentially chronic inflammatory 
process – suggests oAC has immune-modulatory properties. In line with this possibility, we 
observed a lower pro-inflammatory response by CD4+ and CD8+ T cells in the spleen of oAC-
treated compared to untreated PbA-infected mice (Appendix 1). Whole-blood gene expression 
profiling (Appendix 2) identified transcriptional biomarkers potentially associated with oAC-
mediated ECM protection, with many differentially-regulated genes controlling the acute phase 
of inflammation, and suggested that oAC treatment failures can be detected (32). Preliminary 
bioinformatics analysis identified butyric acid to be one of the differentially-regulated metabolites 
in oAC-treated mice (Aziz and Kaye, unpublished), which is known for its anti-inflammatory 
properties (34). Alternatively, other studies suggest that oAC adsorbs cytokines secreted in bile, 
thereby preventing their enterohepatic recirculation (35). In the murine ECM model, however, 
oAC did not influence the TNF clearance rate in serum (Kaye et al., unpublished). 
 
To assess whether oAC affects the pharmacokinetics of intravenous (IV) AS, a controlled, 
randomized, open-label phase 1 pharmacokinetics study (ISRCTN #64793756) was conducted 
by the UK Medical Research Council in The Gambia with healthy (i.e., not infected with P. 
falciparum) adults being randomized to one of three study arms to receive: (1) water and AS 
simultaneously, (2) 50g oAC and AS simultaneously, or (3) 50g oAC 1 h after AS (32). Drugs 
were administered on admission and 12 h later. In addition to standard clinical and biochemical 
safety assessments, plasma levels of AS and its active metabolite dihydroartemisinin (DHA) 
were measured by liquid chromatography – mass spectrometry at 5, 10, 15, 30, 60, and 90 min, 
and at 3 and 6 h after the second dose of AS was given (at 12 h) to determine Cmax, tmax, t½, and 
AUC parameters. Study drugs were safe and well-tolerated, and no serious adverse events 
Figure 1:. oAC treatment prevents ECM.  
C57BL/6 mice were infected with PbA. On day 3 and 
day 5 pi, mice were left untreated (red) or treated 
with oAC (blue). Survival was monitored over 25 
days. The window for CM deaths (days 6-9) is 
indicated by the hatched bar. Data pooled from 5 
independent experiments (n= 23 untreated, n= 31 
oAC-treated mice) are shown with 95%CIs (dotted 
lines). Overall survival was significantly improved by 
oAC treatment (p<0.0001). 


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(SAEs) occurred. No clinically-relevant deviations from normal ranges were observed for 
complete blood count (CBC) and biochemistry tests. For AS and DHA, the geometric mean 
AUC was similar between the three study arms (32), indicating that oAC does not affect the 
pharmacokinetics of IV-administered AS and its DHA metabolite. 
 
Based on intriguing data we obtained in murine ECM and human pharmacokinetics studies (32), 
we propose to clinically evaluate adjunct oAC treatment in Malian children with P. falciparum 
malaria. Unlike other candidate adjunct therapies, oAC perfectly fits the ideal profile of a drug to 
be successfully used at the community level in developing countries: oAC is inexpensive, has 
undemanding storage requirements, has an extremely long shelf-life at room temperature, and 
can be given orally or via nasogastric tube at high doses without major side effects (30, 31, 36). 
In addition to an adjunct treatment for children with SM, oAC may also complement existing 
prevention strategies (37). For example, when administered to children with UM in a primary 
health-care setting, oAC may prevent the development of SM and thus reduce mortality. 
 
The ultimate aim of this protocol and future clinical studies is to determine whether adjunct oAC 
treatment reduces SM mortality and/or prevents the progression of UM to SM episodes. We 
envision a three-step process in which we have already completed the 1st step: demonstrating 
that IV AS and oAC can be co-administered without oAC interfering with the pharmacokinetics 
of AS or DHA (32). Here we describe an open-label, randomized controlled trial (2nd step) to 
determine whether adjunct oAC treatment of children with UM affects parasite clearance rates in 
response to IV AS. If this study concludes that oAC does not slow parasite clearance rates, we 
will conduct a randomized controlled trial (3rd step) to (i) test whether adjunct oAC treatment 
reduces SM morbidity and mortality, and (ii) exploit gene profiling to explore the mode of action 
of oAC and define transcriptional biomarkers for treatment response. 
 
On a previous NIAID protocol (#08-I-N120), we treated UM in 215 Malian children aged 0.5-15 
years with directly-observed, weight-based doses of AS (0, 24, 48 h) and amodiaquine (AQ) 
(72, 96, 120 h), both given orally. We estimated the parasite half-life (a measure of parasite 
clearance rate) using parasite density counts in blood every 6 h until parasitemia was 
undetectable, and evaluated the effects of age, sex, ethnicity, and RBC polymorphisms on half-
life. The half-life, the time it takes for parasite density to decrease by 50%, was calculated from 
the linear portion of the parasite clearance curve. The geometric mean half-life was 1.9 h 
(95%CI 1.8-2.0) (38). In a linear model accounting for host factors, half-life decreased by 4.1 
min for every 1-year increase in age. We thus established the parasite clearance kinetics in 
response to AS in Malian children with UM, and have used the relevant data to design the 
present study. Here we propose to investigate whether adjunct oAC treatment affects the 
parasite half-life in response to AS in Malian children with UM. To mimic the treatment scenario 
for SM patients, we intend to treat UM patients with IV AS. 
2 STUDY OBJECTIVES 
2.1 Primary Objective 
• 
Demonstrate that co-administration of IV AS and oAC is not inferior to administration of 
IV AS alone, with regard to the parasite half-life. 
2.2 Exploratory Objectives 
• 
Assess the effects of oAC on the kinetics of selected cytokine levels in plasma. 
• 
Assess the effects of oAC on whole-blood transcriptional profiles over time. 


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3 STUDY DESIGN AND METHODS 
3.1 Study Sites  
We will conduct this protocol in Kenieroba, Mali, where malaria transmission is highly endemic 
and seasonal. In this village, we recently completed a longitudinal cohort study of malaria 
incidence in which we followed 1350 children aged 0.5-17 years and diagnosed 4200 malaria 
episodes over 4 transmission seasons in 2008-2011. In a subset of 160 children aged 2-10 
years, the geometric mean parasite half-life in response to oral AS was 1.9 h (38). It could be 
argued this study should initially be performed in adult patients. However, this is not feasible 
logistically, since adults living in malaria-endemic areas are immune to clinical malaria, and thus 
are very unlikely to present to clinic when they are infected with P. falciparum. Also, parasite 
densities in such adults are very low, which precludes proper calculation of parasite clearance 
rates. 
3.2 Study Procedures 
In an open-label, randomized controlled study we will compare parasite half-lives between 
children receiving AS or AS+oAC, and assess the safety of AS+oAC, in the 2013 transmission 
season. 
 
While it would be desirable to perform a double-blinded study, this is not possible because, to 
our knowledge, there is no appropriate placebo that would match Actidose®-Aqua in taste, 
appearance, and viscosity. We are aware that the lack of double blinding is a potential source of 
bias. However, we feel that in this study risk is minimal because the primary outcome measure - 
parasite clearance rate - is an objective parameter that cannot be influenced willingly or 
unconsciously by either the participant or the investigator administering the study drug. The 
slide reader producing the raw data for parasite clearance rates will be blinded to the 
participant’s group allocation. 
 
Children will be randomized (1:1) to either the “AS” or “AS+oAC” study arms using block 
randomization, with block sizes ranging from 6 to 12 children. After obtaining informed consent 
from a parent or legal guardian, we will enroll children aged 2-10 years with UM and parasite 
density 10,000–70,000/µL. We will record axillary temperature, blood pressure, heart and 
respiratory rates, weight, and findings from history and physical examination. Recruitment will 
end when complete sets of data and specimens are obtained for 35 children in each group. 
 
All children will have an IV catheter placed in the arm. All children will receive AS 2.4 mg/kg IV 
at 0 and 12 h, 24 h, and 48 h. Children in the AS+oAC group will be given weight-based doses 
of oAC (Table 1) at 0, 6, 12, and 18 h. Children in the AS group will receive a weight-based 
volume of clean water to drink. After the last dose of AS is given, the IV catheter will be 
removed. All children will receive AQ 10 mg/kg PO at 72 h, 96 h, and 120 h. This drug regimen 
mimics the current WHO-recommended treatment for SM: AS 2.4 mg/kg IV at 0, 12, 24, and 48 
h, followed by an appropriate partner drug on Days 4, 5, and 6 (1). This drug regimen also 
avoids the potential adsorption of AQ by oAC, since 54 h will elapse between the last oAC dose 
and the first AQ dose. 
 
We will hospitalize children for 48 h to monitor their clinical status and IV catheter, and ensure 
the accurate timing of blood sampling. Vital signs, state of consciousness, and selected 
symptoms (nausea, vomiting, diarrhea, constipation, abdominal pain, headache, and dizziness) 
will be monitored at 0, 2, 4, 6, 8, and 12 h, and then every 6 h until 48 hours or until parasitemia 
is undetectable (one negative thick blood film), whichever is later. Finger-prick blood samples 
will be obtained at 0, 2, 4, 6, 8, and 12 h, and then every 6 h until parasitemia is undetectable. In 


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Kenieroba, we previously found that 7%, 13%, 34%, 28%, 16%, and 2% of children aged 2-10 
years (n=160) cleared their parasitemia by 12, 18, 24, 30, 36, and 42 h, respectively (38). We 
therefore expect that finger-prick blood sampling will be completed within 48 h for all children. 
 
We will obtain 3 mL venous blood at 0, 24, and 48 h to perform a complete blood count (CBC) 
with differential and platelet counts, preserve RNA, and store plasma for research purposes. 
Transcriptional profiles and plasma cytokine levels in children with UM children will later be 
compared to those with SM. 
 
We previously found that parasite density did not drop in 61% (98/160), 10% (16/160), and 1.9% 
(3/160) of Malian children (aged 2-10 years) by 6, 12, and 18 h, respectively. These “lag” 
phases reflect the fact that, while AS-treated parasites are being cleared, the simultaneous 
release of merozoites from sequestered rupturing schizonts and their development into new ring 
forms yield an apparent steady-state parasite density. In the 16 children with a 12-h lag phase, 
the mean ratio of the peak parasite density (measured at 0 or 6 h) compared to the 12-h 
parasite density was 1.53 (95%CI 1.31-1.88). Based on these data, children receiving AS+oAC 
who show less than a 2.0-fold reduction in parasite density at 18 h, as calculated by dividing the 
peak parasite density (i.e., the highest value measured at either 0, 2, 4, 6, 8, or 12 h) by the 18-
h parasite density will not receive oAC at 18 h. These children will complete the study per 
protocol, except they will not have blood drawn for research purposes at 24 and 48 h. Children 
receiving AS only who show less than a 2.0-fold reduction in parasite density at 18 h will also 
complete the study per protocol, except they will not have blood drawn for research purposes at 
24 and 48 h. 
 
At the discretion of the study clinician, the clinical monitoring for children who ‘failed’ to begin 
clearing parasites at 18 h may be intensified and an additional dose of 2.4 mg/kg artesunate IV 
may be considered. 
 
If the IV line becomes compromised and cannot be replaced, treatment will be continued with 
intramuscular artemether at the recommended maintenance dose of 1.6 mg/kg every 24 h. A 
change to oral amodiaquine will be made after at least 56 h have passed since the last dose of 
oAC was given. 
4 STUDY POPULATION 
4.1 Rationale for Subject Selection 
Our recent study (#08-I-N120) established baseline parasite half-lives in response to oral AS in 
children aged 2-10 years in Kenieroba, Mali. We are thus in a unique position to test whether 
adjunct oAC treatment affects this parameter in the same study population. The age range 2-10 
years was selected to represent that group of children most likely to experience SM in Mali. 
While new drug regimens are usually tested initially in adult patients, this is not feasible 
logistically in this case, since adults living in malaria-endemic areas are immune to clinical 
malaria, and thus very unlikely to present to clinic when they are infected with P. falciparum. 
Also, parasite densities in such adults are very low, which precludes proper calculation of 
parasite clearance rates. 
4.2 Recruitment Plans and Procedures 
At Kenieroba Health Center, we will recruit patients from children aged 2-10 years who present 
with malaria symptoms and are not enrolled on our concurrent cohort study (#13-I-N107). 


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4.3 Description of the Consent Process 
The study will initially be discussed with Kenieroba leaders, seeking their permission to perform 
this trial. If community leaders agree that the trial can take place, study physicians will obtain 
informed consent from an adult parent or guardian (usually uncles/aunts) of eligible children. 
The Malian Ethics Committee has established that the age of consent in Mali is 18 years and 
the age of assent is 12 years; therefore, we will not obtain assent from children in this study. We 
will present written informed consent forms (ICFs) in French. Most adults will not be able to 
read, and so oral consent will typically be obtained in the local language, documented by the 
study physician, and witnessed (signed) by a third party.  
4.4 Subject Inclusion/Exclusion Criteria 
4.4.1 Inclusion Criteria 
1. Age 2 to 10 years, inclusive 
2. Resident of Kenieroba 
3. Uncomplicated malaria* 
4. P. falciparum density 10,000–70,000/µL, inclusive 
5. Willingness to participate in the study as evidenced by informed consent of the child’s 
parent or guardian 
6. Ability to swallow oral medication 
 
*Uncomplicated malaria: axillary temperature >37.5oC or history of fever in the past few days 
and no criteria of SM (see next paragraph) and no other etiologies of febrile illness (e.g., 
respiratory tract infection) on clinical examination. 
 
Severe P. falciparum malaria: parasitemia of any density and any one of the following: coma 
(Blantyre coma score ≤2), convulsions (witnessed by investigator), severe prostration, severe 
anemia (hemoglobin ≤6 g/dl), respiratory distress, hypoglycemia (serum glucose ≤40 mg/dl), 
jaundice/icterus, shock (systolic blood pressure ≤70 mmHg, rapid pulse, cool extremities), 
cessation of eating and drinking, repetitive vomiting. 
4.4.2 Exclusion Criteria 
1. Severe malaria 
2. Any medical condition or history, including allergy to AS, AQ, artemether or lumefantrine, 
that poses a risk to the prospective participant 
3. Any condition that in the opinion of the investigator would render the participant unable 
to comply with the protocol (e.g., psychiatric disease) 
4. Any health condition that in the opinion of the investigator would confound data analysis 
or pose unnecessary risks to study participants (e.g., severe malnutrition, acquired or 
inherited immunodeficiency) 
5. Requirement for any medication for any concurrent illness or condition 
6. Participation on cohort study #13-I-N107 
7. Repetitive vomiting 
 
4.5 Criteria for Withdrawal of Subjects from the Study 
A child will be considered to not have completed the study for any of these reasons: 
1. Research terminated by Sponsor or Investigator – applies to termination of the entire 
study by the Sponsor or Investigator, or other regulatory authority for any reason 
2. Withdrawal of consent – applies to a child whose parent or guardian withdraws consent 
to participate in the study for any reason 


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3. Noncompliant with protocol – applies to a child who does not comply with protocol-
specific visits or evaluations on a consistent basis, such that adequate follow-up is not 
possible and the child’s safety may be compromised by continuing the study 
4. Developed an AE which requires discontinuation of the study involvement or results in 
inability to continue to comply with study procedures 
5. Other – is used when previous categories do not apply (written explanation required). 
 
If a child is withdrawn prior to completion of the study, the reason for this decision will be 
recorded in the case report form (CRF). If a child is withdrawn because of an adverse event 
(AE) or SAE, research interventions will be discontinued; however, the child will be followed for 
clinical care purposes until resolution of the event. Antimalarial treatment will be continued with 
artesunate and amodiaquine. 
4.6 Plan for Maintaining Privacy and Confidentiality of Subject Records 
Standard CRFs containing clinical and laboratory data will be completed, signed by study 
investigators, and stored in folders in a locked room while in use. Relevant patient data will be 
entered onto a hybrid system (Datafax©) capable of collecting, processing, and storing both 
images of paper documents and data through intelligent character recognition software which 
reads and stores handwritten numbers, dates, and check boxes. Electronically-captured data 
will be checked by study personnel and verified by a data manager. Data will be exported to a 
password-protected relational database program (Access©). All electronic data will be stored on 
a secure server. Access to patient charts and databases for data analysis will be restricted to 
the investigators listed on this protocol and those working under their direct supervision. Access 
to ICFs, which link identifying numbers to names, will be restricted to the Principal Investigators 
(PIs) and the Associate Investigators authorized to obtain consent. The Regulatory Compliance 
and Human Subjects Protection Branch (RCHSPB) and their authorized representatives may 
also have access to the subjects’ study records, including ICFs. CRFs and ICFs will eventually 
be transported to our offices in Bamako, where they will be retained under lock and key by the 
Malian PI and made available for clinical monitoring. 
 
Upon enrollment into the protocol, all patients will be assigned a unique identifying number. The 
ICF will serve to link this identifying number with patient name and signature/thumbprint. CRFs, 
databases, and samples will be coded with unique identifying numbers and will not contain 
subject names. Study personnel involved in data acquisition, entry, and analysis will therefore 
not have access to names, assuring the privacy and confidentiality of subjects. 
5 STUDY AGENT 
5.1 Study Agent, Storage, and Stability 
oAC will be obtained as Actidose Aqua® (Paddock Laboratories), which is sold “over the 
counter” in the United States in bottles containing 25 g/120 mL (NDC # 0574-0121-04) or 50 
g/240 mL (NDC # 0574-0121-08). oAC is stable at room temperature. For further information, 
see Package Insert (Appendix 3) and Drug Safety Sheet (Appendix 4). 
 
AS will be obtained from Guilin Pharma (Shanghai), the only pharmaceutical company GMP 
pre-qualified by the WHO. The product ‘artesunate for injection + 5% sodium carbonate inj + 
0.9% sodium chloride inj’ will be delivered in 60-mg vials and will be dosed at 2.4 mg/kg as 
recommended for SM treatment by the WHO (1). 
 


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Amodiaquine will be obtained from Pfizer (Dakar), is provided as 200-mg tablets or syrup (10 
mg/mL), and will be provided as age-based doses per the manufacturer’s directions. 
5.2 Preparation, Administration, and Dosage 
Considering that oAC is an inert substance that is not absorbed from the gut, we estimated a 
human dose equivalent to the 2.6 mg dose we used in a 20 g mouse (32), based on the ratio of 
calculated gut volumes. Chivers et al. established linear relationships (y= mx + c) between log 
gut volume (x) and log bodyweight (y) for faunivore, frugivore, and folivore primates (39), and 
we used the mean values for constants m (slope) and c (intercept) reported in these three 
equations to develop an equation for gut volume for omnivore primates. Gut volumes calculated 
for different human body weights were divided by the calculated mouse gut volume to derive a 
factor by which the mouse 2.6 mg dose was to be multiplied. Chivers et al. give error bounds for 
the constant m based on 95%CIs, and since intestinal volumes may vary depending on food 
intake (40), we have introduced an error term of ± 2SE for constant m. We propose to test the 
dose calculated from the equation, m + 2SE (Table 1). These oAC doses are well within the 
range of doses recommended for the treatment of acute poisoning: 1 g/kg in children aged <1 
year and 25-50 g in children aged 1-12 years (30). Since intestinal transit time in African pupils 
from a semi-urban area is about 18 h (41), and both the efficacy of oAC to prevent ECM and 
treat poisoning is enhanced by repeat dosing (32, 42, 43), we will administer oAC on admission 
and 6, 12, and 18 h later. Actidose Aqua® (in the oAC plus AS group) or an equivalent amount 
of clean water for the control group will be given at the following weight-based doses: 
 
Body 
Dose (g) 
Actidose- 
weight (kg) 
(mL) 
6 
4.3 
20.7 
8 
6.3 
30.1 
10 
8.4 
40.2 
12 
10.6 
50.9 
14 
13.0 
62.2 
16 
15.4 
74.0 
18 
18.0 
86.2 
20 
20.6 
98.9 
22 
23.3 
111.9 
24 
26.1 
125.4 
26 
29.0 
139.1 
28 
31.9 
153.2 
30 
34.9 
167.5 
32 
38.0 
182.2 
34 
41.1 
197.1 
36 
44.2 
212.3 
38 
47.5 
227.8 
40 
50.7 
240.0 
 
Table 1. oAC dose by body weight, derived using formulae in Chivers et al.(39). 
 
Actidose Aqua® will be administered PO at 0, 6, 12, and 18 h. Actidose Aqua® is licensed for 
use in infants and children at single or multiple doses of 25-50 g (120-240 mL) in children 1-12 
years old. In multiple-dose regimens, doses are administered 4 to 6 h apart. The doses and 
dosing schedule proposed here are well within the licensed ranges. Per manufacturer’s 
directions, the bottle will be shaken for 30 sec prior to opening and the appropriate volume 


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Oral Activated Charcoal in Uncomplicated Malaria  
measured in a beaker. There are no absolute contraindications to the use of Actidose Aqua®. 
Side effects may include mild transient constipation and stools will be black for several days. If a 
child vomits within 60 min of taking any dose of oAC or water, the child will be withdrawn from 
the protocol. 
6 ANALYSIS OF THE STUDY 
6.1 Sample Size and Power Calculations 
The sample size was calculated to demonstrate non-inferiority for ‘AS+oAC’ compared to ‘AS’ 
with regard to parasite half-life. The inferiority margin was defined based on the following 
consideration: the variation in parasite half-life we previously observed in patients treated with 
AS is considered acceptable. For children 2-10 years of age with initial parasite densities 
10,000–70,000/µL, the parasite half-life is approximately normal-distributed around a mean of 
1.946 h, with a standard deviation of 0.636 h. Such a distribution is shown in Figure 2A. The 
99.5 percentile is at 3.59 h, indicating that under this distribution 99.5% will have a parasite half-
life ≤ 3.59 h. We postulate that allowing 3% of children in the AS+oAC group to have a parasite 
half-life slightly above the 99.5 percentile of the normal distribution of the children in the AS 
group can be considered as non-inferior. Assuming that a similarly-shaped normal distribution 
for parasite half-life is obtained for children in the AS+oAC group, the corresponding shift in 
mean parasite half-life can be derived from the graph (Figure 2B) as 25.57 min. 
 
A 
 
 
 
  B 
 
 
 
    C 
 
 
Figure 2. Distribution of parasite half-life in children treated with AS (A). Assumed shift of the 
parasite half-life distribution if 3% (B) or 5% (C) of children have a parasite half-life longer than 
that defined by the 99.5 percentile of the distribution depicted in (A). 
 
If, for instance, 5% of children in the AS+oAC group would be allowed a parasite half-life above 
the 99.5 percentile, the mean parasite half-life of this distribution would be 35.05 min longer 
(Figure 2C). Further examples can be derived from Figure 3 below. 


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Figure 3. This graph depicts how the mean parasite half-life distribution shown in Fig. 2A 
changes, depending on what proportion of patients with a parasite half-life greater than the 99.5 
percentile of the original distribution is measured. 
 
Considering a mean parasite half-life of 2.37 h (i.e., a 25.57-min shift corresponding to 3% 
having parasite half-lives above the 99.5 percentile of the initial distribution) as non-inferior, 35 
children in both groups is required to detect a difference as small as this with 80% power at the 
2.5% significance level. Table 2 provides further examples. 
 
 
 
Table 2. Sample size scenarios for different inferiority margins 
6.2 Analysis plan 
 
Analysis of safety data: 
The local reactogenicity at the site where the IV catheter is placed will be assessed using the 
grading scale provided in Appendix 5, which is based on the FDA toxicity grading scale for 
healthy adults and adolescents. 
Descriptive summaries of the frequency and (where applicable) duration of systemic signs and 
symptoms such as nausea, vomiting, diarrhea, abdominal pain, headache, and dizziness will be 
provided for each group. 
Clinical and laboratory assessments resulting in numerical values (pulse, blood pressure, 
respiratory rate, state of consciousness assessed by the Blantyre coma score, axillary 
temperature, white blood cell counts, hemoglobin, and platelet counts) will be compared at each 
time-point between groups in light of age-specific normal values available for African pediatric 
populations (44-46). 
It is expected that all the above listed parameters will be influenced to various degrees by the 
malaria parasite infection itself, and most of the systemic signs or symptoms are also listed as 
1.8
2
2.2
2.4
2.6
2.8
3
0
2
4
6
8
10
12
14
16
half-life (hours)
% greater than 99.5th percentile
Inferiority margin
corresponding to
defined as X %
a shift of mean TH
n for 1:1
> 99.5% percentile
hrs
(same in min) per group
2.0%
0.33
20.00
58
3.0%
0.43
25.57
35
4.0%
0.52
30.94
24
5.0%
0.58
35.05
19


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Oral Activated Charcoal in Uncomplicated Malaria  
common side effects of the antimalarial drugs used to treat the infection. Therefore, it won’t be 
possible to establish the relatedness of any such findings to either the parasite infection, or any 
of the study-related interventions. For that reason, we will limit our analysis to a comparison of 
the frequency and duration (or, for numeric parameters the level) of such findings between both 
groups. This will enable us to determine whether adjunct treatment with oAC significantly alters 
the clinical course of disease, or whether the safety of IV AS is compromised by adding oAC. 
Analysis of parasite clearance data: 
Parasite clearance will be calculated for each participant as previously described (38), and 
compared between groups using a one sided test with a 2.5% significance level. The 
hypotheses are: H0: TH for AS + oAC – AS >25.57 min and H1: TH for AS + oAC – AS <25.57 
min. The Welch’s t-test will be performed and its associated 95% CI will be calculated for the 
mean difference between AS+oAC – AS. If the upper limit of this interval is <25.57 min, then the 
null hypothesis will be rejected and non-inferiority will be demonstrated. 
 
The number/proportion of children who did not receive their last dose of oAC because their peak 
parasite density / 18-h parasite density was <2.0 will be reported in both groups, and their 
parasite clearance rates will be compared with the children who received the full course of oAC. 
 
6.3 Primary and Secondary Outcomes 
6.3.1 Primary Outcome 
1. To assess the safety of adjunct treatment with oAC 
2. To compare parasite clearance half-life in patients treated with oAC + IV AS or IV AS 
6.3.2 Secondary Outcomes 
1. Serum cytokine levels at 0, 24, and 48 h 
2. Whole-blood transcriptional profiles at 0, 24, and 48 h 
7 STUDY PROCEDURES AND EVALUATION 
7.1 Detailed Study Procedure Schedule 
 
0 hours  
1. Verify that informed consent was obtained. 
2. Ensure that all inclusion/exclusion criteria are met. 
3. Measure child’s weight and vital signs: axillary temperature, blood pressure, heart and 
breathing rates, and state of consciousness. 
4. Perform abbreviated history and physical examination and review for specific symptoms 
(i.e., nausea, vomiting, diarrhea, constipation, abdominal pain, headache, dizziness). 
5. Place IV catheter in the arm. 
6. Obtain 3 mL blood via IV catheter for research purposes: CBC with differential and 
platelet count, RNA preservation, and plasma preparation. 
7. Prepare thick/thin blood films from finger-prick blood sample, count parasite density. 
Slide readers will be blinded to study participant’s group allocation. 
8. Administer AS 2.4 mg/kg IV to all children. 
9. Administer a weight-based dose of Actidose Aqua® to children in the AS+oAC group, 
and a weight-based volume of clean water to children in the AS group. 
 


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2 hours (±10 min) 
1. Prepare thick and thin blood films and count parasite density. Slide readers will be 
blinded to study participant’s group allocation. 
2. Measure vital signs, assess consciousness, and review specific symptoms (i.e., nausea, 
vomiting, diarrhea, constipation, abdominal pain, headache, dizziness). 
 
4 hours (±10 min) 
1. Prepare thick and thin blood films and count parasite density. Slide readers will be 
blinded to study participant’s group allocation. 
2. Measure vital signs, assess consciousness, and review specific symptoms. (i.e., nausea, 
vomiting, diarrhea, constipation, abdominal pain, headache, dizziness) 
 
6 hours (±10 min) 
1. Prepare thick and thin blood films and count parasite density. Slide readers will be 
blinded to study participant’s group allocation. 
2. Measure vital signs, assess consciousness, and review specific symptoms. (i.e., nausea, 
vomiting, diarrhea, constipation, abdominal pain, headache, dizziness) 
3. Administer a weight-based dose of Actidose Aqua® to children in the AS+oAC group, 
and a weight-based volume of clean water to children in the AS group. 
 
8 hours (±10 min) 
1. Prepare thick and thin blood films and count parasite density. Slide readers will be 
blinded to study participant’s group allocation. 
2. Measure vital signs, assess consciousness, and review specific symptoms. (i.e., nausea, 
vomiting, diarrhea, constipation, abdominal pain, headache, dizziness) 
 
12 hours (±10 min) 
1. Prepare thick and thin blood films and count parasite density. Slide readers will be 
blinded to study participant’s group allocation. 
2. Inspect IV catheter. 
3. Measure vital signs, assess consciousness, and review specific symptoms. (i.e., nausea, 
vomiting, diarrhea, constipation, abdominal pain, headache, dizziness). 
4. Administer AS 2.4mg/kg IV to all children. 
5. Administer a weight-based dose of Actidose Aqua® to children in the AS+oAC group, 
and a weight-based volume of clean water to children in the AS group. 
 
18 hours (±45 min) 
1. Prepare thick and thin blood films and count parasite density. Slide readers will be 
blinded to study participant’s group allocation. 
2. Measure vital signs, assess consciousness, and review specific symptoms. (i.e., nausea, 
vomiting, diarrhea, constipation, abdominal pain, headache, dizziness) 
3. Identify the highest parasite density measured between 0 h and 12 h and divide it by the 
parasite density measured at 18 h. If this ratio is <2.0, complete the protocol as outlined 
below but do not administer the last dose of Actidose®-Aqua (for children in the AS+oAC 
group) or water (for control group), and do not draw venous blood at 24 h and 48 h (if the 
child is either in the AS or the AS+oAC group). Consider intensified clinical monitoring 
and an additional dose of 2.4 mg/kg AS IV for children with a ratio <2.0, if warranted by 
clinical signs and symptoms. 
4. Administer a weight-based dose of Actidose Aqua® to children in the AS+oAC group 
and a weight-based volume of clean water to children in the AS group whose ratio of 
peak parasite density/18-h parasite density is ≥2.0 or if the 18-h parasitemia is zero. 


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24 hours (±10 min) 
1. Prepare thick and thin blood films and count parasite density. Slide readers will be 
blinded to study participant’s group allocation. 
2. Inspect IV catheter. 
3. Measure vital signs, assess consciousness, and review specific symptoms. (i.e., nausea, 
vomiting, diarrhea, constipation, abdominal pain, headache, dizziness) 
4. Obtain 3 mL blood via IV catheter for research purposes. 
5. Administer AS 2.4 mg/kg IV to all children. 
 
30 hours (±10 min) 
1. Prepare thick and thin blood films and count parasite density. Slide readers will be 
blinded to study participant’s group allocation. 
2. Measure vital signs, assess consciousness, and review specific symptoms. (i.e., nausea, 
vomiting, diarrhea, constipation, abdominal pain, headache, dizziness) 
 
36 hours (±10 min) 
1. Prepare thick and thin blood films and count parasite density. Slide readers will be 
blinded to study participant’s group allocation. 
2. Inspect IV catheter. 
3. Measure vital signs, assess consciousness, and review specific symptoms. (i.e., nausea, 
vomiting, diarrhea, constipation, abdominal pain, headache, dizziness) 
 
42 hours (±10 min) 
1. Prepare thick and thin blood films and count parasite density. Slide readers will be 
blinded to study participant’s group allocation. 
2. Measure vital signs, assess consciousness, and review specific symptoms. (i.e., nausea, 
vomiting, diarrhea, constipation, abdominal pain, headache, dizziness) 
 
48 hours (±10 min) 
1. Prepare thick and thin blood films and count parasite density. Slide readers will be 
blinded to study participant’s group allocation. 
2. Inspect IV catheter. 
3. Measure vital signs, assess consciousness, and review specific symptoms. (i.e., nausea, 
vomiting, diarrhea, constipation, abdominal pain, headache, dizziness) 
4. Obtain 3 mL blood via IV catheter for research purposes. 
5. Administer AS 2.4 mg/kg IV to all children. 
6. Remove IV catheter. 
7. If the parasitemia is undetectable, discharge participant from inpatient ward. 
 
If parasitemia is detected at 48 h, we will retain the child as an inpatient, and continue preparing 
thick and thin blood films and counting parasite density until parasitemia is undetectable on thick 
smear in 6-hourly intervals. 
 
Three age-based doses of AQ will be given orally on Days 4 (approx. 72 h), 5 (approx. 96 h), 
and 6 (approx. 120 h). On each day, we will record whether the child has passed stool. 
 
On day 7 (approx. 168 h), we will follow up the participant to ensure (s)he is in good health. The 
site where the IV catheter was placed will be inspected, vital signs will be monitored, specific 
symptoms will be reviewed, and the outcome of any AE will be documented. At the discretion of 
the investigator, a focused clinical exam may be performed. A finger-prick blood sample will be 


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Oral Activated Charcoal in Uncomplicated Malaria  
obtained from all children. If the child is healthy-appearing, the slide will be read at a later time. 
If the axillary temperature is >37.5oC, the slide will be examined immediately for malaria 
parasitemia. If the child is parasitemic, we will provide a full 3-day course of Coartem as directly-
observed therapy. One day after the last dose of Coartem, we will take a finger-prick blood 
sample to document undetectable parasitemia. 


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A summary of study procedures is shown in Table 3. 
 
 
Table 3: Summary of study procedures 
Intervention / Procedure
0 hrs
2 hrs
4 hrs
6 hrs
8 hrs
12 hrs 18 hrs 24 hrs 30 hrs 36 hrs 42 hrs 48 hrs 72 hrs 96 hrs 120 hrs
168 hrs
admission for 48 hrs
x
History and physical exam + weight
x
focussed physical exam 
x*
IV catheter remains in place for 48 hrs
x
inspection of IV catheter
x
x
x
x
x
Artesunate IV dosage
x
x
x
x
Charcoal dosage per os (1)
x
x
x
x
Amodiaquine per mouth
x
x
x
microscopic slide (2)
x
x
x
x
x
x
x
x
x
x
x
x
x
Ratio peak parasitemia/current parasitemia
 
x
 
clinical assessment (2, 3)
x
x
x
x
x
x
x
x
x
x
x
x
x
blood for RNA preservation (4)
1.5
1.5
1.5
Plasma for cytokine kinetics (4)
1
1
1
blood for CBC (4)
0.5
0.5
0.5
(1) for participants randomized to the oral activated charcoal arm only
(2) will be repeated every 6 hrs until parasitemia is undetectable
(3) comprises of axillary temperature, pulse, blood pressure, respiratory rate, state of consciousness, and review of specific clinical symptoms
(4) numbers in fields refer to mL of whole blood collected. In total, 3 mls of blood will be collected at 0, 24 and 48hrs
at the discretion of the clinical investigator are in brackets
x* will be performed at the discretion of the investigator


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7.2 Clinical Evaluation 
The clinical laboratory at Universite des Sciences, Techniques, et Technologies de Bamako 
(USTTB) will perform routine CBCs with differential and platelet counts. 
7.3 Laboratory Evaluation 
In an exploratory analysis, the levels of multiple cytokines will be measured in plasma using a 
LUMINEX assay platform. Cytokines will include (but may not be limited to) those we previously 
found to be up-regulated in response to malaria (47): IL-4, IL-6, IL-10, IL-12, IFN-γ, and TNF. 
8 POTENTIAL RISKS AND BENEFITS 
8.1 Potential Risks 
Potential risks to participants are associated with the following procedures: 
 
Venipuncture and finger sticks. Risks occasionally associated with venipuncture include pain, 
bruising, bleeding, and infection at the site of venipuncture, lightheadedness, and rarely, 
syncope. 
 
Indwelling venous catheterization. Risks rarely associated with the placement of indwelling 
venous catheters include line infection and venous thrombosis. 
 
If the IV line becomes compromised and cannot be replaced, treatment will be continued with 
intramuscular artemether. In rare circumstances, intramuscular injection may cause infection of 
superficial and deep tissues, including muscle abscess. Inappropriate injection techniques may 
result in nerve damage that may be permanent. 
 
Drug administration. Expected AEs of drugs used in this study are generally mild in nature and 
not treatment-limiting.  
Repeat dosing of oAC may cause constipation, and stools may be blackened. Aspiration of oAC 
in patients who vomit has been reported to produce airway obstruction (which is one reason 
why children presenting with repeated vomiting will not be eligible). oAC can reduce the 
absorption of other oral medications for as long as it is present in the intestines. The effect is 
greatest when oAC is given simultaneously (i.e., within 1 h) with other oral medication, 
additional doses of which may be required to obtain the same clinical effect. 
Gastrointestinal effects (nausea, vomiting, diarrhea, abdominal discomfort) have been noted 
with AQ treatment, but have been extremely uncommon in our study population in the past 5 
years. Rarely, itching and skin rash may occur. 
 
No AEs are expected from AS or artemether treatment. The drugs are well tolerated, and there 
are no known common side effects. Rarely, allergic reactions and skin rash have been 
described. 
 
Study participants will be made fully aware that this is the first time that patients with malaria will 
receive adjunct treatment with oAC. While there is currently no evidence that oAC might do any 
harm, we cannot exclude the theoretical possibility that oAC may produce unexpected, less 
desirable outcomes. 


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Coartem is now widely used for the treatment of acute uncomplicated malaria in many African 
countries. In 10% of patients, Coartem may cause headache, dizziness, abdominal pain and 
loss of appetite. In 1-10% of patients, Coartem may cause insomnia, palpitations, nausea, 
vomiting, diarrhea, itchiness, skin rash, cough, myalgias, arthralgias and malaise. 
8.2 Potential Benefits 
Children that participate in this study will directly benefit from malaria diagnosis and treatment. 
Study participants will be made aware that IV administration of AS is not the standard of care for 
UM and that the malaria episode can be treated equally well with oral ACTs that will be provided 
to the child in case the caregiver chooses for the child not to participate in this study. 
Information gained from this study might contribute to the development of a safe and effective 
adjunct treatment to prevent the development of SM or lessen the morbidity and mortality of SM. 
The alternative to participating in this study is to not participate. 
9 ASSESSMENT OF SAFETY AND ADVERSE EVENT REPORTING 
PLAN  
9.1 Definitions 
AE: Any untoward or unfavorable medical occurrence in a human subject, including any 
abnormal sign (e.g., abnormal physical exam or laboratory data), symptom, or disease, which is 
temporally associated with the subject’s participation in the research, whether or not it is 
considered related to the research. 
 
 
SAE: Any AE that 
• 
results in death; 
• 
is life-threatening (places subject at immediate risk of death from event as it occurs); 
• 
results in inpatient hospitalization or prolongation of existing hospitalization; 
• 
results in a persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions; 
• 
results in a congenital anomaly/birth defect; or 
• 
based upon appropriate medical judgment, may jeopardize the subject’s health and may 
require medical or surgical intervention to prevent one of the other outcomes listed in this 
definition. 
 
Unanticipated Problem that is not an Adverse Event (UPnonAE): Any unanticipated problem 
that does not fit the definition of an AE but which may, in the opinion of the investigator, involve 
risk to the subject, affect others in the research study, or significantly impact the integrity of 
research data, for example, occurrences of breaches of confidentiality, accidental destruction of 
study records, or unaccounted-for study drug will be reported. 
 
Protocol Violation: Any change, divergence, or departure from the study procedures in an 
Institutional Review Board (IRB)-approved research protocol that has a major impact on the 
subject’s rights, safety, or well-being, and/or the completeness, accuracy, or reliability of the 
study data. 
 
Protocol Deviation: Any change, divergence, or departure from the IRB-approved study 
procedures in a research protocol that does not have a major impact on the subject's rights, 
safety or well-being, or the completeness, accuracy, and reliability of study data. 


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Unanticipated Problem: Any incident, experience, or outcome that is 
1. unexpected in terms of nature, severity, or frequency in relation to 
a. the research risks described in the IRB-approved protocol and ICF, or other study 
documents; and 
b. the characteristics of the subject population being studied; and 
2. related or possibly related to participation in the research; and 
3. places subjects or others at a greater risk of harm (including physical, psychological, 
economic, or social harm) than was previously known or recognized. 
9.2 Recording/Documentation 
AEs discovered by appropriate questioning and examination will be recorded in the AE section 
of the CRF. Mild or moderate events that are reasonably expected in this study (symptoms of 
malaria such as fever, myalgias, arthralgias, anorexia, nausea, and malaise) will be recorded in 
the Review of Symptoms section of the CRF. Source documents will include progress notes and 
laboratory reports. 
9.3 Reporting Procedures 
9.3.1 Expedited Reporting 
The only research-related procedures in this protocol are finger-prick and venous blood 
sampling, indwelling intravenous catheterization, IV administration of AS, and oAC 
administration. The risk of these procedures is minimal and is generally confined to the time at 
which they are performed. It is expected that all patients will complete these procedures within 
48 h. All unanticipated problems, related SAEs,  and any protocol violations that occur between 
0 and 168 h, will be reported to the NIAID IRB and USTTB EC within 7 days of PI awareness. 
9.3.2 Annual Reporting 
The following items will be reported to the NIAID IRB at the time of Continuing Review: 
• 
All unanticipated problems (including AEs and non-AEs) 
• 
Expected SAEs that are possibly, probably, or definitely related to the research 
• 
SAEs that are not related to the research 
• 
All protocol deviations that the investigator believes should be reported 
• 
Any trends or events that the investigator believes should be reported 
10 DATA AND SAFETY MONITORING PLAN 
 
The NIH and USTTB PIs will monitor protocol data that could affect patient safety or 
confidentiality, including occurrence of AEs, documentation of patient evaluation, treatment, and 
disposition, and coding of patient data and samples. 
11 DATA MANAGEMENT PLAN 
 
The PI is responsible for assuring that the data collected is complete, accurate, and recorded in 
a timely manner. CRFs may be used as source documents for some information. CRFs will be 
completed and signed by study personnel, stored in folders while in use, and maintained in 
locked file cabinets on site during the transmission season. CRF data will be entered 


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electronically into Datafax© within 2 weeks of a study visit. Free-form data (e.g., physician 
comments) will be entered manually. Electronically-captured and manually-entered data will be 
checked by an on-site study manager and verified by an off-site data manager. After two-tiered 
validation, data will be exported to a password-protected relational-database program 
(Access©) and stored on a secure server. Data from this study will be prepared for presentation 
at scientific meetings and publication in peer-reviewed scientific journals. Under no 
circumstances will a patient’s identity or identifying characteristics be revealed. 
12 PROTOCOL MONITORING PLAN 
 
The study will be conducted in accordance with the design and specific provisions of this IRB-
approved protocol, in accordance with the ethical principles originating in the Declaration of 
Helsinki, and that are consistent with the ICH-GCP and any applicable regulatory requirements, 
as well as in accordance with NIAID policies. The PIs will assure that no deviation from, or 
changes to, the protocol will take place without prior agreement and documented approval from 
the NIAID IRB and USTTB EC, except where necessary to eliminate an immediate hazard to 
study participants. The PI will promptly report to the NIAID IRB and USTTB EC any changes in 
research activity and all unanticipated problems involving risk to human subjects or others. 
 
As per ICH-GCP 5.18, clinical protocols are required to be adequately monitored by the study 
sponsor. This monitoring will be conducted according to the “NIAID Intramural Clinical 
Monitoring Guidelines.” Monitors under contract to the NIAID/RCHSPB will visit the study site to 
monitor aspects of the study in accordance with appropriate regulations and the approved 
protocol. The objectives of a monitoring visit will be to (1) verify the prompt reporting of data 
points, including SAEs, (2) verify the existence of signed ICFs, (3) examine individual subject 
CRFs and source documents, and (4) help ensure protection of study subjects, compliance with 
the protocol, and accuracy and completeness of records. The monitors will also inspect the 
clinic site regulatory files to ensure that regulatory requirements [Office of Human Research 
Protections (OHRP)/ICH-GCP] are being followed. At monitoring visits, the PIs [and/or 
designee(s)] and other study personnel will be available to discuss the study progress and 
monitoring visit. The PIs [and/or designee(s)] will make study ICFs, CRFs, source documents, 
and data readily available for inspection by the site monitors and NIAID staff for confirmation of 
study data. A specific protocol-monitoring plan will be discussed with the PIs and study staff 
prior to enrollment. The plan will outline the anticipated frequency of monitoring visits based on 
factors such as study enrollment, data collection status, and regulatory obligations. 
 
The investigators conducting this clinical trial have reported potential conflicts of interest 
according to NIAID guidelines. Specifically, assets, income, liabilities, outside positions, 
agreements, arrangements, gifts, and travel reimbursements of the investigators, their spouses, 
and their minor children have been reported according to the guidelines. No reportable conflicts 
of interest have been identified by any of the investigators conducting this trial. 
13 RESEARCH USE OF STORED HUMAN SAMPLES, SPECIMENS, OR 
DATA  
 
All bio-specimens will be stored at the Laboratory of Malaria and Vector Research (LMVR), 
Laboratory of Malaria Immunology and Vaccinology (LMIV), or USTTB, and may be used to 
study malaria and related conditions. Access to research samples will be limited using a locked 


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room. Samples will be tracked using the Biological Sample Inventory (BSI) software system for 
bio-specimen management. Samples and data will be stored using codes assigned by the 
investigators [or their designee(s)]. Data will be kept in password-protected computers. Only PIs 
[or their designee(s)] will have access to samples and data. In the future, other investigators 
(both at NIAID and elsewhere) may wish to study these samples and/or data. In that case, 
approval from the NIAID IRB will be sought prior to any sharing of samples, as well as any 
clinical information shared about the sample with or without patient identifiers. Institutions and 
individuals approved to receive samples from this study will be listed in an appendix as needed. 
Recipients will sign an agreement stating that they will receive no identifying information with the 
shared samples and that they will not request such information in the future. At the completion 
of the protocol (termination), samples and data will either be destroyed or, after IRB approval, 
transferred to another existing protocol or a repository. Any loss or unanticipated destruction of 
samples (for example, due to freezer malfunction) or data (for example, misplacing a printout of 
data with identifiers) will be reported to the NIAID IRB. Additionally, subjects may decide at any 
time not to have their samples stored. In this case, the PIs will destroy all known remaining 
samples and report what was done to both the subject and to the NIAID IRB. This decision may 
not affect the subject’s participation in this protocol or any other NIH-sponsored protocols. 
14 RECORD RETENTION 
 
The investigator is responsible for retaining all essential documents listed in the ICH Good 
Clinical Practice Guideline. All essential documentation for all study subjects is to be maintained 
by the investigators in a secure storage facility for a minimum of 3 years per NIAID policies.  
These records are also to be maintained in compliance with IRB/EC, state, and federal medical 
records retention requirements, whichever is longest. All stored records are to be kept 
confidential to the extent required by federal, state, and local law. 
 
Should the investigator wish to assign the study records to another party and/or move them to 
another location, the investigator must provide written notification of such intent to 
RCHSPB/NIAID with the name of the person who will accept responsibility for the transferred 
records and/or their new location. NIAID must be notified in writing and written NIAID/RCHSPB 
permission must be received by the site prior to destruction or relocation of research records. 
15 REMUNERATION PLAN FOR SUBJECTS 
 
At the completion of core protocol activities (anticipated to be at the 48-h time point for all 
patients), we will provide a selection of local staple foods (i.e., milk, millet, rice, sugar, etc.) 
equivalent to 32 USD to the parent/guardian of each child to compensate for the time, 
inconvenience, and discomfort of the enrollment process, intravenous catheterization, finger-
prick and venous blood sampling, and hospitalization. The total of 32 USD is based on the USD 
amounts we have previously used in Kenieroba to compensate for particular types of protocol 
activities: enrollment (1 USD), venipuncture (5 USD), finger-prick blood sampling (0.5 USD), 
and IV catheterization (10 USD). 
 
 


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Appendix 1:  oAC treatment of mice with P. berghei ANKA (PbA) 
infection affects T cell cytokine production.  
 
a-d) PbA infected (grey bars) and PbA-infected oAC-treated (black bars) mice were killed on 
day 6 and cytokine measured either directly (a, b) or after PMA stimulation (c, d).  The absolute 
number of splenic IFNγ+, TNF+ and IFNγ+TNF+ CD4+ (a, c) and CD8+ (b, d) are shown.  
Uninfected mice (open bars) are shown as baseline.  Data represent mean ± 1SE (n=10 
individual mice from 2 independent experiments; *: p<0.05; **: p<0.01; ***: p<0.001). 
 
 
Appendix 2:  Gene expression profiling of AC-treated PbA-infected 
mice  
 
a) 20 C57BL/6 mice were infected with PbA, and at d3 and d5, 10 were treated with oAC. At day 
6, 5 mice per group were killed for gene expression analysis and the remainder monitored for 
survival. b) Survival of PbA-infected oAC-treated mice (blue line) was significantly greater than 
PbA-infected and untreated mice (red line). p<0.0021. c) 68 genes identified as differentially 
expressed (red, up-regulated; blue, down-regulated) when comparing oAC-treated PbA-infected 
mice to untreated PbA-infected mice are shown, with normalized log2 expression values. 
Expression of these genes in uninfected mice (baseline) is also shown for comparison, though 
this data was not used to identify this gene set. d) Heat maps for individual gene expression in 
individual mice (n=5 group) clustered by gene expression pattern.  Genes were numbered 
sequentially from top to bottom to provide cluster designations indicated. (red = upregulated, 
blue = downregulated). e) Transcriptional vectors for each cluster were calculated as the 
arithmetic mean of the normalized gene expression level for each transcript in the cluster. Data 
for uninfected mice are also shown for comparison (baseline). 


Protocol 13-I-N209 Version 1.0 
4 September 2013 
Fairhurst, Walther, Diakite 
 
 32 
Oral Activated Charcoal in Uncomplicated Malaria  
 
 
 
See attached pdf documents for appendices 3 and 4. 
 
 


Protocol 13-I-N209 Version 1.0 
4 September 2013 
Fairhurst, Walther, Diakite 
 
 33 
Oral Activated Charcoal in Uncomplicated Malaria  
Appendix 3:  Actidose Aqua ® package insert (see separate pdf) 
 
Appendix 4:  Actidose Aqua ® safety data sheet (see separate pdf) 
 
Appendix 5:  Grading of local reactogenicity at IV catheter site 
 
 
Local Reaction to  
Injectable Product  
Mild 
 (Grade 1)  
Moderate 
(Grade 2)  
Severe  
(Grade 3)  
Potentially Life  
Threatening  
(Grade 4)  
Pain  
Does not interfere  
with activity  
Repeated use of 
non-narcotic pain 
reliever > 24 hrs or 
interferes with 
activity  
Any use of narcotic 
pain reliever or 
prevents daily  
activity  
Severity requiring 
hospital based 
management  
Tenderness  
Mild discomfort to 
touch  
Discomfort with 
movement  
Significant  
discomfort at rest  
Severity requiring 
hospital based 
management 
Erythema/Redness   
2.5 – 5 cm  
5.1 – 10 cm  
> 10 cm  
Necrosis or  
exfoliative 
dermatitis  
Induration/Swelling   
2.5 – 5 cm and does 
not interfere  
with activity  
5.1 – 10 cm or  
interferes with  
activity  
> 10 cm or  
prevents daily  
activity  
Necrosis  
 
(Based on FDA recommended Toxicity Grading Scale for Healthy Adults and Adolescents)