Intermittent Preventive Treatment Versus Scheduled Screening and Treatment of Malaria in Pregnancy

Study Overview
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Brief Summary
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The incidence of malaria, including the incidence in pregnant women, is declining in many African countries. Thus, there is a need to re-examine the efficacy and cost effectiveness of giving intermittent preventive treatment with sulphadoxine-pyrimethamine in pregnancy (SP-IPTp) on several occasions during pregnancy, an intervention that is threatened by increasing resistance to SP. Possible alternatives to SP-IPTp need to be explored. This applies especially to areas with highly seasonal malaria transmission where women are at risk for only a short period of the year. The goal of this project is to determine whether in pregnant women who sleep under a long lasting insecticide treated bed net, screening and treatment at each scheduled antenatal clinic visit is as effective in protecting them from anaemia, low birth weight and placental infection as SP-IPTp. Primigravidae and secundigravidae who present at antenatal clinics in study sites in four West African countries (Burkina Faso, Ghana, Mali and The Gambia) will be randomised to one of two groups. All women will be given a long lasting insecticide treated bed net on first presentation at the antenatal clinic. Women in group 1 (reference group) will receive SP-IPTp according to the current WHO guidelines. Those in group 2 will be screened with a rapid diagnostic test at each scheduled antenatal clinic visit and treated if parasitaemic. Approximately 5000 women will be recruited, 2500 in each group. Women will be encouraged to deliver in hospital where maternal haemoglobin and birth weight will be recorded and a placental sample obtained. Those who deliver at home will be visited within a week of delivery and maternal haemoglobin and infant weight recorded. Mothers and infants will be seen again six weeks after delivery. Also at delivery peripheral maternal blood sample will be obtained for the diagnosis of malaria using RDT, microscopy and PCR. The primary end points of the trial will be birth weight and anaemia at 38 weeks (+/-2 weeks) of gestation. The study is powered to show non-inferiority of group 2 compared to group 1. The costs and cost effectiveness of each intervention will be evaluated. In the light of recent evidence suggesting that malaria infection during pregnancy, particularly in the last trimester may influence an infant's risk of malaria, we proposed to follow infants born to mothers recruited in the Navrongo site in Ghana who have received either IST or IPTp in pregnancy throughout the whole of their first year of life beyond the six weeks originally proposed. We have received approval for this from the ethic committees at Kwame Nkrumah University of Science and Technology, Ghana Health Service and Navrongo Health Research Centre. The aim is to obtain information on the incidence of both symptomatic and asymptomatic malaria infections in these infants during follow up of the infants. The study will provide information to national malaria control programmes on whether there are alternative, safe and effective methods to the SP IPTp regimen for reducing the burden of malaria in pregnancy.

Official Title
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A Trial of Intermittent Preventive Treatment With Sulfadoxine-pyrimethamine Versus Intermittent Screening and Treatment of Malaria in Pregnancy

Conditions
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Malaria, Pregnancy, Anaemia

Intervention / Treatment
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* Drug: Intermittent screening and treatment of malaria in pregnancy (IST)
* Drug: SP-IPTp


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Presence of a first or second pregnancy. Gestation between 16 to 30 weeks inclusive at first booking as determined by symphysio-fundal measurements. Provision of informed consent to join the trial. Residence in the study area and intention to stay in the area for the duration of the pregnancy. Exclusion Criteria: Absence of informed consent. An intention to leave the study area before delivery. A history of sensitivity to sulphonamides. Clinical AIDS or known HIV positivity. Presence of any systemic illness likely to interfere with interpretation of the results of the trial.

Ages Eligible for Study
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Minimum Age: 16 Years
Maximum Age: 45 Years

Sexes Eligible for Study
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Female

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: IPTp with SP<br>Study women will receive at least two doses of SP during their pregnancy, one at each of the recommended ante-natal visits during the 2nd and 3rd trimester. | Drug: SP-IPTp<br>* Study women will receive at least two doses of Sulfadoxine Pyrimethamine during their pregnancy, one at each of the recommended ante-natal visits during the 2nd and 3rd trimester.<br>* Other names: SP;|
| Experimental: IST using RDTs<br>Scheduled intermittent screening using rapid diagnostic tests and treatment of those who are RDT positive during ante-natal clinic visits in the 2nd and 3rd trimester. | Drug: Intermittent screening and treatment of malaria in pregnancy (IST)<br>* Scheduled intermittent screening of study women using rapid diagnostic test and treatment of those who are RDT positive during ante-natal clinic visits in the 2nd and 3rd trimester with arthemether lumefantrine.<br>* Other names: Coartem;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Prevalence of low birth weight |  | 6 - 18 months | 
| Prevalence of third trimester anaemia |  | 3 - 12 months | 
| Prevalence of placenta malaria |  | 6 - 18 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Prevalence of anaemia at the time of delivery or shortly afterwards. |  | 6 - 18 months | 
| Prevalence of peripheral blood parasitaemia |  | 6 - 18 months | 
| Episodes of clinical malaria during the course of the pregnancy. |  | 1 year | 
| Serious adverse events in the mother. |  | 6 - 18 months | 
| Adverse outcome of pregnancy - abortions, still births and neonatal deaths. |  | 6 - 18 months | 
| Occurrence of congenital abnormalities. |  | 6 - 18 months | 
| Feasibility and costs of each approach to the control of malaria in pregnancy. |  | 1 year | 
| Cost per cases of maternal anaemia (severe and non-severe) and peripheral malaria averted. |  | 1 year | 
| Acceptability of each approach by pregnant women and antenatal clinic staff. |  | 1 year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Low birth weight, Placenta malaria, Anaemia, Intermittent preventive treatment, Intermittent screening and treatment, Rapid diagnostic test