Conditions: Malaria
Keywords: Chemoprevention Malaria Uganda Sulfadoxine-pyrimethamine Dihydroartemisinin-piperaquine
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 300
Healthy volunteers: yes

Brief summary:
This will be a double-blinded randomized controlled phase III trial of 300 HIV uninfected pregnant women and the children born to them. The study interventions will be divided into two phases. In the first phase, HIV uninfected women at 12-20 weeks gestation will be randomized in equal proportions to one of three intermittent preventive therapy in pregnancy (IPTp) treatment arms: 1) 3 doses of sulfadoxine-pyrimethamine (SP), 2) 3 doses of dihydroartemisinin-piperaquine (DP), or 3) monthly DP. All three interventions arms will have either SP or DP placebo to ensure adequate blinding is achieved. Follow-up for the pregnant women will end approximately 6 weeks after giving birth. In the second phase of the study, all children born to mothers enrolled in the study will be followed from birth until they reach 36 months of age. Children born to mothers randomized to receive 3 doses of SP during pregnancy will receive DP every 3 months between 2-24 months of age. Children born to mothers randomized to receive 3 doses of DP or monthly DP during pregnancy will receive either DP every 3 months or monthly DP between 2-24 months of age. To ensure adequate blinding, children who will receive DP every 3 months will be given DP placebo during the months they will not be taking DP. Children will then be followed an additional year between 24-36 months of age following the interventions. We will test the hypothesis that IPT with DP will significantly reduce the burden of malaria in pregnancy and infancy and improve the development of naturally acquired antimalarial immunity.

Detailed description:
Pregnant women will be scheduled to be seen in the clinic every 4 weeks during their pregnancy and 6 weeks following delivery. In addition, pregnant women will be instructed to come to the study clinic for all their medical care and avoid the use of any outside medications. Children will be scheduled to be seen in the clinic every 4 weeks and parents /guardians of children will be instructed to bring their child to the study clinic for all medical care and avoid the use of any outside medications. The study clinic will remain open 7 days a week from 8 a.m. to 5 p.m.

Each time a study participant is seen in the clinic a standardized history and physical exam will be performed. Patients who are febrile (tympanic temperature \> 3 8.0˚C) or report history of fever in the past 24 hours will have blood obtained by finger prick for a thick blood smear. If the thick blood smear is positive, the patient will be diagnosed with malaria. If the thick blood smear is negative, the patient will be managed by study physicians for a non-malarial febrile illness. If the patient is afebrile and does not report a recent fever, a thick blood smear will not be obtained, except when following routine testing schedules.

Routine assessments will be done in the clinic every 4 weeks for both pregnant women and children. Pregnant women and children will receive standards of care as designated in the Uganda MOH guidelines. Routine care in children will use Integrated Management of Childhood Illness (IMCI) guidelines. During routine assessments subjects will be asked about visits to outside health facilities and the use of any medications outside the study protocol. Standardized assessment of adherence will also be done for study drugs administered at home and Insecticide Treated Net use. A routine history and physical exam will be performed using a standardized clinical assessment form. Blood will be collected by finger prick for thick smear, collection of plasma for PK studies, and filter paper samples. Phlebotomy for routine laboratory tests (CBC and ALT) to monitor for potential adverse events from study medications and for immunology studies will be performed every 8 weeks in pregnant women and every 16 weeks in children. Non malaria screening will also include stool ova and parasite examination, circulating filarial antigens (by ICT card for Wucheria), and blood smear for microfilaremia (including Mansonella perstans) using Knott's technique. For pregnant women and children 2-24 months of age, study drugs will be administered at the time of each routine visit.

Arms:
arm 1: Women will be given SP (3 full strength tabs, 500 mg/25 mg) 3 times during pregnancy at 20, 28, and 36 weeks gestational age. In addition, placebos will be used to mimic the identical dosing strategy such that every 4 weeks women will receive two pills on day 1 (SP and placebo, DP and placebo, or two placebos) followed by one pill on days 2 and 3 (DP or placebo). Two placebos will be used, one that mimics the appearance of SP and one that mimics the appearance of DP.

Infants will be given DP (once a day for 3 consecutive days using weight-based guidelines) every 12 weeks between 8 and 104 weeks of age. Infants randomized to receive DP every 12 weeks will receive placebo mimicking the dosing of DP every 4 weeks when they are not receiving study drug. arm 2: Women will be given DP (3 full strength tabs, 40 mg/320 mg, given once a day for 3 consecutive days) 3 times during pregnancy at 20, 28, and 36 weeks gestational age. In addition, placebos will be used to mimic the identical dosing strategy such that every 4 weeks women will receive two pills on day 1 (SP and placebo, DP and placebo, or two placebos) followed by one pill on days 2 and 3 (DP or placebo). Two placebos will be used, one that mimics the appearance of SP and one that mimics the appearance of DP.

Infants will be given DP (once a day for 3 consecutive days using weight-based guidelines) every 12 weeks between 8 and 104 weeks of age. Infants randomized to receive DP every 12 weeks will receive placebo mimicking the dosing of DP every 4 weeks when they are not receiving study drug. arm 3: Women will be given DP (3 full strength tabs, 40 mg/320 mg, given once a day for 3 consecutive days) 3 times during pregnancy at 20, 28, and 36 weeks gestational age. In addition, placebos will be used to mimic the identical dosing strategy such that every 4 weeks women will receive two pills on day 1 (SP and placebo, DP and placebo, or two placebos) followed by one pill on days 2 and 3 (DP or placebo). Two placebos will be used, one that mimics the appearance of SP and one that mimics the appearance of DP.

Infants will be given DP (once a day for 3 consecutive days using weight-based guidelines) every 4 weeks between 8 and 104 weeks of age. arm 4: Women will be given DP (3 full strength tabs, 40 mg/320 mg, given once a day for 3 consecutive days) every 4 weeks during pregnancy. In addition, placebos will be used to mimic the identical dosing strategy such that every 4 weeks women will receive two pills on day 1 (SP and placebo, DP and placebo, or two placebos) followed by one pill on days 2 and 3 (DP or placebo). Two placebos will be used, one that mimics the appearance of SP and one that mimics the appearance of DP.

Infants will be given DP (once a day for 3 consecutive days) every 12 weeks between 8 and 104 weeks of age. Infants randomized to receive DP every 12 weeks will receive placebo mimicking the dosing of DP every 4 weeks when they are not receiving study drug. arm 5: Women will be given DP (3 full strength tabs, 40 mg/320 mg, given once a day for 3 consecutive days) every 4 weeks during pregnancy. In addition, placebos will be used to mimic the identical dosing strategy such that every 4 weeks women will receive two pills on day 1 (SP and placebo, DP and placebo, or two placebos) followed by one pill on days 2 and 3 (DP or placebo). Two placebos will be used, one that mimics the appearance of SP and one that mimics the appearance of DP.

Infants will be given DP (once a day for 3 consecutive days) every 4 weeks between 8 and 104 weeks of age.

Interventions: intervention 1: Monthly dihydroartemisinin-piperaquine (DP) for adult women during pregnancy intervention 2: 3 dose dihydroartemisinin-piperaquine (DP) for adult women during pregnancy intervention 3: 3 dose sulfadoxine-pyrimethamine (SP) for adult women during pregnancy intervention 4: Monthly dihydroartemisinin-piperaquine (DP) for infants intervention 5: 3-monthly dihydroartemisinin-piperaquine (DP) for infants
Intervention descriptions: intervention 1: None intervention 2: None intervention 3: None intervention 4: None intervention 5: None

Protocol document:
Prot_001.pdf: 
 
 
 
 
“Novel Strategies to Prevent Malaria and Improve  
Maternal-Child Health in Africa” 
(PROMOTE II) 
 
A UCSF/ MAKERERE UNIVERSITY COLLABORATION 
 
 
Title: Reducing the Burden of Malaria in HIV-uninfected  
Pregnant Women and Infants 
 
Short Title: PROMOTE Birth Cohort 1 
 
 
 
 
 
 
 
VERSION 6.0 
 
 
 
 
Sponsored by: 
 
The National Institute of Child Health and Human Development 
 
 
 
 
 
Principal Investigators: 
 
Grant Dorsey, MD, PhD 
 
 
 
 
 
University California San Francisco 
 
 
 
 
 
 
Moses Kamya, MBChB, MMed, PhD 
 
 
 
 
 
Makerere University College of Health Sciences 
 
 
Protocol Version   6.0 25th October 2017  


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TABLE OF CONTENTS 
 
PROTOCOL TEAM ROSTER .............................................................................................................. 6 
GLOSSARY ....................................................................................................................................... 9 
SCHEMA ........................................................................................................................................ 10 
1. 
INTRODUCTION ................................................................................................................ 11 
1.1. 
Background ....................................................................................................................... 11 
1.2. 
Preliminary studies .......................................................................................................... 14 
Figure 1. Prevalence of key antifolate resistance-conferring mutations over time ...... 16 
Figure 2. Cumulative risk of recurrent malaria following treatment with DP vs. AL ..... 17 
Table 1. Protective efficacy against incident episodes of malaria ................................. 18 
Figure 3. Incidence of malaria over age stratified by assigned treatment arm ............. 18 
Table 2. Incidence of malaria following cessation of chemoprevention ....................... 19 
1.3. 
Rationale........................................................................................................................... 19 
2. 
STUDY OBJECTIVES ........................................................................................................... 20 
2.1. 
Objective 1 ........................................................................................................................ 20 
2.2. 
Objective 2 ........................................................................................................................ 21 
2.3. 
Objective 3 ........................................................................................................................ 21 
3. 
STUDY DESIGN .................................................................................................................. 21 
4. 
SELECTION AND ENROLLMENT OF SUBJECTS .................................................................. 22 
4.1. 
Inclusion Criteria .............................................................................................................. 22 
4.2. 
Exclusion Criteria .............................................................................................................. 22 
4.3. 
Initial Screening ................................................................................................................ 22 
4.4. 
Study Enrollment Procedures and Baseline Evaluation .................................................. 23 
5. 
STUDY TREATMENT .......................................................................................................... 24 
5.1. 
Treatment Group Assignments ........................................................................................ 24 
Table 3. Treatment arms with assignment of study drugs during pregnancy and infancy
 .......................................................................................................................................... 24 
5.2. 
Treatment Allocation ....................................................................................................... 24 
5.3. 
Study Drug Dosing and Formulations .............................................................................. 25 
Table 5. Drug formulation and labeling ........................................................................... 25 


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5.4. 
Blinding, Study Drug Administration, and Duration ....................................................... 25 
5.5. 
Study Drug Accountability ............................................................................................... 26 
6. 
SUBJECT MANAGEMENT .................................................................................................. 26 
6.1. 
Subject Follow-up ............................................................................................................. 26 
6.2. 
Diagnosis and Management of Malaria .......................................................................... 27 
6.3. 
Management of Non-Malaria Illnesses ........................................................................... 28 
6.4. 
After Hours Visits ............................................................................................................. 28 
6.5. 
Routine Assessments ....................................................................................................... 29 
6.6. 
Delivery visit ..................................................................................................................... 30 
6.7. 
Postpartum visits. ............................................................................................................ 30 
6.8. 
Medical Care Outside the Study Clinic ............................................................................ 31 
6.9. 
Duration of Follow-up and Criteria for Premature Study Withdrawal........................... 31 
6.10. 
Diagnostic and Laboratory Testing .................................................................................. 32 
6.10.1. Microscopy ........................................................................................................ 32 
6.10.2. Clinical Laboratory Studies ............................................................................... 32 
6.10.3. Placental Studies ............................................................................................... 32 
6.10.4. Molecular and Parasitology Studies ................................................................. 33 
6.10.5. Immunology Studies ......................................................................................... 33 
6.10.6. Pharmacokinetic (PK) Studies ........................................................................... 34 
6.11. 
Co-enrollment Guidelines ................................................................................................ 34 
6.12. MANAGEMENT OF ADVERSE EVENTS POTENTIALLY RELATED TO STUDY DRUGS ........ 34 
6.13. 
Grade 1 or 2 Adverse Events ............................................................................................ 35 
6.14. 
Grade 3 or 4 Adverse Events ............................................................................................ 35 
7. 
MONITORING OF ADVERSE EVENTS AND MANAGEMENT ............................................. 35 
7.1. 
Monitoring and Reporting of Adverse Events ................................................................. 35 
7.1.1. Definitions ........................................................................................................... 36 
7.1.2. Identification of Adverse Events ........................................................................ 36 
7.1.3. Reporting of Adverse Events .............................................................................. 37 
Table 6. Guidelines for reporting adverse events ........................................................... 37 
8. 
STATISTICAL CONSIDERATIONS ....................................................................................... 38 
8.1. 
Hypothesis 1 ..................................................................................................................... 38 
8.1.1. Primary Outcome ................................................................................................ 38 
8.1.2. Secondary Outcomes .......................................................................................... 38 
Table 7. Secondary outcomes .......................................................................................... 38 


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8.1.3. Analyses............................................................................................................... 39 
8.2. 
Hypothesis 2 ..................................................................................................................... 39 
8.2.1. Primary Outcome ................................................................................................ 40 
8.2.2. Secondary Outcomes .......................................................................................... 40 
Table 8. Secondary outcomes .......................................................................................... 40 
8.2.3. Analyses............................................................................................................... 40 
8.3. 
Hypothesis 3 ..................................................................................................................... 41 
8.3.1. Primary Outcome ................................................................................................ 41 
8.3.2. Secondary Outcomes .......................................................................................... 41 
8.3.3. Analyses............................................................................................................... 42 
8.4. 
Sample size and power .................................................................................................... 42 
Table 9. Intervention arms during pregnancy and infancy ............................................. 43 
Table 10. Minimum relative differences in outcomes detectable given estimated 
effective sample sizes ...................................................................................................... 43 
8.5. 
Data and Safety Monitoring Plan .................................................................................... 43 
8.5.1. Data and Safety Monitoring Board .................................................................... 44 
8.5.2. Interim safety analysis ........................................................................................ 45 
Table 11. Schedule of interim safety analysis and boundaries to monitor study 
outcome ............................................................................................................................ 46 
8.5.3. Stopping rules ..................................................................................................... 46 
9. 
DATA COLLECTION AND MONITORING ........................................................................... 46 
9.1. 
Record Keeping ................................................................................................................ 46 
9.2. 
Data Quality Assurance and Monitoring ......................................................................... 47 
10. 
HUMAN SUBJECTS ............................................................................................................ 47 
10.1. 
Subject Selection Criteria ................................................................................................. 47 
10.2. 
Risks and Discomforts ...................................................................................................... 47 
10.2.1. Privacy ............................................................................................................... 47 
10.2.2. Finger Pricks, Heel Sticks, and Venipuncture ................................................... 48 
10.2.3. Risks of Study Medications ............................................................................... 48 
Table 12. Summary of adverse events following treatment with dihydroartemisinin-
piperaquine ...................................................................................................................... 49 
Table 14. Comparison of adverse events among children between 6-24 months of age
 .......................................................................................................................................... 52 
10.3. 
Treatment and Compensation for Injury......................................................................... 52 
10.4. 
Costs to the Subjects ........................................................................................................ 52 
10.5. 
Reimbursement of Subjects ............................................................................................. 52 
10.6. 
Institutional Review Board (IRB) Review and Informed Consent................................... 53 


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11.7 
Definition of Parent/Guardianship. ................................................................................. 53 
12. 
PUBLICATION OF RESEARCH FINDINGS ........................................................................... 53 
13. 
BIOHAZARD CONTAINMENT ............................................................................................ 54 
14.  
REFERENCES ...................................................................................................................... 54 
15.  
APPENDICES ...................................................................................................................... 61 
Appendix A. Information Sheet .................................................................................................... 61 
Appendix B.  Determination of Gestational Age ............................................................................ 62 
Appendix C. Household survey ..................................................................................................... 63 
Appendix D. Administration of study drugs and placebos .......................................................... 67 
Appendix E. Weight-based dosing guidelines for DP during infancy .......................................... 68 
Appendix F. WHO Criteria for Severe Malaria and Danger Signs ................................................ 69 
Appendix G. Uganda Ministry of Health Guidelines for Routine Care of Pregnant and 
Postpartum Women, and Newborns ............................................................................................ 70 
Appendix H. Schedule of routine assessments and procedures in pregnant women ................ 71 
Appendix I. Schedule of routine assessments and procedures in children ................................. 73 
Appendix J.    DAIDS Toxicity Table (Dec 2004, clarification Aug 2009) ...................................... 75 
Adult Laboratory Toxicity Tables.................................................................................................. 88 
Pediatric Laboratory Toxicity Tables ............................................................................................ 89 
Appendix K. List of drugs associated with known risk of torsades de pointes.............................. 90 
Appendix L. List of drugs that potentially prohibit the metabolism of piperaquine ..................... 93 


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PROTOCOL TEAM ROSTER   
 
Investigators   
 
 
 
 
Grant Dorsey, MD, PhD University of California, San Francisco 
 
Address:  San Francisco General Hospital, 995 Potrero Avenue, 
 
Building 30, Room 3240, UCSF Box 0811, San Francisco CA, 94110, U.S.A. 
Phone Number: 01-415-206-4680 
Fax Number:   01-415-648-8425 
 
Email: gdorsey@medsfgh.ucsf.edu  
 
Moses R. Kamya, MBChB, MMed, PhD, Makerere University College of Health Sciences 
 
Address:  Department of Medicine, P.O. Box 7072, Kampala, Uganda   
 
Phone Number:  +256-312281479  
 
Fax Number:      +256-414-540524 
 
Email:  mkamya@infocom.co.ug 
 
Diane V. Havlir, MD, University of California, San Francisco 
Address: San Francisco General Hospital, 995 Potrero Avenue,  
Building 80, Ward 84, UCSF Box 0874, San Francisco, CA 94110, U.S.A.  
Phone Number:  01-415-476-4082, ext 400   
  
Fax Number:      01-415-502-2992 
 
Email:  dhavlir@php.ucsf.edu 
 
Miriam Nakalembe, MBChB, MMed Ob/Gyn, Makerere University College of Health Sciences 
 
Address: Department of Medicine,  
P.O. Box 7072, Kampala, Uganda   
 
Phone Number: +256 753 857 433 (Mobile), +256 414 534 361 (Office) 
Fax +256 414 533 451 (AOGU Office)  
Email: ivuds@yahoo.com 
 
 
Deborah Cohan, MD MPH, University California San Francisco 
Address: San Francisco General Hospital, 995 Potrero Avenue 
SFGH Box 6D22, San Francisco, CA. 94143 - SFGH  
Phone Number: 01-415-206-3658         
Fax Number: 01-415-206-3112  
Email:  cohand@obgyn.ucsf.edu  
 
Edwin Charlebois, PhD, University of California, San Francisco 
Address:  50 Beale St., 13th Floor, San Francisco, CA 94105, U.S.A. 
Phone Number: 01-415-597-9301 
Fax Number:   01-415-597-9213 
Email:  edwin.charlebois@ucsf.edu   
 


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
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Abel Kakuru, MBChB, MSc, Infectious Diseases Research Collaboration 
Address: Infectious Diseases Research Collaboration,                                            
       
P.O. Box 7475, Kampala, Uganda 
 
 
 
 
 
      
Phone Number:  +256-414-530692  
 
 
                                
Fax Number:      +256-414-540524 
 
 
 
 
 
   
Email:  abelkakuru@gmail.com 
 
Maggie Feeney, MD, MSc, University of California, San Francisco 
 
Address:  UCSF, Parnassus Avenue Box 1234, San Francisco, CA  94143, U.S.A. 
Phone Number: 415-206-8218 
 
Email: feeneym@medsfgh.ucsf.edu 
 
Tamara Clark, MPH, University of California, San Francisco 
             Address:  UCSF, Parnassus Avenue Box 0811, San Francisco, CA  94143, U.S.A. 
Phone Number: 01-415-206-8790 
Fax Number: 01-415-648-8425 
             Email:   tclark@medsfgh.ucsf.edu  
 
Theodore Ruel, MD, Assistant Professor, University of California, San Francisco, Dept Pediatrics 
Address: UCSF, 500 Parnassus Avenue, MU4E, Campus Box 0136, San Francisco, CA 
94143-0136 
Phone Number: 01-415 476 9198 
Fax Number: 01-415 476 1343 
Email:  ruelt@peds.ucsf.edu 
 
Prasanna Jagannathan, MD, Assistant Professor, Stanford University, Division of Infectious 
Diseases and Geographic Medicine 
Address: Lane Building, L133, 300 Pasteur Dr, Stanford, CA 94305 
Phone Number: 01-650-724-5343 
Email: prasj@stanford.edu 
 
 


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OTHER PERSONNEL 
Name 
Title 
Institution 
Dr. Mary Kakuru 
Study Coordinator 
IDRC, Uganda 
Dr. Paul Natureeba 
Study Coordinator 
IDRC, Uganda 
Dr. Stephen Kinara 
Study Coordinator 
IDRC, Uganda 
Peter Olwoch 
Laboratory Manager 
IDRC, Uganda 
Bishop Opira 
Study Pharmacist  
IDRC, Uganda 
Jaffer Okiring 
Data Manager 
IDRC, Uganda 
Dr. Bridget Nzarubara 
Regulatory Affairs Manager 
IDRC, Uganda 
Katherine Snyman 
Quality Assurance Manager 
UCSF 
 
 
 
 
 
 
 
 
 


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GLOSSARY 
 
AE 
 
Adverse event 
ACT 
 
Artemisinin-based combination therapy 
AL 
 
Artemether-lumefantrine 
ALT 
 
Alanine transaminase (SGPT) 
CAB 
 
Community advisory board 
CBC 
 
Complete blood cell count 
CRF 
 
Case report form 
DP 
 
Dihydroartemisinin-piperaquine 
DSMB  
Data and Safety Monitoring Board 
IDRC 
 
Infectious Diseases Research Collaboration 
IPTp 
 
Intermittent preventive therapy in pregnancy 
IRB 
 
Institutional review board 
ITN 
 
Insecticide treated net 
MOH  
Ministry of Health 
MU 
 
Makerere University 
NICHD  
National Institute of Child Health and Human Development 
NIH 
 
National Institute of Health 
SAE 
 
Serious adverse event 
SP 
 
Sulfadoxine-pyrimethamine 
TDH 
 
Tororo District Hospital 
UCSF  
University California San Francisco 
WHO  
World Health Organization 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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SCHEMA 
Title 
Reducing the Burden of Malaria in HIV-uninfected Pregnant Women and Infants 
Description 
Double blinded randomized controlled trial 
Study Objectives 
1. 
To compare the risk of placental malaria among HIV-uninfected pregnant women randomized to receive IPTp with 3 dose SP 
vs. 3 dose DP vs. monthly DP.  
2. 
To compare the incidence of malaria among infants randomized to receive q 3 monthly DP vs. monthly DP between 2-24 
months of age. 
3. 
To compare the incidence of malaria among infants and children following the two phases of the intervention through 36 
months of  age   
Participants and 
Sample Size 
300 HIV-uninfected pregnant women and the children born to them 
Clinical Site 
The study will be conducted in Tororo, Uganda. A designated study clinic will be located within the Tororo District Hospital 
Complex. The study clinic will be open daily from 8:00 am to 5:00 pm and after-hours care will be available at Tororo District 
Hospital.  
Selection Criteria 
Inclusion Criteria 
1. 
Pregnancy confirmed by positive urine pregnancy test or intrauterine pregnancy by ultrasound 
2. 
Estimated gestational age between 12-20 weeks  
3. 
Confirmed to be HIV- uninfected by rapid test 
4. 
16 years of age or older 
5. 
Residency within 30km of the study clinic 
6. 
Provision of informed consent  
7. 
Agreement  to come to the study clinic for any febrile episode or other illness and avoid medications given outside the 
study protocol 
8. 
Plan to deliver in the hospital 
Exclusion Criteria: 
1. 
History of serious adverse event to SP or DP 
2. 
Active medical problem requiring inpatient evaluation at the time of screening 
3. 
Intention of moving more than 30km from the study clinic 
4. 
Chronic medical condition requiring frequent medical attention 
5. 
Prior SP preventive therapy or any other antimalarial therapy during this pregnancy 
6. 
Early or active labor (documented by cervical change with uterine contractions) 
Treatment 
assignment 
HIV-uninfected pregnant and their unborn child(ren) will be randomized at the time of enrollment.  
Treatment arms 
IPTp during pregnancy 
Chemoprevention in children 2-24 months of age 
1. 
3 dose SP 
2. 
3 dose DP 
3. 
Monthly DP 
1. 
Monthly DP 
2. 
3 monthly DP 
Follow-up and 
Diagnosis of 
Malaria 
Study participants will be followed for all of their outpatient medical care in our study clinic. Pregnant women will be followed 
until 6 weeks postpartum and children will be followed until 36 months of age. Routine assessments will be performed in the 
study clinic for all study participants every 4 weeks. Patients presenting with a new episode of fever will undergo standard 
evaluation for the diagnosis of malaria.  
Malaria Case 
Definitions 
Uncomplicated malaria (all of the following):  
1. Documented fever or history of fever in the prior 24 hours  
2. Positive thick blood smear  
3. Absence of complicated malaria 
Complicated malaria (any of the following):    
1. Evidence of severe disease with a positive thick blood smear (Appendix F) 
2. Danger signs in children with a positive thick blood smear (Appendix F) 


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1. INTRODUCTION 
 
1.1. Background  
 
Malaria in Pregnancy: burden of disease and prevention. In sub-Saharan Africa approximately 
25 million pregnant women are at risk of P. falciparum infection every year and 25% have 
evidence of placental infection.1 Among pregnant women living in areas of stable transmission 
few infections lead to symptomatic malaria, however, infection is associated with maternal 
morbidity, such as anemia, and adverse birth outcomes including abortions, stillbirth, preterm 
delivery, low birth weight (LBW), and infant mortality.2, 3  
In Africa the only widely available tools for the prevention of malaria in pregnancy are 
ITNs and IPTp with SP. Older studies demonstrated the efficacy of IPTp with SP in reducing the 
risk of placental malaria and LBW.4-8 However, there are now concerns about the continued 
efficacy of IPTp given the spread of antifolate resistance. A 2007 review suggested that IPTp 
with SP remained beneficial in areas with antifolate resistance, however, this conclusion was 
based on communities where SP treatment failure rates in children remained at moderate 
levels.9 More recently, reports from East Africa have documented SP failure rates over 65% in 
children when used for treatment10 or prevention11, and near saturation of common SP 
resistance alleles.12, 13 In a recent study from Tanzania IPTp with SP was not associated with a 
decreased risk of placental malaria, maternal anemia, or LBW, and unexpectedly associated 
with an increased risk of fetal anemia.14 In a recent study from Uganda there was no significant 
difference in the risk of maternal infection, maternal anemia, and LBW for pregnant women 
receiving IPTp with SP plus ITNs vs. ITNs alone.15 In addition, most IPTp studies have defined 
placental malaria on the basis of placental blood smears, which dramatically underestimate the 
true prevalence of placental malaria. In summary, there are several lines of evidence suggesting 
that IPTp with SP is no longer effective in areas of East Africa with widespread antifolate 
resistance. New interventions to reduce the burden of malaria in pregnancy in this region are 
desperately needed. 
 
The ACT class of drugs offers an attractive alternative to SP for use in pregnancy. In a 
recent systematic review of parasitological efficacy for the treatment and prevention of 
falciparum malaria in pregnancy, placenta-positive rates were unacceptably high in a majority 
of SP trial arms and ACTs provided the lowest parasitological failure rates.16 The authors 
recommended that SP should no longer be used for treatment or prevention of malaria in 
pregnancy and that ACTs provide the most efficacious and safe alternative therapy. Two studies 
of the ACT artesunate (AS) + SP from Africa concluded that this drug was safe for the treatment 
of malaria in pregnant women.17, 18 More recent studies have focused on artemether-
lumefantrine (AL), considering efficacy, pharmacokinetics, and safety. In a prospective study 
from Zambia, 495 pregnant women exposed to AL (including 156 in the 1st trimester) had 


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similar risks of adverse maternal and infant outcomes compared to pregnant women exposed 
to SP.19  In a recent study from Uganda, pregnant women in their 2nd or 3rd trimester with 
peripheral parasitemia treated with AL had a cure rate of 99%.20 DP has also been safely used 
for the treatment of uncomplicated malaria in pregnancy in studies from Asia.21, 22 In two recent 
studies on the treatment of uncomplicated malaria with DP in pregnant and non-pregnant 
women, one concluded that there were no clinically important differences in piperaquine 
pharmacokinetics in pregnancy 23 and another concluded that pregnancy was associated with 
an unaltered total exposure to piperaquine but a shorter terminal elimination half-life.24 
In summary, most African countries continue to recommend IPTp with SP, however, there 
are serious concerns about the efficacy of SP given widespread resistance, especially in East 
Africa. Available data have shown that ACTs are effective and safe for the treatment of malaria 
in pregnancy and are now recommended by the WHO as 1st line therapy for pregnant women in 
their 2nd or 3rd trimester.25 However, there are no published studies evaluating the safety and 
efficacy of ACTs for use as preventive therapy in pregnant women.  
 
Malaria in Infants and Young Children: burden of disease and prevention. Partial immunity to 
malaria develops through repeated exposure, leading first to protection against severe forms of 
disease, followed by protection against symptomatic illness.26 Thus, the burden of malaria in 
Africa is heavily borne by young children. Newborns are protected during the first few months 
of life, likely due to the transplacental acquisition of maternal antibodies and relatively high 
fetal hemoglobin content.27 After about 2-3 months of age, protection from these factors 
wanes.28 However, the age at which malaria risk peaks in endemic areas of Africa varies from 1-
2 years of age in areas of high transmission intensity to approximately 5 years of age in areas of 
low to moderate transmission intensity.29 When studying malaria incidence and interventions 
to prevent malaria, it is essential to have a thorough understanding of the local epidemiology of 
the disease. Our proposed studies will benefit from the extensive experience we have gained 
studying malaria in Uganda.  
The only widely used tool for the prevention of malaria in African children is ITNs, 
however, there is concern for diminishing efficacy of ITNs due to the alarming emergence of 
vector resistance to pyrethroids (currently the only class of insecticides used in ITNs) in Uganda 
30, 31 and other parts of Africa.32, 33 Our collaboration has been following a cohort of 350 children 
since 2007 in Tororo, the site of our proposed trial. To date, children between 6-24 months of 
age have suffered over 5 episodes of malaria per year, and between 2008-11 the incidence of 
malaria increased by over 50%, despite the use of ITNs.34 Extending the use of IPT to African 
infants and children at high risk for malaria offers a potential new preventive tool that has 
recently received widespread attention. The intervention that has been most extensively 
studied is SP given at the time of routine vaccination in infants (termed IPTi). A recent pooled 
analysis of 6 RCTs reported that IPTi was safe and associated with a modest 30% protective 


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efficacy against clinical malaria in the first year of life.35-40 In a study from Kenya, IPTi with SP + 
AS or amodiaquine (AQ) + artesunate was associated with a 22% and 25% protective efficacy 
against malaria, respectively.41 A different approach to IPT has been taken in parts of West 
Africa, where the main burden of malaria is in older children and transmission is highly 
seasonal. In this setting, studies of IPT (termed seasonal malaria chemoprevention or SMC) 
have delivered drugs at monthly intervals during the transmission season, targeting children 
under 5 years of age. In two such studies using SP+AQ, the protective efficacy ranged from 70-
82%.42, 43 In a systematic review and meta-analysis of 12 studies, monthly SMC was safe , with 
an overall protective efficacy of 82% against clinical malaria and 57% against all-cause 
mortality.44 SMC has now been recommended as a new malaria control strategy following a 
meeting of the Malaria Policy Advisory Committee to the WHO in early 2012.45 However, this 
recommendation only pertains to areas with seasonal malaria transmission, and so not to the 
vast parts of Africa, such as Uganda, with year-round transmission. In addition, good efficacy for 
SMC with SP+AQ has been documented in regions of West Africa with considerably lower 
prevalence of resistance to both SP and AQ than is the case in many other areas, including 
Uganda. 
In summary, IPT offers great promise for reducing the burden of malaria in African 
infants and children, however, interventions must be carefully chosen based on drug resistance 
patterns and the local epidemiology of disease. IPTi with SP has been associated with modest 
protective efficacy, however, the WHO recommends IPTi only in countries with moderate to 
high malaria transmission, where parasite resistance to SP is low.46 SMC using monthly dosing 
with primarily SP containing combination therapies has been highly efficacious in areas of West 
Africa where malaria transmission is seasonal, however, this strategy would not be appropriate 
in most areas of Central and East Africa were transmission is perennial and SP resistance 
widespread. DP is a new co-formulated ACT that has been suggested as an excellent candidate 
for IPT in infants and children.27 Several studies from Africa have demonstrated that DP is safe 
and highly efficacious for the treatment of uncomplicated malaria and has the added benefit 
over other ACTs in terms of prolonged post-treatment prophylaxis.47-50 DP is now one of the 
WHO recommended 1st line treatments for malaria and was approved for use in Uganda in 
2005. In the only published randomized, placebo-controlled trial of DP for the prevention of 
malaria conducted in healthy adult Thai males, the protective efficacy of DP over a 9 month 
period was 98% when the drug was given monthly and 86% when the drug was given every 2 
months. 51 In an ongoing study carried out by our group, monthly DP given to infants between 
the ages of 6-24 months has been highly efficacious for the prevention of malaria in a high 
transmission setting of Uganda (see section 1.2 preliminary studies). 
 
Impact of Malaria Prevention on the Development of Immunity. Increasing evidence suggests 
that maternal infection during pregnancy affects the developing immune system of fetuses 


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14 
 
 
independent of potential vertical transmission of pathogens.52 Several studies indicate that 
placental malaria is associated with altered parasite-specific immune responses in neonates 
that could affect response to malaria after birth.53-56 In addition, several clinical studies have 
reported that infants born to mothers with placental malaria have a higher risk of death 57 and 
malaria during infancy.58-61 However, all of these were observational studies in which it is very 
difficult to control for exposure, which is tightly linked between pregnant women and their 
infants. It remains unclear whether, as we hypothesize in this proposal, prevention of malaria 
during pregnancy improves the development of antimalarial immunity and reduces the risk of 
malaria after birth.  
 
There is conflicting evidence on the impact of chemoprevention in children on the 
development of antimalarial immunity and the risk of malaria after chemoprevention has 
stopped. Studies from Tanzania and the Gambia reported that children receiving highly 
effective chemoprophylaxis had a higher incidence of malaria compared to those receiving 
placebo in the year following the intervention.62, 63 In contrast, more recent studies have 
reported no association between IPTi with SP and the risk of malaria following the 
intervention.35, 41 Differences in these findings could be due to differences in transmission 
intensity, ages of study subjects, protective efficacy of study drugs, and dosing strategies 
(continuous prophylaxis vs. intermittent therapy). Recent unpublished data from our group 
suggest that in a high transmission setting, chemoprevention may actually improve the 
development of antimalarial immunity. Children randomized to daily trimethoprim-
sulfamethoxazole (TS) had a 39% reduction in the incidence of malaria during the time the 
intervention was given 13 and a 23% reduction in the incidence of malaria in the 1 year after the 
intervention was stopped, although this did not reach statistical significance (p=0.12). This may 
be due to improved priming of cellular immune responses to pre-erythrocytic stage antigens, as 
has been observed in several animal and experimental models where parasitemia is suppressed 
with drugs that are active only against erythrocytic stages.64-68 
 
1.2. Preliminary studies  
 
Intermittent preventive therapy in pregnancy with sulfadoxine-pyrimethamine. We 
conducted a cross-sectional study of 565 HIV-uninfected women giving birth between February 
– July 2011 at Tororo District Hospital (manuscript currently in press). The primary objective of 
the study was to measure associations between use of SP during pregnancy from antenatal 
records and the risk of adverse outcomes including placental malaria, low birth weight, 
maternal parasitemia and maternal anemia. The proportion of women who reported taking 0, 
1, 2, and 3 doses of SP during pregnancy was 5.7%, 35.8%, 56.6% and 2.0% respectively. 
Overall, the prevalence of placental malaria was 17.5%, 28.1%, and 66.2% by placental smear, 
PCR, and histopathology, respectively. In multivariate analyses controlling for potential 


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confounders, > 2 doses of SP was associated with non-significant trends towards lower odds of 
placental malaria by placental smear (OR=0.75, p=0.25), placental malaria by PCR (OR=0.93, 
p=0.71), placental malaria by histopathology (OR=0.75, p=0.16), low birth weight (OR=0.63, 
p=0.11), maternal parasitemia (OR=0.88, p=0.60) and maternal anemia (OR=0.88, p=0.48). 
Using a composite outcome, > 2doses of SP was associated with a significantly lower odds of 
placental malaria, low birth weight, maternal parasitemia, or maternal anemia (OR=0.52, 
p=0.01). In this area with intense malaria transmission, the prevalence of placental malaria by 
histopathology was high even among women who reported taking at least 2 doses of SP during 
pregnancy. The reported use of > 2 doses of SP was not associated with protection against 
individual birth and maternal outcome.  
 
Antifolate Resistance in Uganda. Surveillance of key mutations in P. falciparum dhfr and dhps 
genes, which encode the target enzymes of SP and TS, has been proposed as a means of 
monitoring antifolate drug resistance in Africa. We have studied the association between the 
five key mutations commonly reported in Africa and clinical treatment failure in children 
treated with SP for uncomplicated malaria in Kampala 69, 70. The prevalences of the dhfr 108N 
(98%) and 51I (95%) mutations were very high, and therefore these mutations were not useful 
independent predictors of treatment outcome. Considering combinations of mutations, there 
was generally a “dose response” relationship, with an increasing number of mutations resulting 
in stronger associations with treatment failure. Infections with parasites containing the 
quintuple mutant (dhfr 108N + 51I +59R; dhps 437G + 540E) was associated with over 10 times 
the odds of treatment failure compared to infections with parasites containing only the 108N 
and 51I mutations (OR = 10.7, 95%CI 1.8-64.4, p = 0.009).  
 
We have measured the prevalence of key antifolate resistance-conferring mutations 
from subjects living in Tororo (the site of this proposal) over a 4 year period. From 2002-2006 
the prevalence of the dhfr triple mutant increased from 40% to almost 80% and the prevalence 
of the dhps triple mutant increased from 60% to almost 100% (Figure 1). This temporal increase 
in the prevalence of molecular markers of antifolate resistance corresponds to the 2001 
implementation of a national policy change from CQ to CQ+SP as the recommended first-line 
treatment for malaria in Uganda 71. We have also measured the prevalence of key antifolate 
resistance-conferring mutations from the 9 children in a cohort of HIV-infected children who 
developed symptomatic malaria while taking TS prophylaxis 72. All of these samples contained 
the dhfr/dhps quintuple mutant and one sample contained an additional mutation (dhfr 164L) 
associated with high-level antifolate resistance (probably leading to complete loss of 
antimalarial activity of antifolates) that is rare in Africa 73 and was only very rarely detected in 
hundreds of prior samples from Uganda evaluated by our group. These data provided further 
evidence that SP, currently the regimen used for IPTp in Uganda, may be faced with diminishing 


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protective efficacy. Thus, alternative regimens and strategies, such as DP as proposed in our 
protocol, should be considered.  
 
Figure 1. Prevalence of key antifolate resistance-conferring mutations over time 
0%
20%
40%
60%
80%
100%
2002
2003
2004
2005
2006
Prevalence of dhfr triple mutant
0%
20%
40%
60%
80%
100%
2002
2003
2004
2005
2006
Prevalence of dhps double mutant
 
 
Clinical trials of DP. DP is a new co-formulated ACT that was approved for use in Uganda in 
2005. We have completed two standard clinical trials in Uganda comparing DP to AL, 50, 74. 
These trials were conducted at sites with both low (Kanungu) and high (Apac) malaria 
transmission intensity, enrolling 835 patients, including 741 children under the age of 5 years. 
Both drugs were highly efficacious, with a low risk of recrudescence after therapy. Relevant to 
this proposal is the drugs’ post-treatment prophylactic effect up to one month after therapy. 
One month after therapy, risks of recurrent parasitemia with DP were 4% and 11% at the low 
and high transmission sites, respectively, compared to risks of 18% and 29% with AL (p<0.0001 
for both comparisons). In addition, DP was better tolerated than AL at both sites, with no 
serious adverse events related to DP.  
More recently we completed a longitudinal clinical trial comparing DP to AL in a cohort 
of young children in Tororo (manuscript submitted for publication). Overall, 312 children were 
randomized to DP or AL at the time of the first episode of uncomplicated malaria (median age 
10.5 months).  The same treatment was given for all subsequent episodes of uncomplicated 
malaria and children were followed until they reached 5 years of age. The cohort included a 
subgroup that was HIV-infected or HIV-exposed prescribed TS prophylaxis. Outcomes included 
time to recurrent malaria following individual treatments and the overall incidences of 
treatments for malaria, complicated malaria, and hospitalizations. Among children not 
prescribed TS prophylaxis, 4443 treatments for malaria were given over 790 person years 
following randomization. Treatment with DP was associated with a less than 5% risk of 
recurrent malaria within 28 days and a lower hazard of recurrent malaria over 84 days 
compared to AL (HR=0.66, 95% CI 0.61-0.70, P<0.001)(Figure 2). Children randomized to DP also 
had a lower incidence of all treatments for malaria (IRR=0.85, 95% CI 0.75-0.96, P=0.01), 
complicated malaria (IRR=0.12, 95% CI 0.04-0.39, P<0.001), and hospitalizations (IRR=0.31, 95% 
CI 0.13-0.77, P=0.01). In addition, repeated treatments with DP were safe, with a low risk of 
adverse events that were comparable to AL.75 
 


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Figure 2. Cumulative risk of recurrent malaria following treatment with DP vs. AL 
 
Clinical trial of chemoprevention in young Ugandan children living in Tororo. 
Chemoprevention offers a promising strategy for the prevention of malaria in African children. 
However, the optimal chemoprevention drug and dosing strategy is unclear in areas of year-
round transmission and high prevalence of resistance to many antimalarial drugs. We recently 
completed an open-label, randomized controlled trial of antimalarial chemoprevention in 
young children living in Tororo, an area of intense, year-round transmission in Eastern Uganda. 
A total of HIV-unexposed 400 infants were enrolled between 4-5 months of age and 393 
randomized to one of four treatment arms at 6 months of age: no chemoprevention, monthly 
SP, daily TS, or monthly DP. Study drugs were administered at home without supervision. 
Participants were given a long-lasting insecticide treated bednet at enrollment and followed for 
all their health care needs. At 24 months of age the intervention was stopped and study 
participants were then followed to 36 months of age to compare the incidence of malaria over 
the 1 year period after chemoprevention was stopped.  During the intervention, the incidence 
of malaria in the no chemoprevention group was 6.95 episodes per person-year. Monthly DP 
had a protective efficacy of 58% (95% CI 45-67%, p<0.001) against malaria and 47% (95% CI 1-
72%, p=0.04) against moderate-severe anemia. Daily TS had a protective efficacy of 28% (95% 
CI 7-44%, p=0.01) against malaria but offered no protection against moderate-severe anemia (-
21%, 95% CI -107 to 29%, p=0.49). Monthly SP offered no protection against malaria (7%, 95% 
CI, -19 to 28%, p=0.57) and had an excess risk of moderate-severe anemia (-70%, 95% CI -184 to 
-2%, p=0·04)(Table 1).  
 


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Table 1. Protective efficacy against incident episodes of malaria 
Treatment arm 
6-24 months of age 
Number of 
cases 
PYAR 
Incidence per 
PYAR 
PE  (95% CI) 
p value 
Control 
760 
109.3 
6.95 
reference 
- 
Monthly SP 
725 
107.8 
6.73 
7% (-19 to 28) 
0.57 
Daily TS 
609 
116.8 
5.21 
28% (7 to 44) 
0.01 
Monthly DP 
366 
121.3 
3.02 
58% (45 to 67) 
<0.001 
PYAR=person years at risk; PE=protective efficacy 
 
In all 4 arms the incidence of malaria increased with age (Figure 3), and the protective efficacies 
of all 3 interventions decreased over the course of the study. Supporting pharmacokinetic data 
suggests that the majority of children randomized to DP were not compliant with their regimen 
at the times they were diagnosed with malaria.  Another finding of interest was that the 
incidence of malaria was over 5 episodes per year in children 4-5 months of age prior to 
randomization, suggesting the need to begin chemoprevention earlier than 6 months of age as 
was done in this study. 
 
Figure 3. Incidence of malaria over age stratified by assigned treatment arm 
 
 
Data are also available for the one year period following the completion of the intervention 
(Table 2). Of 352 children who reached 24 months of age when chemoprevention was stopped; 
340 reached 36 months of age and completed the study and 12 were withdrawn before 
reaching 36 months of age. The incidence of malaria was very high after stopping 
chemoprevention, reaching almost 11 episodes per year at risk. Importantly, these data do not 
show a “rebound” of increased malaria after completion of chemoprevention. For all arms, 


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there has been no significant difference in the incidence of malaria following chemoprevention 
compared to the control group. 
 
Table 2. Incidence of malaria following cessation of chemoprevention 
 
Treatment arm 
24-36 months of age 
Number of 
cases 
PYAR 
Incidence per 
PYAR 
IRR  (95% CI) 
p value 
No prior therapy 
670 
61.8 
10.85 
1.0 (reference) 
- 
Prior Monthly SP 
689 
57.5 
11.98 
 1.11 (0.88-1.40) 
0.37 
Prior Daily TS 
678 
62.2 
10.90 
1.01 (0.80-1.27) 
0.95 
Prior Monthly DP 
659 
61.2 
10.77 
0.99 (0.79-1.25) 
0.96 
PYAR=person years at risk; IRR = incidence rate ratio 
 
1.3. Rationale 
 
Malaria remains one of the most important infectious diseases worldwide with an estimated 
3.3 billion people at risk leading to hundreds of millions of cases and 660,000 deaths each 
year.46, 76 In 2010, 81% of cases and 91% of deaths were estimated to have occurred in Africa, 
with children under five years of age and pregnant women most severely affected.46 The 
primary tools currently available for malaria prevention in Africa include ITNs and IPTp. 
However, there are limitations with these interventions and the burden of malaria remains high 
in many parts of Africa despite recent increases in coverage levels. ITNs do not fully protect 
against malaria and there is concern for waning efficacy given the emergence of resistance to 
pyrethroid insecticides (the only class used in ITNs).32, 33 The only drug widely used for IPTp is 
SP, and there are recent reports suggesting that IPTp with SP is no longer effective, especially in 
East Africa, where resistance to this drug is now widespread.14, 77 Recent increases in funding 
for malaria control offer an unprecedented opportunity to expand preventative interventions; 
however, new strategies are urgently needed to reduce the burden of malaria for those at 
greatest risk.  
One of the most important malaria control interventions is the use of ACTs for the 
treatment of malaria. ACTs are highly efficacious, and now the recommended first-line 
treatment for uncomplicated falciparum malaria in all countries of sub-Saharan Africa , 
including the treatment of malaria in pregnant women during the 2nd and 3rd trimesters.25 ACTs 
also offer the opportunity to greatly reduce the burden of malaria in pregnant women and 
young children if their role is expanded to chemoprevention. IPT with the ACTs artesunate-
amodiaquine, artesunate-SP, and DP have been shown to be effective and safe for the 
prevention of malaria in African children.41, 78, 79 IPT with DP is especially attractive given its 


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prolonged post-treatment prophylactic effect, due to the unusually long half-life of 
piperaquine.27  
This proposal will be the first clinical trial we are aware of to evaluate the efficacy and 
safety of DP for the prevention of malaria in pregnant women. We will perform a randomized, 
double-blinded, controlled trial to compare 2 dosing strategies of this novel intervention with 
the current standard of care of IPTp with SP in an area of high transmission intensity and 
widespread antifolate resistance. Pregnant women will undergo frequent sampling using a 
highly sensitive PCR assay to better define the timing and frequency of malaria infection during 
pregnancy and the primary outcome will be based on placental histopathology to maximize the 
detection of placental infection throughout pregnancy. At enrollment mothers will also consent 
for participation of their unborn children in the 2nd phase of the study. Unborn children will be 
randomly assigned to receive q 3 monthly DP vs. monthly DP between 2-24 months of age and 
then followed for an additional 1 year after the intervention is stopped. We will be advancing 
the knowledge gained from our ongoing chemoprevention studies in infants by focusing on DP 
as the most effective candidate drug, utilizing a birth cohort and starting the intervention at an 
earlier age (2 months vs. 6 months) when the risk of malaria becomes high, and utilizing a 
double-blinded trial with directly observed therapy to more accurate assess safety and 
tolerability. In addition, by studying two different dosing strategies for DP in both pregnancy 
and infancy, we will be able compare the practical benefits of less frequent dosing with the 
potential greater efficacy of more frequent dosing. Perhaps the most innovative and novel 
aspect of this proposal will be the use of a two-phase study design that will allow us to 
independently test the hypotheses that prevention of malaria in pregnancy and infancy will 
improve the acquisition of naturally acquired antimalarial immunity and reduce the subsequent 
risk of malaria in infants and young children. The overall theme of this proposal will be that in 
areas of high malaria transmission intensity where the burden of malaria remains high despite 
the use of currently available control interventions, aggressive and strategic use of highly 
effective drugs for chemoprevention may dramatically reduce malaria associated morbidity and 
improve the development of antimalarial immunity.  
 
 
2. STUDY OBJECTIVES 
 
We will test the hypothesis that IPT with DP will significantly reduce the burden of malaria in 
pregnancy and infancy and improve the development of naturally acquired antimalarial 
immunity. The specific study objectives are as follows: 
 
2.1. Objective 1 
 


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To compare the risk of placental malaria among HIV uninfected pregnant women randomized 
to receive IPTp with 3 dose SP vs. 3 dose DP vs. monthly DP. We will test the hypothesis that 
pregnant women who receive IPTp with either 3 doses of DP or monthly DP will have a lower 
risk of placental malaria defined by histopathology compared to those who receive 3 doses of 
SP. Secondary outcomes will include maternal and fetal clinical outcomes. We will also compare 
the two different dosing strategies of DP. 
 
2.2. Objective 2 
 
To compare the incidence of malaria among infants randomized to receive q 3 monthly DP vs. 
monthly DP between 2-24 months of age. We will test the hypothesis that infants randomized 
to receive monthly DP between 2-24 months of age will have a lower incidence of malaria 
during the first 24 months of life compared to infants randomized to receive q 3 monthly DP. 
Secondary outcomes will include the incidence of complicated malaria, hospitalizations, 
adverse events, and the prevalence of anemia. 
 
2.3. Objective 3 
 
To compare the incidence of malaria among infants and children following the two phases of 
the intervention. We will test the hypotheses that 1) infants born to mothers randomized to 
receive IPTp with 3 doses of DP or monthly DP will have a lower incidence of malaria during the 
first 24 months of life compared to infants born to mothers who were randomized to receive 
IPTp with 3 doses of SP, and 2) infants randomized to receive monthly DP between 2-24 months 
of age will have a lower incidence of malaria between 24-36 months of age after the 
intervention is stopped compared to infants randomized q 3 monthly DP between 2-24 months 
of age. 
 
3. STUDY DESIGN 
 
This will be a double-blinded randomized controlled phase III trial of 300 HIV uninfected 
pregnant women and the children born to them. The study interventions will be divided into 
two phases. In the first phase, HIV uninfected women at 12-20 weeks gestation will be 
randomized in equal proportions to one of three IPTp treatment arms: 1) 3 doses of SP, 2) 3 
doses of DP, or 3) monthly DP. All three interventions arms will have either SP or DP placebo to 
ensure adequate blinding is achieved in the study as outlined in appendix D. Follow-up for the 
pregnant women will end approximately 6 weeks after giving birth. In the second phase of the 
study, all children born to mothers enrolled in the study will be followed from birth until they 
reach 36 months of age. Children born to mothers randomized to receive 3 doses of SP during 


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pregnancy will receive DP every 3 months between 2-24 months of age. Children born to 
mothers randomized to receive 3 doses of DP or monthly DP during pregnancy will receive 
either DP every 3 months or monthly DP between 2-24 months of age. To ensure adequate 
blinding, children who will receive DP every 3 months will be given DP placebo during the 
months they will not be taking DP. Children will then be followed an additional year between 
24-36 months of age following the interventions. 
 
4. SELECTION AND ENROLLMENT OF SUBJECTS 
 
4.1. Inclusion Criteria 
 
1) Pregnancy confirmed by positive urine pregnancy test or intrauterine pregnancy by 
ultrasound 
2) Estimated gestational age between 12-20 weeks  
3) Confirmed to be HIV uninfected by rapid test 
4) 16 years of age or older 
5) Residency within 30km of the study clinic 
6) Provision of informed consent by the pregnant woman for herself and her unborn child 
7) Agreement  to come to the study clinic for any febrile episode or other illness and avoid 
medications given outside the study protocol 
8) Plan to deliver in the hospital 
 
4.2. Exclusion Criteria 
 
1) History of serious adverse event to SP or DP 
2) Active medical problem requiring inpatient evaluation at the time of screening 
3) Intention of moving more than 30km from the study clinic 
4) Chronic medical condition requiring frequent medical attention 
5) Prior SP preventive therapy or any other antimalarial therapy during this pregnancy 
6) Early or active labor (documented by cervical change with uterine contractions) 
 
4.3. Initial Screening 
 
We will recruit pregnant women presenting for routine care at the TDH antenatal clinic, at local 
health centers within 30 km, or referred by the Uganda government voluntary health teams. 
Pregnant women will be approached about participating in the study and will be provided an 
information sheet about the requirements of the study (Appendix A).  If women are initially 
agreeable to screening for participation in the study and are < 20 weeks gestation by LMP, 16 
years of age or older, and not known to be HIV infected, they will either be escorted to the 


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study clinic or made an appointment to return at a later date.  At our study clinic adjacent to 
the TDH antenatal clinic, study physicians will assess for initial eligibility criteria through 
conversation with the woman (confirming the age of the woman, residency within 30km of the 
study clinic, agreement to come to the study clinic for any febrile episode or other illness and 
avoid medications given outside the study protocol, plan to deliver in the hospital, no history of 
serious adverse event to SP or DP, no active medical problems requiring inpatient evaluation at 
the time of screening, no intention of moving more than 30km from the study clinic, no chronic 
medical condition requiring frequent medical attention, and no prior SP preventive therapy or 
any other antimalarial therapy during this pregnancy). Women who pass initial screening based 
on conversation with study physicians will undergo the following additional screening 
procedures: 1) rapid HIV testing to confirm HIV negative status, 2) ultrasound dating to confirm 
intrauterine pregnancy and gestational age of 12-20 weeks in conjunction with LMP (Appendix 
B), and 3) a pelvic examination to exclude early or active labor if clinically indicated. Women 
who are not eligible for the study will be referred back to the TDH antenatal clinic. 
 
4.4. Study Enrollment Procedures and Baseline Evaluation 
 
Informed consent will be obtained from women who pass initial screening. Study physicians will 
conduct the informed consent discussion in the study clinic. Informed consent will include both 
participation of the pregnant woman and her unborn child (or children in the case of non-
singleton pregnancies). Informed consent will be conducted in the appropriate language and a 
translator will be used if necessary. The study will be described and consent obtained in one of 
5 languages (Dopadhola, Ateso, Swahili, Luganda, or English). The consent forms will be 
translated into each language and back-translated into English to check for any loss or change 
of meaning. Following the informed consent discussion, pregnant women will be asked by the 
study physicians to sign a written consent form approved by the UCSF Committee for Human 
Research (UCSF CHR), Makerere University School of Medicine - Research and Ethics Committee 
(SOM-REC) or Makerere University School of Biomedical Sciences - Research and Ethics 
Committee (SBS-REC), and the Uganda National Council for Science and Technology (UNCST) for 
their own participation in the research study and a second approved consent form for the 
future use of biological specimens obtained during the course of the study.  If the pregnant 
woman is unable to read or write, their fingerprint will substitute for a signature, and a 
signature from an impartial witness to the informed consent procedures will be obtained.   
 
Women will be enrolled in study on the same day that they provide informed consent 
for participation in the research study.  On the day of enrollment, women will undergo a 
standardized history and physical examination, and have blood collected by venipuncture (15 
cc’s) for filter paper sample (for future molecular studies), routine baseline laboratory testing 
and storage.  Routine baseline laboratory testing will consist of a CBC and ALT measurement. 
Women who have history of fever in the previous 24 hours or a temperature > 38.0ºC 
(tympanic) will have a thick blood smear read urgently in the study clinic.  Women with history 
of fever in the previous 24 hours or a temperature > 38.0ºC (tympanic) and a positive blood 
smear will be diagnosed with malaria and treated as described in section 6.2. At the end of the 
enrolment visit all study participants will be given a long lasting insecticide treated bed net 


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(ITN) and a household survey appointment will be scheduled within 2 weeks to collect 
household-level information on the use of bednets, house members, household characteristics, 
and GPS coordinates (Appendix C). 
 
 
5. STUDY TREATMENT 
 
5.1. Treatment Group Assignments 
There will be 5 treatment arms which include both the intervention for the woman during 
pregnancy and her unborn child(ren) during infancy (Table 3). Non-singleton births from the 
same mother will be assigned to the same intervention.  We will use a 2:1:1:1:1 randomization 
scheme targeting 100, 50, 50, 50, 50 pregnant women in treatment arms A-E respectively. A 
randomization list will be computer generated by a member of the project who will not be 
directly involved in the conduct of the study. The randomization list will include consecutive 
treatment numbers with corresponding random treatment assignments. Randomized codes will 
correspond to the 5 treatment groups using permuted variable sized blocks of 6 and 12 (to 
account for treatment group A being represented twice as often as the other 4 treatment 
groups). Sealed copies of the original randomization list and documentation of the procedure 
used to generate the lists will be stored in the project administrative offices in San Francisco 
and Kampala. Prior to the onset of the study, a set of sequentially numbered, opaque, sealed 
envelopes will be prepared.  Each envelope will be marked on the outside with the treatment 
allocation number. The inside of the envelope will contain a piece of paper with the treatment 
allocation number and treatment group assignment along with a piece of carbon paper.  
 
Table 3. Treatment arms with assignment of study drugs during pregnancy and infancy 
Phase of 
intervention 
Treatment arm 
A 
B 
C 
D 
E 
During pregnancy 
3 dose SP 
3 dose DP 
3 dose DP 
Monthly DP 
Monthly DP 
During infancy 
3 monthly DP 
3 monthly DP 
Monthly DP 
3 monthly DP 
Monthly DP 
 
5.2. Treatment Allocation 
 
On the day of enrollment, pregnant women will be referred to a study pharmacist responsible 
for treatment allocation. The study pharmacist will assign treatment arms as follows: 
1. Select next available envelope 
2. Note treatment number on the outside of the envelope 
3. Write date, time, and study number on the outside of the envelope 
4. Open envelope 


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5. Remove form containing code for treatment arm and date, time, and study number 
(transferred to form via carbon paper inside of envelope) 
6. Store form in lockable file box in study pharmacy 
7. Record onto the treatment allocation master list the study number, enrollment date, 
treatment assignment code, treatment arm, and study medications to be given during 
pregnancy and infancy 
8. Store treatment allocation Master list in a lockable cabinet in study pharmacy 
9. Record treatment number in the study participant’s file 
 
5.3. Study Drug Dosing and Formulations 
 
During pregnancy, women will be given 1 of 3 treatment regimens: 1) SP given 3 times 
during pregnancy, 2) DP given 3 times during pregnancy, or 3) DP given every 4 weeks during 
pregnancy. Each treatment with SP will be given as a single dose consisting of 3 full strength 
tablets. Each treatment with DP will consist of 3 full strength tablets given once a day for 3 
consecutive days. In addition, placebos will be used to mimic the identical dosing strategy such 
that every 4 weeks women will receive two pills on day 1 (SP and placebo, DP and placebo, or 
two placebos) followed by one pill on days 2 and 3 (DP or placebo). Two placebos will be used, 
one that mimics the appearance of SP and one that mimics the appearance of DP. Dosing 
schedules for each treatment regimen according to gestational age are presented in Appendix 
D. Details of the study drug formulations are included in Table 5. 
During infancy, children will be given DP either every 4 weeks or every 12 weeks. Each 
treatment with DP will consist of half-strength tablets given once a day for 3 consecutive days 
according to weight based guidelines outlined in Appendix E. Infants randomized to receive DP 
every 12 weeks will receive placebo mimicking the dosing of DP every 4 weeks when they are 
not receiving study drug. Dosing schedules for each treatment regimen according to the child’s 
age are presented in Appendix D. 
 
Table 5. Drug formulation and labeling   
Drug 
Formulations 
Trade name (Manufacturer) 
Sulfadoxine-Pyrimethamine (SP) 
500mg/25mg tabs 
Kamsidar (KPI) 
Dihydroartemisinin-Piperaquine (DP) 
Full strength tablets 
40mg/320mg tabs 
Duo-Cotexin (Holley-Cotec) 
Dihydroartemisinin-Piperaquine (DP) 
Half strength tablets 
20mg/160mg tabs 
Duo-Cotexin (Holley-Cotec) 
 
 
5.4. Blinding, Study Drug Administration, and Duration 
 


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26 
 
 
Administration of all study drugs will be double blinded. All doses of study drugs will be 
prepackaged by a study pharmacist and administered by a study nurse blinded to the study 
participant’s treatment regimen. All doses of SP (or SP placebo) administered will be directly 
observed in the clinic. For DP (or DP placebo), the first of the 3 daily doses will be directly 
observed in the clinic and the 2nd and 3rd daily doses will be administered at home using pre-
packaged study drugs in opaque envelopes with dosing instructions written on the outside. For 
doses of study drugs administered in the clinic, if a study participant vomits the study drug 
within 30 minutes of administration, the drug will be re-administered. For doses of study drugs 
administered at home, if a study participant vomits the study drug within 30 minutes of 
administration or study drug is lost, the study participant will be instructed to come to the 
study clinic as soon as possible where the study drug will be re-administered/replaced. For 
pregnant women all doses of study drugs will be given between 16 and 40 weeks gestation and 
for children all doses of study drugs will be given between 8 and 104 weeks (2 years) of age as 
outlined in Appendix D.   
 
5.5. Study Drug Accountability 
 
The study pharmacist will maintain complete records of all study drugs received in the study 
pharmacy.  Lot number and number of pills given to each study participant will be recorded. A 
registry of all study medication, current product labels, and Certificates of Analysis, provided by 
suppliers will be maintained within the regulatory binder for the study.  The date received, lot 
number, expiration date, and date used will be recorded for each of the study medications.  
Monthly inventory of all study medications will be conducted and a record log of investigational 
medications will be kept at the study clinic.  
 
 
6. SUBJECT MANAGEMENT 
 
6.1. 
Subject Follow-up 
 
Pregnant women will be scheduled to be seen in the clinic every 4 weeks during their 
pregnancy and 6 weeks following delivery. In addition, pregnant women will be instructed to 
come to the study clinic for all their medical care and avoid the use of any outside medications. 
Children will be scheduled to be seen in the clinic every 4 weeks and parents /guardians of 
children will be instructed to bring their child to the study clinic for all medical care and avoid 
the use of any outside medications. The study clinic will remain open 7 days a week from 8 a.m. 
to 5 p.m.  Pregnant women and children who are not seen on the day of their regularly 
scheduled visits will be visited at home and instructed to come to the clinic as soon as possible.  


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Each time a study participant is seen in the clinic a standardized history and physical 
exam will be performed including temperature, pulse, and blood pressure measurement. 
Patients who are febrile (tympanic temperature > 3 8.0˚C) or report history of fever in the past 
24 hours will have blood obtained by finger prick for a thick blood smear (in very young 
children, heel sticks may be substituted for finger pricks). If the thick blood smear is positive, 
the patient will be diagnosed with malaria.  If the thick blood smear is negative, the patient will 
be managed by study physicians for a non-malarial febrile illness (Section 6.3).  If the patient is 
afebrile and does not report a recent fever, a thick blood smear will not be obtained, except 
when following routine testing schedules (Section 6.5).  
 
6.2. 
Diagnosis and Management of Malaria 
 
Patients found to have malaria based on laboratory confirmation will have a second finger prick 
for a thin smear (to determine parasite species), hemoglobin measurement using a portable 
spectrophotometer (HemoCue), and collection of plasma for future PK studies.  All episodes of 
malaria will be classified as uncomplicated or complicated based on the following criteria:   
 
Uncomplicated malaria (all of the following) 
1) Fever (> 38.0ºC tympanic) or history of fever in the previous 24 hours 
  
2) Positive thick blood smear 
3) Absence of complicated malaria 
 
Complicated malaria (any of the following) 
1) Evidence of severe malaria (Appendix F) and parasitemia  
2) Danger signs present in children (Appendix F) and parasitemia 
 
Episodes of malaria will also be classified into the following categories according to the timing 
of previous malaria episodes for treatment purposes: 
1. New episodes of malaria will be defined as any first episode or any episode occurring > 
14 days after the diagnosis of a previous episode 
2. Treatment failures will be defined as any of the following: 
a. Complicated malaria occurring 1-14 days after the diagnosis of a previous 
episode 
b. Fever (> 38.0°C tympanic) or history of fever in the previous 24 hours with a 
parasite density > the parasite density of an episode of malaria diagnosed 2 days 
prior 


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c. Fever (> 38.0°C tympanic) or history of fever in the previous 24 hours with a 
parasite density > 25% of the parasite density of an episode of malaria diagnosed 
3 days prior 
d. Fever (> 38.0°C tympanic) or history of fever in the previous 24 hours with a 
positive thick blood smear of any parasite density occurring 4-14 days after the 
diagnosis of a previous episode 
 
 
All patients diagnosed with new episodes of uncomplicated malaria will be prescribed 
AL, the recommended first-line treatment in Uganda for children and pregnant women in their 
2nd or 3rd trimester. Patients with complicated malaria will be prescribed quinine or artesunate 
according to national malaria treatment guidelines. Children who are less than 4 months of age 
or weigh <5kg, will be treated with quinine for uncomplicated malaria in accordance with the 
Uganda Ministry of Health Guidelines. Patients with treatment failure within 14 days following 
treatment with AL will be prescribed quinine according to national malaria treatment 
guidelines. Patients with treatment failure within 14 days following treatment with quinine or 
artesunate will be treated with quinine plus clindamycin or artesunate.  
 
6.3. 
Management of Non-Malaria Illnesses 
 
Patients who are found to have illnesses other than malaria will receive standard-of-care 
treatment in the study clinic, according to standardized algorithms, or will be referred to the 
Tororo District Hospital.  We will avoid the routine use of non-study medications with 
antimalarial activity, including tetracyclines, antifolates (with the exception of assigned 
chemopreventive regimens), and macrolide antibiotics, when acceptable alternatives are 
available. In addition, drugs with known risk of torsades de pointes or CYP3A inhibitors 
(Appendix K and L) will be avoided when prescribing treatment to pregnant women or children 
during the time they are taking study drugs. If the study clinician deems treatment with one of 
the drugs listed on Appendix K or L is required, the clinical management team will be consulted. 
During follow-up for non-malarial illnesses, blood smears will be done at the discretion of the 
study physician if the subjects are febrile (tympanic temperature > 38.0˚C) or report history of 
fever in the past 24 hours.  If the blood smear is positive, the patient will be diagnosed with a 
new episode of malaria and managed per study protocol.  
 
6.4. 
After Hours Visits 
 
Pregnant women will be encouraged to come to the TDH maternity ward (open 24 hours a day) 
and parents/guardians will be encouraged to bring their child to the TDH pediatric inpatient 
ward (open 24 hours a day) when urgent care is needed outside of study clinic hours. Pregnant 


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
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women or parents/guardians of children will be instructed to inform hospital personnel of their 
involvement in the study at the time of registration and to visit the study clinic on the following 
day. If a patient is diagnosed with uncomplicated malaria they will receive treatment from a 
hospital supply of AL and the doctors will be instructed to refer patients to our study clinic 
when it opens at 8 am the following day.  If a patient is diagnosed with severe malaria, he/she 
will receive quinine or artesunate following standard treatment guidelines. Patients with non-
malarial illnesses will be managed at the discretion of the Tororo District Hospital staff.  Upon 
discharge, patients will receive follow-up at the study clinic as outlined above.  Study personnel 
will visit the Tororo District Hospital daily to inquire about visits from study subjects and 
facilitate follow-up in the study clinic. 
 
 
6.5. 
Routine Assessments 
 
Routine assessments will be done in the clinic every 4 weeks for both pregnant women and 
children. Study participants not seen in the clinic for their every 4 week routine visits will be 
visited at home and requested to come to the study clinic as soon as possible. Pregnant women 
and children will receive standards of care as designated in the Uganda MOH guidelines 
(Appendix G). Routine antenatal care will include screening and treatment for sexually 
transmitted Infections, blood pressure assessment, urine dipstick for proteinuria, prescription 
of iron, folate, multivitamins and mebendazole. Routine care in children will include 
immunizations, vitamin A supplementation, and management of anemia using Integrated 
Management of Childhood Illness (IMCI) guidelines. During routine assessments subjects will be 
asked about visits to outside health facilities and the use of any medications outside the study 
protocol.  The study protocol will be reinforced with discussion regarding the need to come to 
the study clinic promptly upon the onset of any illness and to avoid use of outside medications.  
Standardized assessment of adherence will also be done for study drugs administered at home 
and ITN use.  A routine history and physical exam will be performed using a standardized 
clinical assessment form.  Blood will be collected by finger prick (in very young children, heel 
sticks may be substituted for finger pricks) for thick smear, collection of plasma for PK studies, 
and filter paper samples. If a pregnant woman or parent/guardian of a child reports a fever in 
the last 24 hours or the patient has a documented temperature > 38.0˚C tympanic, the patient’s 
thick blood smear will be read immediately and if positive the patient will be diagnosed and 
treated for malaria (see section 6.2). Phlebotomy for routine laboratory tests (CBC and ALT) to 
monitor for potential adverse events from study medications and for immunology studies will 
be performed every 8 weeks in pregnant women and every 16 weeks in children. Screening for 
non-malaria parasitic infections will be performed once in pregnant women after the 1st 
trimester at the time routine medendazole is administered and in children at 1yearof age. 


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Screening will consist of stool ova and parasite examination, circulating filarial antigens (by ICT 
card for Wucheria), and blood smear for microfilaremia (including Mansonella perstans) using 
Knott’s technique. For pregnant women and children 2-24 months of age, study drugs will be 
administered at the time of each routine visit as described in sections 5.3 and 5.4.  
 
6.6. 
Delivery visit  
 
Addressing one of the main study outcomes, placenta malaria, requires collection and 
processing of specimens at delivery. Systems will be in place to facilitate a birth plan which will 
encourage women to come to the hospital for delivery, including access to transportation 24 
hours a day. However for women who are unable to travel to the hospital for delivery or choose 
to deliver at home, a study staff member will be driven to the home to follow study procedures.  
Study staff will document details of the delivery, including date and time, type of delivery, 
estimated blood loss and any maternal, obstetrical or neonatal complications. Study staff will 
document the infant’s Apgar score and birth weight with calibrated scales. Biological samples 
collected at the time of delivery will include maternal venous blood (for thick blood smear, filter 
paper samples, CBC, ALT, immunology studies, and PK studies), cord blood (for thick blood 
smear, filter paper samples, hemoglobin measurement, and immunology studies) and placental 
tissue.  Following delivery, neonatal care, as per national guidelines, will include polio and BCG 
immunization, ophthalmic tetracycline, vitamin K, and vitamin A supplementation. 
 
At the time of delivery, women will undergo repeat rapid HIV testing based on national 
guidelines. If women are found to have become HIV-infected during pregnancy, both the 
mother and their newborn will be withdrawn from the study and immediately referred for care 
following local prevention of mother-to-child transmission (PMTCT) guidelines.  
 
6.7. Postpartum visits.  
 
Women will be evaluated within 1 week following delivery and 6 weeks postpartum as part of 
routine care. Both visits will include an abdominal exam syndromic management of STIs, and 
follow-up on any obstetrical complications that occurred including evaluation of the neonate 
for any congenital abnormalities. Pelvic and breast exam will be done if clinically indicated. 
Contraceptive counseling, nutritional assessment and infant feeding and support will be 
provided. Following the 6 weeks visit, women will no longer be considered study participants, 
although most will remain primary care givers for their children enrolled in the second phase of 
the study. 
 
Summaries of all procedures done during routine visits in pregnant women and children are 
presented in Appendix H and I, respectively. 


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6.8. Medical Care Outside the Study Clinic 
 
We will provide routine medical care in our clinic free of charge, including medications, to the 
extent possible given resources available. Study participants and their guardians we will be 
reimbursed for costs of any transportation to and from our clinic.  In addition, we will 
reimburse the cost of tests and drugs for referrals of study participants made by study 
physicians to other clinics and services as well as after-hours visits at TDH.  We anticipate 
reimbursing the cost of most diagnostic tests (including laboratory tests, X-rays, and 
ultrasounds) and medications resulting from these referrals, using available funds. However, 
reimbursement of all diagnostic tests and treatment recommended outside the study clinic 
cannot be guaranteed in all circumstances.  Decisions on reimbursement will be made by the 
study coordinator and the investigators, in conjunction with the funding agency if necessary.  
 
6.9. Duration of Follow-up and Criteria for Premature Study Withdrawal 
 
Pregnant women will be followed until their 6 week postpartum visit. Children will be followed 
through 30th June 2018 until they reach 36 months of age. Women will be asked to bring in the 
biological father to the study clinic for informed consent discussion when child is born. He will 
be asked to provide written consent or a fingerprint to allow participation of the infant. If a 
father is unknown or unavailable, the woman will document in accordance with UNCST 
guidance and participation will continue for both the woman and infant. If the biological father 
refuses consent for the child’s participation, the child will not be enrolled. 
 
Study participants will be prematurely withdrawn from the study for: 1) movement out of study 
area or inability to be located for > 60 consecutive days, 2) withdrawal of informed consent, 3) 
inability to comply with the study schedule and procedures, 4) at the discretion of the site 
investigator if the study is not in the best interest of the participant, 5) subject or 
parent/guardian judged by the site investigator to be at significant risk of failing to comply with 
the study protocol as to cause them harm or seriously interfere with the validity of study 
results, 6) women found to have become HIV infected at the time of delivery, or 7) father does 
not consent to the child’s participation (child withdrawal only). If a subject is withdrawn for 
reasons # 1 or 2, we will be unable to perform any additional study procedures.   If a subject is 
withdrawn for reasons # 3-5, plans to obtain appropriate follow-up tests outside of the study 
will be individualized for each subject depending on the health status of the subject at the time 
of withdrawal and the willingness of the participant and his or her parent/guardian to proceed 
with additional testing.  If a subject is withdrawn for #6-7, the will be referred for appropriate 
care following local PMTCT guidelines. 
 


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6.10. 
Diagnostic and Laboratory Testing 
 
6.10.1. 
Microscopy 
 
Thick and thin blood smears will be stained with 2% Giemsa and read by experienced laboratory 
technologists.  Parasite densities will be calculated by counting the number of asexual parasites 
per 200 leukocytes (or per 500 leukocytes, if the count is <10 asexual parasites/200 leukocytes), 
assuming a leukocyte count of 8,000/µl.  A blood smear will be considered negative when the 
examination of 100 high power fields does not reveal asexual parasites. Gametocytemia will 
also be determined from thick smears.  Thin smears will be used for parasite species 
identification.  For quality control, all slides will be read by a second microscopist and a third 
reviewer will settle any discrepant readings. 
 
6.10.2. 
Clinical Laboratory Studies 
 
At enrollment and every 8 weeks during follow-up for pregnant women and every 16 weeks for 
children, venipuncture blood samples will be collected for routine clinical laboratory studies, 
including CBC and ALT measurements. Additional venipunctures will be performed, as 
appropriate, for laboratory testing to evaluate non-malarial medical illnesses at the discretion 
of study physicians. Results will be made available to study physicians in a timely manner for 
patient management decision-making. Additional hemoglobin measurements will be performed 
each time a patient is diagnosed with malaria using a portable spectrophotometer (HemoCue, 
Angholm, Sweden) and results will be immediately available.  
 
6.10.3. 
Placental Studies 
 
Cord blood will be collected for immunology studies described below. Placental blood collected 
for Giemsa-stained blood smears and PCR will be obtained by making a small incision on the 
maternal surface of the placenta within 1 hour of delivery, collecting blood from the intervillous 
space via syringe, and then placing the blood in an EDTA tube. Placental tissue will be collected 
for histological assessment. Two 1 cm-wide full thickness biopsies from each placenta, obtained 
about 5 cm from the cord, will be obtained within 1 hour of delivery and placed in 10% neutral 
buffered formalin. Biopsy specimens will be embedded in paraffin wax, sectioned into 3 μM 
slices using a rotary microtome, fixed to glass slides, and dehydrated in sequential ethanol 
baths. Separate slides will then be stained in 0.1% hematoxylin and 1% eosin for 5 and 1 min, 
respectively, or in 2% Giemsa for 30 minutes. All necessary expertise and infrastructure for 
these studies is in place in Tororo. For assessment of histologic evidence of placental malaria, 
placentas will be graded into 5 categories using a standardized approach.80 The presence of 


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intervillous parasite-infected erythrocytes and of pigment in monocyte/macrophages or fibrin 
will be noted. Quantitative assessments of placental malaria will be as follows. First, 1000 
intervillous blood cells will be counted under high power. Percentages of intervillous 
erythrocytes infected with parasites and of monocyte/macrophages containing malarial 
pigment will be counted. Placental specimens will be examined by two experts, and any 
discrepant readings will be resolved by a third reader. 
 
6.10.4. 
Molecular and Parasitology Studies 
 
Each time a thick blood smear is obtained; blood will also be collected onto filter paper. 
Samples will be collected by venipuncture or by finger prick sampling.  Blood will be placed onto 
filter paper in approximately 25 μl aliquots per blood spot (4 blood spots per sample).  The 
samples will be labeled with study numbers and dates, air-dried, and stored in small, sealed 
sample bags at ambient temperature or 4°C with desiccant.  Molecular studies will include the 
extraction of DNA from filter paper and followed by characterization of parasite genetic 
polymorphisms using standard molecular procedures including PCR, DNA hybridization, and/or 
restriction enzyme digestion.  Additional molecular studies will include analyses of 
polymorphisms in parasite genes for mutations that may impact on malaria infection and 
response to antimalarial therapy.  Molecular studies will be performed only for research 
purposes and will have no impact on the clinical management of study patients. Molecular 
studies will be formed in Uganda whenever possible and at UCSF when facilities/equipment are 
not available in Uganda.  
 
Blood collected by venipuncture on the day malaria in child is diagnosed will be used in selected 
subjects for parasite culture and/or immunology studies (below). For these studies the skin will 
be prepped with 3 washes with a betadine or equivalent sterilizing solution, and then 
approximately 3-5 mls of blood in children <2 years of age, or 6-10 mls of blood in children ≥2 
years of age will be collected in an anticoagulated sterile tubes and transferred promptly 
(generally within 30 minutes) to our molecular laboratory. Parasites will be cultured following 
standard protocols. In brief, erythrocytes will be separated from plasma by centrifugation and 
removal of the supernatant and buffy coat, and the infected erythrocytes will then be cultured 
in RPMI medium supplemented with human serum or Albumax serum substitute. Cultured 
parasites will be evaluated for in vitro drug sensitivity, molecular characteristics, and other 
features to characterize antimalarial drug resistance and other aspects of malaria. Information 
from the parasitology studies will have no impact on patient care. 
 
6.10.5. 
Immunology Studies 
 


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Venipuncture blood samples collected at enrollment, during routine visits done every 8 weeks 
in pregnant women and every 16 weeks in children, and in select subjects on the day malaria is 
diagnosed (above) will be made available for immunology studies. Approximately 15mls of 
blood in pregnant women and 5mls of blood in children will be collected and separated into 
plasma and peripheral blood mononuclear cells (PBMC) using a Ficoll gradient, following 
standard protocols.  Plasma will be stored at -80°C for future immunologic, which may include 
measurement of levels of cytokines, antibodies, and other features related to the host immune 
response.  PBMCs will be stored in liquid nitrogen to maintain viability, and will be evaluated 
using flow cytometry, ELISPOT, RT-PCT, expression microarrays and other assays to assess the 
host immune response.  Stool will be collected at 1, 2, and 3 years of age in children and 
evaluated for parasitic infections, and remaining stool will be stored for future studies analyzing 
the influence of parasitic and bacterial infections on immunity. Information from immunology 
studies will have no impact on patient care. Immunology studies will be done in Uganda 
whenever possible. However, due to technological limitations some immunology studies may 
be done at UCSF. 
 
6.10.6. 
Pharmacokinetic (PK) Studies 
 
As resources permit, stored plasma samples and dried blood spots on filter paper will be 
available for measuring DHA and piperaquine levels in a subset of patients who are randomized 
to receive DP. PK studies will be done at UCSF as the capacity for performing these assays does 
not exist in Uganda. 
 
6.11. 
Co-enrollment Guidelines  
 
The pregnant women and children from this study may be co-enrolled in observational studies.  
They may not be co-enrolled in protocols that utilize concomitant study medications. Co-
enrollment in other studies will be determined on a case-by-case basis by the protocol team. 
 
 
6.12. 
Management of Adverse Events Potentially Related to Study Drugs 
 
The following section outlines management of adverse events potentially related to study drugs 
(SP or DP). Given the double blinded nature of the intervention, study clinicians and study 
participants will not be aware of what study drugs are being administered. Therefore all study 
participants will be considered potentially exposed to either study drug during the period study 
drugs are first given up to one month after the last dose of study drug is given.  
 


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6.13. 
Grade 1 or 2 Adverse Events 
 
Participants who develop grade 1 or 2 adverse events may continue study drugs.  The study 
clinicians will manage the grade 1 or 2 events according to standard practice.  
 
6.14. 
Grade 3 or 4 Adverse Events 
 
Management will be as follows: 
 
• Repeat observation or lab test within 72 hours of observation or of receiving lab results 
report. 
• For grade 3 or non-life threatening grade 4 adverse events, subjects may continue taking 
study drugs pending clinic visit or repeat laboratory tests.  Clinician has the option of 
immediately stopping the study drugs if subject cannot be examined in clinic, if a repeat 
laboratory test cannot be performed within 72 hours, or if the clinician determines that the 
continuation of study drugs is unsafe while awaiting clinic exam or test results.  
• For grade 4 life-threatening adverse events, study clinicians should hold study drugs 
pending laboratory confirmation. 
• Work-up to exclude other causes. 
• For all grade 3 or 4 adverse events supported by repeat clinical exam or laboratory test results, 
study drugs will be held, and laboratory tests will be repeated every 1-2 weeks, until the adverse 
event resolves to < grade 2 unless there is strong evidence that the adverse event is not related to 
either study drug.  
• If the adverse event persists at grade 3 or 4 for more than 28 days or recurs on re-challenge, 
and the adverse event is thought to be possibly related to one of the study drugs, the study 
drugs will be permanently discontinued.  
 
In the event that study drugs are permanently discontinued, study participants will remain in 
the study, following our intention-to-treat analysis approach. In the event that study drugs are 
permanently discontinued, study clinicians may become un-blinded to the study participant 
assigned treatment regimen if this knowledge may assist in the management of the grade 3 or 4 
adverse event(s) that lead to the permanent discontinuation of the study drugs. 
 
 
7. MONITORING OF ADVERSE EVENTS AND MANAGEMENT 
 
7.1. Monitoring and Reporting of Adverse Events 
 


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7.1.1. Definitions 
 
An adverse event is defined as "any untoward medical occurrence in a patient or clinical 
investigation subject administered a pharmaceutical product that does not necessarily have a 
causal relationship with this treatment" (ICH Guidelines E2A).  An adverse event can further be 
broadly defined as any untoward deviation from baseline health, which includes:  
• Worsening of conditions present at the onset of the study 
• Deterioration due to the primary disease 
• Intercurrent illness 
• Events related or possibly related to concomitant medications  
(International Centers for Tropical Disease Research Network Investigator Manual, Monitoring 
and Reporting Adverse Events, 2003).    
 
7.1.2. Identification of Adverse Events 
 
At each scheduled and unscheduled visit to the clinic, study clinicians will assess patients 
according to a standardized case record form.  A severity grading scale, based on toxicity 
grading scales developed by the NIH Divisions of AIDS (DAIDS) and the Division of Microbiology 
and Infectious Diseases (DMID) Pediatric Toxicity Tables, will be used to grade severity of all 
symptoms, physical exam findings, and laboratory results (Appendix J).  All participants, 
regardless of treatment arm, will be assessed using the same standardized case record form.  
Adverse event monitoring will occur during the period when study drugs are given and up to 1 
month after cessation of study drugs.  
 
Data will be captured on the incidence of all adverse events, regardless of severity. For each 
adverse event identified and graded as severe or life threatening and felt to be possibly, 
probably or definitely related to study drugs, an adverse event report form will be completed.  
In addition, an adverse event form will be completed for all serious adverse events and 
unexpected events, regardless of severity. An adverse event report form will not be completed 
for events classified as mild or moderate (unless they are serious or unexpected), as mild and 
moderate symptoms are common and difficult to distinguish from signs and symptoms due to 
malaria and other common illnesses.  The following information will be recorded for all adverse 
experiences that are reported:  
1) Description of event  
2) Date of event onset 
3) Date event reported 
4) Maximum severity of the event 
5) Maximum suspected relationship of the event to study drugs (either SP or DP)   


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
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6) Whether the event is a serious adverse event 
7) Initials of the person reporting the event 
8) Outcome  
9) Date event resolved 
 
7.1.3. Reporting of Adverse Events 
 
Guidelines for reporting of adverse events provided by NICHD, UCSF Committee for Human 
Research (CHR), and the Food and Drug Administration (FDA) in the U.S. and the Makerere 
University IRB (SOMREC), and National Drug Authority (NDA) in Uganda will be followed as 
summarized in Table 6 below.  
 
Table 6. Guidelines for reporting adverse events 
Institution 
Type of Adverse Events 
When to Report 
 
NICHD 
• 
Definitely, Probably, or Possibly related 
AND Serious or Unexpected 
• 
Within 10  working days of 
awareness 
UCSF-CHR 
External [off-site] adverse event that UCSF PI 
determines: 
• 
changes the study risks or benefits, 
OR 
• 
necessitates modification to the CHR-
approved consent document(s) and/or the 
CHR-approved application/protocol 
• 
Within 10 working days of PI’s 
awareness 
MU-SBSREC 
• 
All Serious and Unexpected events 
irrespective of relationship; 
• 
Fatal or life-threatening events 
within 3 working days of awareness  
• 
All other SAEs within 7 calendar days 
NDA 
• 
All Serious and Unexpected events 
irrespective of relationship 
• 
Within 7 calendar days of awareness 
FDA 
• 
Definitely, Probably or Possibly related 
AND BOTH Serious* AND Unexpected± 
• 
For fatal or life-threatening events, 
by telephone or fax within 7 
calendar days of first awareness 
• 
All other reportable events within 15 
calendar days of first awareness 
 
 
Serious Adverse Event (SAE) is any AE that results in any of the following outcomes:  
• Death,  
• Life-threatening adverse experience.  
• Inpatient hospitalization or prolongation of existing hospitalization,  
• Persistent or significant disability/incapacity,  
• Congenital anomaly/birth defect, or cancer, or  
• Any other experience that suggests a significant hazard, contraindication, side effect 
or precaution that may require medical or surgical intervention to prevent one of the 
outcomes listed above,  
• Event occurring in a gene therapy study  


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• Event that changes the risk/benefit ratio of the study. 
 
Unexpected Adverse Event An adverse event is defined as being unexpected if the event 
exceeds the nature, severity, or frequency described in the protocol, consent form and 
investigator brochure (when applicable). An unexpected AE also includes any AE that meets any 
of the following criteria:  
• Results in subject withdrawal from study participation,  
• Due to an overdose of study medication, or  
• Due to a deviation from the study protocol  
 
8. STATISTICAL CONSIDERATIONS 
 
8.1. Hypothesis 1 
 
We will test the hypothesis that pregnant women who receive IPTp with either 3 dose DP or 
monthly DP will have a lower risk of placental malaria defined by histopathology compared to 
those who receive 3 doses of SP. Secondary outcomes will include maternal and fetal clinical 
outcomes. We will also compare the two different dosing strategies of DP. 
 
8.1.1. Primary Outcome 
 
The primary outcome will be the prevalence of placental malaria based on placental 
histopathology and dichotomized into any evidence of placental infection (parasites or 
pigment) vs. no evidence of placental infection. We will also evaluate placental malaria defined 
by histopathology as a categorical variable (active-acute, active-chronic, and past infection) 
based on the criteria developed by Rogerson et al.80  
 
8.1.2. Secondary Outcomes 
 
Secondary outcomes are summarized in Table 7 below. 
Table 7. Secondary outcomes  
Secondary outcome 
Definition 
Placental parasitemia 
Proportion of placental blood samples positive for 
parasites by microscopy or PCR 
Maternal malaria 
Any treatment for malaria 
Composite birth outcome 
Congenital malformations, late spontaneous 
abortion (<28 weeks), LBW (<2500g), still birth 
(fetal demise ≥28 weeks), congenital anomaly, or 
preterm delivery (<37 weeks). 


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Incidence of adverse events 
Adverse events stratified by type, severity score 
and relationship to study drugs 
Prevalence of anemia 
Proportion of routine hemoglobin measurements 
< 10 g/dL & < 8 g/dL 
Prevalence of asymptomatic 
parasitemia 
Proportion of routine monthly samples positive 
for parasites by PCR 
 
8.1.3. Analyses 
 
An intention-to-treat approach to all analyses will be used, including all study participants 
randomized to therapy and including all follow-up time until the study participants complete 
the study or early study termination regardless of whether the intervention was stopped due to 
an adverse event.  
 
Primary analysis. We will compare the prevalence of placental malaria defined by 
histopathology at birth between the study arms using the Chi-Square test for all pair-wise 
comparisons. We will explore for any differences of potential confounders between the 
treatment arms and if necessary adjust our analysis using multivariate logistic regression. 
 
Secondary analyses. We will compare the prevalence of placental parasitemia and our 
composite birth outcome using the Chi-Square test. We will compare the incidence of maternal 
malaria and adverse events using Poisson or negative binomial regression models. The Poisson 
models will include the logarithm of the follow-up time as an offset. We will translate the fitted 
coefficients and their confidence bounds into percentage effects with the formula 
100*[exp(coefficient)-1]. This approach is closely related to exponential survival models for 
analyzing events per follow-up time, but is better able to adjust for violated assumptions. 
Testing for overdispersion in the Poisson regression can detect violations of these assumptions, 
and variances can be adjusted accordingly to produce valid p-values and confidence interval.  If 
significant deviations from required distributions in study data are detected, we will employ 
negative-binomial or zero-inflated negative-binomial models to account for the observed 
pattern of data. We will compare the prevalence of maternal anemia and asymptomatic 
parasitemia using generalized estimating equations with adjustments for repeated measures in 
the same study participant. If necessary, multivariate analyses will be performed to adjust for 
potential confounders and effect modifiers.  
 
8.2. Hypothesis 2 
 


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We will test the hypothesis that infants randomized to receive monthly DP between 2-24 
months of age will have a lower incidence of malaria during the first 24 months of life 
compared to infants randomized to receive q 3 monthly DP. Secondary outcomes will include 
the incidence of complicated malaria, hospitalizations, adverse events, and the prevalence of 
anemia, asymptomatic parasitemia, and gametocytemia. This hypothesis will be limited to only 
infants born to mothers assigned to receive IPTp with 3 dose DP or monthly DP to ensure an 
equal balance of this prior phase of the interventions. 
 
8.2.1. Primary Outcome 
 
The primary outcome will be the incidence of malaria, defined as the number of incident 
episodes per time at risk. Incident cases will include all treatments for malaria not proceeded by 
another treatment in the previous 14 days. Time at risk will begin at birth and will end when 
study participants reaches 24 months of age, when the intervention will be stopped, or early 
study termination (if prior to 24 months of age). 
 
8.2.2. Secondary Outcomes 
 
Secondary outcomes are summarized in Table 8 below. 
 
Table 8. Secondary outcomes  
Secondary outcome 
Definition 
Incidence of complicated malaria 
Any treatment for malaria meeting criteria for 
severe malaria or danger sings 
Incidence of hospital admissions 
Admission to the pediatric ward for any cause 
Incidence of adverse event 
Adverse events stratified by type, severity score 
and relationship to study drugs 
Prevalence of anemia 
Proportion of routine hemoglobin measurements 
< 10 g/dL & < 8 g/dL 
Prevalence of asymptomatic 
parasitemia 
Proportion of routine samples (PCR or blood 
smears) positive for asexual parasites. 
Prevalence of gametocytemia 
Proportion of routine blood smears positive for 
gametocytes. 
 
8.2.3. Analyses 
 
An intention-to-treat approach to all analyses will be used, including all infants born to mothers 
assigned to receive IPTp with 3 dose DP or monthly DP and including all follow-up time until the 


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
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study participants reach 24 months of age or early study termination regardless of whether the 
intervention was stopped due to an adverse event.  
 
Primary analysis. We will compare the incidence of malaria using Poisson or negative binomial 
regression models as described in section 9.1.3. In necessary, multivariate analyses will be 
performed to adjust for potential confounders and effect modifiers.  
 
Secondary analyses. We will compare the incidence of complicated malaria, hospitalizations, 
and adverse events using Poisson or negative binomial regression models as described in 
section 9.1.3. We will compare the prevalence of anemia, asymptomatic parasitemia, and 
gametocytemia using generalized estimating equations with adjustments for repeated 
measures in the same study participant. In necessary, multivariate analyses will be performed 
to adjust for potential confounders and effect modifiers. 
 
8.3. Hypothesis 3 
 
We will test the hypotheses that A) infants born to mothers randomized to receive IPTp with 3 
dose DP or monthly DP will have a lower incidence of malaria during the first 24 months of life 
compared to infants born to mothers who were randomized to receive IPTp with 3 doses of SP, 
and, B) infants randomized to receive monthly DP between 2-24 months of age will have a 
lower incidence of malaria between 24-36 months of age after the intervention is stopped 
compared to infants randomized q 3 monthly DP between 2-24 months of age. For hypothesis 
3A, we will only include infants randomized to receive q 3 monthly DP during infancy. For 
hypothesis 3B, we will also explore for interaction with the intervention given during 
pregnancy.  
 
8.3.1. Primary Outcome 
 
The primary outcome will be the incidence of malaria, defined as the number of incident 
episodes per time at risk. Incident cases will include all treatments for malaria not proceeded by 
another treatment in the previous 14 days. For hypothesis 3A, time at risk will begin at birth 
and will end when study participants reaches 24 months of age or early study termination (if 
prior to 24 months of age). For hypothesis 3B, time at risk will begin at 24 months of age and 
will end when study participants reaches 36 months of age or early study termination (if 
between 24-36 months of age). 
 
8.3.2. Secondary Outcomes 
 


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The incidence of complicated malaria will be included as a secondary outcome for both 
hypothesis 3A and 3B. 
 
8.3.3. Analyses 
 
An intention-to-treat approach to all analyses will be used. For hypothesis 3A, we will only 
include infants randomized to receive q 3 monthly DP during infancy. For hypothesis 3B, we will 
include all infants that reach 24 months of age. We will compare the incidence of malaria and 
the incidence of complicated malaria using Poisson or negative binomial regression models as 
described in section 9.1.3. For hypothesis 3B, we will also explore for interaction with the 
intervention given during pregnancy.  
 
8.4.     Sample size and power 
 
The number of pregnant women enrolled and the number of study participants reaching the 
various endpoints will determine the samples sizes for each of the primary outcomes of our 
study aims (Table 9). The primary determinant of our target sample size was based on testing 
hypotheses 3 given that the magnitude of differences anticipated for this hypothesis would be 
smaller than those anticipated for hypothesis 1 and 2. We conservatively estimate that 90% of 
pregnant women enrolled will reach the primary study endpoint and we will lose 5% of follow-
up time per year in the infants. The minimum relative differences detectable for the primary 
outcomes of the 3 hypotheses given our estimated sample sizes are summarized in Table 10 
below. For hypotheses 1, we will be powered to detect a 33% relative difference in the 
prevalence of placental malaria in the 3 dose DP arm or the monthly DP arm compared to the 3 
dose SP arm assuming a prevalence of placental malaria of 62% in the 3 dose SP arm based on 
prior data. We will also be powered to detect a 41-70% relative difference in the prevalence of 
placental malaria in the monthly DP arm compared to the 3 dose DP arm assuming a prevalence 
of placental malaria in the 3 dose DP arm ranging from 20-50%. For hypothesis 2, we will be 
powered to detect an 18-23% relative difference in the incidence of malaria between 0-24 
months of age in the monthly DP arm compared to the q 3 monthly DP arm assuming an 
incidence of malaria in the q 3 monthly DP arm ranging from 3-5 episodes PPY. For hypothesis 
3A, we will be powered to detect a 22-28% relative difference in the incidence of malaria 
between 0-24 months of age among children assigned to receive q 3 monthly DP when 
comparing those born to mothers who received 3 dose SP to those born to mothers who 
received 3 dose DP or monthly DP assuming an incidence of malaria in the control group 
ranging from 3-5 episodes PPY. For hypothesis 3B, we will also be powered to detect a 16-21% 
relative difference in the incidence of malaria between 24-36 months of age among children 
assigned to receive monthly DP during infancy compared to those who received q 3 monthly DP 


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during infancy assuming an incidence of malaria in the control group ranging from 3-5 episodes 
PPY.    
 
Table 9. Intervention arms during pregnancy and infancy 
Study populations 
Intervention arms 
Assigned treatment arms in pregnant women 
3 doses of SP 
3 doses of DP 
monthly DP 
Estimated number of pregnant women enrolled 
100 
100 
100 
Estimated number with placental outcomes 
90 
90 
90 
Assigned treatment arms in infants 
q 3 monthly DP 
q 3 monthly DP 
monthly  DP 
q 3 monthly DP 
monthly DP 
Estimated number of infants enrolled 
90 
45 
45 
45 
45 
Estimated number of infants reaching 24 months of age 
81 
41 
41 
41 
41 
 
Table 10. Minimum relative differences in outcomes detectable given estimated effective sample sizes 
Hypothesis 
Analysis population 
Control group and 
estimated sample size 
Comparison group and 
estimated sample size 
Estimated outcome 
measure in control 
group 
Minimum 
relative 
difference 
detectable* 
1 
Pregnant women with placental 
malaria measured at birth 
3 dose SP 
(n=90) 
3 dose DP or monthly DP 
(n=90 each) 
Prevalence of 
placental malaria = 
62% 
33% 
3 dose DP 
(n=90) 
monthly DP 
(n=90) 
Prevalence of 
placental malaria = 20-
50% 
41-70% 
2 
Infants 0-24 months of age born to 
mothers assigned to receive IPTp 
with 3 dose DP or monthly DP 
Infants assigned q 3 
monthly DP (n=90) 
Infants assigned monthly 
DP (n=90) 
Incidence of malaria = 
3-5 episode PPY 
18-23% 
 
3 
Infants 0-24 months of age 
randomized to q 3 monthly DP  
Infants of mothers 
assigned 3 dose SP 
(n=90) 
Infants of mothers 
assigned 3 dose DP or 
monthly DP (n=45 each) 
Incidence of malaria = 
3-5 episodes PPY 
22-28% 
Infants 24-36 months of age after 
chemoprevention stopped 
Infants assigned q 3 
monthly DP (n=162) 
Infants assigned monthly 
DP (n=81) 
Incidence of malaria = 
3-5 episodes PPY 
16-21% 
* Relative difference = (estimated outcome in control arm – estimated outcome in the comparison arm) / 
estimated outcome on the control arm (two-sided alpha = 0.05, power = 80%). 
 
8.5. Data and Safety Monitoring Plan 
 
The proposed study will conform to rigorous standard monitoring procedures, standardized 
reporting of adverse events (Adverse Event Report Forms are completed by study coordinators 
and sent immediately to the investigators), and regular review of the study by a Data and Safety 
Monitoring Board (DSMB). The PI has primary responsibility for the overall conduct of the 
study, including the safety of human subjects. The PI will ensure appropriate (1) conduct of the 
informed consent process (e.g. that informed consent is obtained before proceeding with study 
procedures); (2) enrollment of study subjects; (3) collection and analysis of data; (4) 
implementation of study procedures to ensure consistent monitoring of subjects for possible 
adverse events; (5) review of adverse events and reporting to the DSMB and the IRBs; and (6) 
maintenance of the privacy and confidentiality of study subjects. The PI maintains ultimate 
responsibility for the project and for the safety of study participants.  The PI will be in contact 
with the research team on a regular basis to review the progress of the study and address any 
human subject issues that occur. These discussions may involve adverse event prevention 


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
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measures, recruiting of appropriate study subjects, research staff training on protection of 
human subjects, as well as occurrence of adverse events, unexpected incidents, or protocol 
problems. 
 
8.5.1. Data and Safety Monitoring Board 
 
A DSMB will be established by the study team in cooperation with the sponsor to assess at 
intervals the progress of a clinical trial, safety data, and critical efficacy variables and 
recommend to the sponsor whether to continue, modify or terminate a trial. The DSMB will 
have written operating procedures and maintain records of all its meetings, including interim 
results; these will be available for review when the trial is complete. The DSMB will be a 
separate entity from the US and host-country Institutional Review Boards (IRBs). The 
independence of the DSMB is intended to control the sharing of important comparative 
information and to protect the integrity of the clinical trial from adverse impact resulting from 
access to trial information.  DSMB members will not participate in the study as investigators 
and will not have conflicts of interest regarding the study or the investigational product. The 
composition of the DSMB will include at minimum: 
 
DSMB Chair, having experience and expertise in clinical trials 
Scientist with expertise in malaria. 
Scientist with expertise in pharmacology 
Biostatistician with expertise in clinical trials. 
 
A member of the sponsor, NICHD, will be invited to attend and thus have access to unblinded 
information, and control of dissemination of interim trial results within the sponsor 
organization. The DSMB will meet at least annually to review progress of the clinical trial and 
safety data.   
 
The DSMB will review the study for progress and safety. The PI will provide information that will 
allow the DSMB to review and assess the following: 
• The research protocol, informed consent documents and plans for data safety 
and monitoring;   
• Periodic assessments of data quality and timeliness, participant recruitment, 
accrual and retention, participant risk versus benefit, and other factors that can 
affect study outcome;  
• Factors external to the study when relevant information, such as scientific or 
therapeutic developments, may have an impact on the safety of the participants 
or the ethics of the trial;   


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
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• Study performance to make recommendations and assist in the resolution of 
problems;    
• The safety of the study participants;   
• The safety and scientific progress of the trial;  
• The continuation, termination or other modifications of the trial based on the 
observed beneficial or adverse effects of the treatment under study;   
• The confidentiality of the data and the results of monitoring; and  
• Any problems with study conduct, enrollment, sample size and/or data collection. 
 
The first meeting of the DSMB will take place prior to the initiation of the study to discuss the 
protocol and the Data Safety Monitoring Plan.  Meetings of the DSMB shall be held according to 
the plan outlined above. Meetings shall be closed to the public because discussions may 
address confidential patient data. Meetings may be convened as conference calls as well as in 
person. An emergency meeting of the Board may be called at any time should questions of 
patient safety arise. The DSMB may request the presence of study investigators at such 
meetings.  
 
The study PI will distribute study information to the DSMB at least 10 days prior to a scheduled 
meeting. The DSMB may request additions and other modifications to this information on a 
one-time or continuing basis. This information will consist of two parts: (1) information on 
study progress such as accrual, baseline characteristics, and other general information on study 
status and (2) any confidential data on study outcomes, including safety data. A formal report 
from the DSMB should be supplied to the PI within 6 weeks of each meeting. Each report 
should conclude with a recommendation to continue or to terminate the study. This 
recommendation should be made by formal majority vote. A recommendation to terminate the 
study should be transmitted to the PI, IRBs and NIH as rapidly as possible, by immediate 
telephone and fax if sufficiently urgent. In the event of a split vote in favor of continuation, a 
minority report should be contained within the regular DSMB report. 
 
 
8.5.2. Interim safety analysis 
 
Over the course of the trial, we will perform an interim safety analysis in addition to a final 
safety analysis for a total of two sequential evaluations of study safety.  Safety will be evaluated 
separately for pregnant women and infants evaluating the incidence rate ratio of significant 
adverse events (grade 3/4 & SAEs).  The interim safety analysis for pregnant women will be 
performed when ½ of the study subjects have given birth and for infants 0-24 months of age 
when ½ of the anticipated total observation time has been accrued. A separate standardized 


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
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test statistic will be calculated for the adverse event incidence rate ratio for pregnant women 
and infants. If this statistic exceeds the nominal critical value calculated using the error 
spending function (Table 11), then a statistically significant result will have been achieved at the 
time of that analysis.  In that event, the sponsor will be notified and a report submitted for 
review by the Data Safety Monitoring Board (DSMB). In each interim safety analysis, the study 
team will present information on recruitment and the results of interim safety analyses to the 
DSMB, which will review the data and recommend a course of action.  
 
 
Table 11. Schedule of interim safety analysis and boundaries to monitor study outcome 
Number of Evaluable Subjects Accrued  
or % of Total Accrual Time 
Test Statistic 
Alpha 
Cumulative  
Alpha 
Lower Bound Upper Bound 
N=150 or 50% of accrual time 
-2.51 
2.51 
0.00601 
0.01210 
N=300 or 100% of accrual time 
-1.99 
1.99 
0.02313 
0.05000 
This analysis assumes α=0.05 (two-sided test), O’Brien-Fleming boundaries (DeMets error-
spending function) and 300 trial participants. We will utilize Programs for Computing Group 
Sequential Boundaries Using the Lan-DeMets Method. 
 
 
8.5.3. Stopping rules 
 
The DSMB will determine whether to stop the study for early evidence of intervention safety 
problems after a thorough review of interim data. Interim reports will provide cumulative 
enrollment figures and cumulative adverse birth outcomes, serious adverse events (classified 
according to grade) for both women and children, sorted by study arm. Brief clinical 
descriptions of key events will also be provided. The PI will be responsible for immediately 
reporting to the funding agency any temporary or permanent suspension of the project and the 
reason for the suspension.  
 
9. DATA COLLECTION AND MONITORING 
 
9.1. Record Keeping  
 
All clinical data will be recorded onto standardized case record forms (CRFs) by study clinicians.  
Blood smear results will be recorded in a laboratory record book by the study laboratory 
technologists and then transferred to the case record forms by study coordinators, who will 
review the case record forms frequently for completeness and accuracy.  Other laboratory data 
(CBC, ALT measurements) will be entered into the CRFs and hard copies of the original results 


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
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will be stored in a file. Data will be entered directly from CRFs into a computerized database or 
transferred from the CRFs onto standardized data extraction forms and then into a 
computerized database.  All computerized data will be double entered to verify accuracy of 
entry.  Electronic data including all study databases and supporting electronic documentation 
will be archived to large-scale digital tape on a daily basis.  On a monthly basis, a complete 
backup tape will be transported off-site to the Kampala Data Management Center for rotating 
secure storage. In addition, the database from the backup will be placed onto one of the 
Kampala DMC servers as a data mirror for read-only access in the event that the Tororo web-
site becomes temporary unavailable.   
 
9.2. Data Quality Assurance and Monitoring  
 
In order to insure data quality, the study Data Manager will perform a quarterly data quality 
audit.  For this audit a 1% random sample of study forms entered into the data management 
system from the previous 2 weeks will be selected and compared for accuracy with the original 
case-report forms and source documents.  In addition the study the Data Manager will perform 
monthly reviews of the 100% double data entry data verification logs and the data 
management system audit trail log to identify potential data quality issues. The data will be 
owned by the Makerere University-University of California, San Francisco Research 
Collaboration. 
 
 
10. HUMAN SUBJECTS 
 
10.1. 
Subject Selection Criteria 
 
Study subjects will be HIV-uninfected pregnant women and the children born to them who 
meet our selection criteria and provide informed consent.  We plan to recruit only Ugandan 
residents and will recruit both pregnant women age 16 and above and male or female children.  
Enrollment of children is appropriate for study, as malaria is primarily a pediatric disease in 
highly endemic countries such as Uganda.  In addition, pregnant women and young children are 
groups that have a high risk of malaria and therefore are expected to benefit most from 
antimalarial chemoprevention.  
 
10.2. 
Risks and Discomforts 
 
10.2.1. Privacy 
 


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Care will be taken to protect the privacy of subjects, as described in this protocol. However, 
there is a risk that others may inadvertently see patients’ medical information, and thus their 
privacy may be compromised.  
 
10.2.2. Finger Pricks, Heel Sticks, and Venipuncture 
 
Risks of these procedures include pain, transient bleeding and soft-tissue infection. 
 
10.2.3. Risks of Study Medications 
 
Risk of Sulfadoxine-Pyrimethamine 
 
Although technically a combination regimen, SP is generally considered a single antimalarial 
agent, as its success depends on the synergistic action of its two component inhibitors of folate 
synthesis. SP is approved in the USA for the treatment of falciparum malaria and for 
chemoprophylaxis against malaria in travelers, but it is no longer recommended for this second 
use due to rare, but serious toxicity. Adverse reactions listed on the SP package insert (Roche, 
USA) are blood dyscrasias (agranulocytosis, aplastic anemia, thrombocytopenia), allergic 
reactions (erythema multiforme and other dermatological conditions), gastrointestinal 
reactions (glossitis, stomatitis, nausea, emesis, abdominal pain, hepatitis, diarrhea), central 
nervous system reactions (headache, peripheral neuritis, convulsions, ataxia, hallucinations), 
respiratory reactions (pulmonary infiltrates), and miscellaneous reactions (fever, chills, 
nephrosis); based on widespread experience with the drug, all of these reactions appear to be 
uncommon or rare with short-term therapeutic use. The best-documented severe adverse 
effects with SP are cutaneous reactions, primarily noted when SP was used for long-term 
chemoprophylaxis in non-African populations. Reported rates of serious reactions to SP in the 
UK, with long-term use for chemoprophylaxis, were 1:2100, with 1:4900 serious dermatological 
reactions and 1:11,100 deaths.81 Estimated rates of toxicity in the US were 1:5000-8000 severe 
cutaneous reactions and 1:11,000-25,000 deaths.82 Clinical experience suggests that risks of 
severe toxicity are much lower with malaria treatment regimens in Africa.  
 
The WHO currently recommends IPTp with SP in areas with moderate-to-high malaria 
transmission.83 In a recent systematic review and meta-analysis of 7 trials from sub-Saharan 
Africa, IPTp with 3 or more doses of SP was associated with a higher birth weight and lower risk 
of low birth weight compared to 2 doses of SP. In addition there were no differences in the 
rates of serious adverse events between the two groups.84  
 
Risk of Dihydroartemisinin-piperaquine 
 


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Risks associated with DP among adults and children. Minyt and colleagues conducted a 
systematic review of DP efficacy and safety for treatment of malaria using data from 14 clinical 
trials involving adults and children.85 There were 2636 study participants treated with DP in 13 
trials in which safety data were reported. Overall, DP was associated with fewer adverse events 
compared to comparator medications. The most common adverse events were dizziness, 
nausea and vomiting, though generally the medication was well-tolerated by both adults and 
children (Table 12). Of note, the only serious adverse events in these 14 studies included 5 
deaths (2 adults, 3 children) that were thought unrelated to DP.  
 
Table 12. Summary of adverse events following treatment with dihydroartemisinin-piperaquine 
 
More recently Lwin et al conducted a randomized controlled trial of monthly vs. bimonthly DP 
IPT among 961 adults at high risk of malaria at the Northwest border of Thailand.51 Overall, 69% 
of the participants included in the final analysis reported at least one adverse event. There was 
no difference in the proportion of those reporting at least one adverse event among 
participants in the monthly vs. bimonthly vs. placebo arms. There was an increased risk of joint 
pain among participants randomized to the placebo arm, but otherwise there was no 
differences noted in adverse events by study arm. There was only one serious adverse event 
not related to the use of DP (Table 13).   
 
 


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Table 13. Frequency, incidence, and risk of the 20 most frequently reported adverse events  
 
 
Risks associated the use of DP for IPT in infants. Relevant to this protocol is the PROMOTE 
Chemoprevention study, an open label randomized clinical trial being conducted by our group 
evaluating the protective efficacy of 3 different chemoprevention regimens against malaria 
compared to the current standard of care of no chemoprevention. This is the first study to 
evaluate the safety of DP when used for IPT in infants. Final results have been generated and 
show DP to be very well-tolerated and associated with a significantly lower rate of all grade 3-4 
adverse events, elevated temperature, anemia, and thrombocytopenia compared to the control 
arm (Table 14)(unpublished data). In addition, 145 ECGs performed 19 study participants randomized 
to DP have documented QTc intervals to be within normal limits. 


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Table 14. Comparison of adverse events among children between 6-24 months of age 
Characteristic 
Number of events (incidence per PYAR) by treatment arm 
Control 
Monthly SP 
Daily TS 
Monthly DP 
All grade 3-4 adverse events 
169 (1·159) 
202 (1·415) 
135 (0·914) 
87 (0·611) ‡ 
All serious adverse events 
26 (0·178) 
52 (0·364) 
29 (0·196) 
13 (0·091) 
Grade 3-4 adverse events possibly related to study drugs 
N/A 
8 (0·056) 
8 (0·054) 
3 (0·021) 
Individual grade 3-4 adverse events* 
     Elevated temperature 
     Anaemia 
     Thrombocytopenia 
     Elevated aspartate aminotransferase 
     Elevated alanine aminotransferase 
     Neutropenia 
 
79 (0·542) 
56 (0·384) 
18 (0·123) 
7 (0·048) 
4 (0·027) 
3 (0·021) 
 
78 (0·546) 
86 (0·602) 
17 (0·119) 
8 (0·056) 
4 (0·028) 
6 (0·042) 
 
58 (0·393) 
47 (0·318) 
9 (0·061) 
6 (0·041) 
4 (0·027) 
2 (0·014) 
 
46 (0·323) † 
24 (0·168) † 
5 (0·035)α 
3 (0·021) 
3 (0·021) 
1 (0·007) 
PYAR = person-years at risk.  
SP = sulfadoxine-pyrimethamine. TS = trimethoprim-sulfamethoxazole. DP = dihydroartemisinin-piperaquine. 
* Only includes those with at least 5 total events.  
α p-value < 0.05 compared to control group; † p-value < 0.01 compared to control group; ‡ p-value < 0.001 compared to control 
group. 
 
Risks associated with DP during pregnancy. While data are limited, preclinical animal studies 86-
88 and clinical studies involving pregnant women 22, 23 have not demonstrated significant safety 
concerns with the use of DP. Given the devastating effects of malaria during pregnancy and the 
suboptimal preventive measures of ITNs and IPTp with SP, the potential benefit of DP during 
pregnancy is tremendous. Other than IPTp with SP and ITNs, there are no other viable, 
sustainable antimalarial preventive measures that have proven successful at addressing malaria 
during pregnancy. While there are no known teratogenic risks of DP, women will undergo 
ultrasound at screening to ensure that there is no first trimester exposure to DP. If it is 
launched prior to study implementation or while the study is underway, we will enroll study 
participants in the Antimalarial Pregnancy Exposure Registry. 
 
10.3. 
Treatment and Compensation for Injury  
 
If the participant is injured as a result of being in this study, treatment will be available through 
Tororo District Hospital.  The costs of the treatment may be covered by the study sponsor, 
NICHD, depending on a number of factors.  Makerere University, UCSF, and NICHD do not 
normally provide any other form of compensation for injury.   
 
10.4. 
Costs to the Subjects  
 
There will be no cost to the participant or their parents/guardians for participation in this study. 
 
10.5. 
Reimbursement of Subjects 


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Participants will not be paid for their participation in the study. The study will provide all 
routine medical care, including evaluations, medications available in our clinic, and cost of any 
transportation free of charge. In addition, we will reimburse the cost of consultation for 
referrals made by study physicians to other clinics and services within Tororo District Hospital 
and visits the cost of most diagnostic tests (including laboratory test, X-rays, and ultrasounds) 
and medications resulting from referrals by the study team, using available funds. However, 
reimbursement of all diagnostic tests and treatment recommended outside the study clinic 
cannot be guaranteed in all circumstances. 
 
 
10.6. 
Institutional Review Board (IRB) Review and Informed Consent  
 
This protocol, all procedures and consent forms, and any subsequent modifications must be 
reviewed and approved by the IRBs of all the participating institutions in both the U.S. and in 
Uganda. This includes the UCSF Committee on Human Research (CHR), the MU School of 
Medicine - Research and Ethics Committee (SOM-REC) or MU School of Biomedical Sciences – 
Research and Ethics Committee (SBS-REC), and the Uganda National Council of Science and 
Technology (UNCST). 
 
All consent forms will be translated into the local languages (Dopadhola, Ateso, Swahili, 
Luganda, and English) and back-translated into English to ensure correct use of language. 
Consent forms will be read aloud to parents by trained study interviewers. The informed 
consent will describe the purpose of the study, all the procedures involved, and the risks and 
benefits of participation. Study physicians will ask parents/guardians of study participants to 
summarize the study and explain the reasons why they want to participate. Either a signature 
or a thumbprint (for parents/guardians who cannot read) will be acceptable to confirm 
informed consent for participation in the study.  
 
11.7 
Definition of Parent/Guardianship.   
 
For this study, we will define a parent/primary guardian of the child enrolled in the study as the 
women giving birth to the child. However to the extent possible, consent of the father will be 
also obtained.  
 
12. 
PUBLICATION OF RESEARCH FINDINGS  
 


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The findings from this study may be published in a medical journal.  No individual identities will 
be used in any reports or publications resulting from the study. The researchers will publish 
results of the trial in accordance with NICHD, UNCST, UCSF, and Makerere University guidelines.  
 
 
13. 
BIOHAZARD CONTAINMENT 
 
As the transmission of HIV and other blood-borne pathogens can occur through contact with 
contaminated needles, blood, and blood products, appropriate blood and secretion precautions 
will be employed by all personnel involved in the drawing of blood, exposure to blood and 
secretions, and shipping and handling of all specimens for this study. We will follow the current 
guidelines set forth by the Centers for Disease Control and Prevention and the NIH.  All 
infectious specimens will be transported using packaging mandated in the Federal Code of 
Regulations, CDC 42 CFR Part 72. 
 
14.  
REFERENCES 
 
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36. 
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39. 
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as a means of malaria control: a randomized, double-blind, placebo-controlled trial in northern 
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anaemia control at time of routine vaccinations in Tanzanian infants: a randomised, placebo-
controlled trial. Lancet 2001; 357(9267): 1471-7. 
41. 
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infants for the prevention of malaria in rural Western kenya: a randomized, double-blind 
placebo-controlled trial. PLoS ONE 2010; 5(4): e10016. 
42. 
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provides substantial protection against malaria in children already protected by an insecticide-
treated bednet in Mali: a randomised, double-blind, placebo-controlled trial. PLoS Med 2011; 
8(2): e1000407. 
43. 
Konate AT, Yaro JB, Ouedraogo AZ, et al. Intermittent preventive treatment of malaria 
provides substantial protection against malaria in children already protected by an insecticide-
treated bednet in Burkina Faso: a randomised, double-blind, placebo-controlled trial. PLoS Med 
2011; 8(2): e1000408. 
44. 
Wilson AL. A systematic review and meta-analysis of the efficacy and safety of 
intermittent preventive treatment of malaria in children (IPTc). PLoS ONE 2011; 6(2): e16976. 
45. 
Inaugural meeting of the malaria policy advisory committee to the WHO: conclusions 
and recommendations. Malar J 2012; 11: 137. 
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47. 
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for treating uncomplicated malaria in African children: a randomized trial. PLoS Med 2011; 
8(11): e1001119. 
48. 
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dihydroartemisinin-piperaquine for falciparum malaria: a longitudinal, randomized trial in young 
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49. 
Kamya MR, Yeka A, Bukirwa H, et al. Artemether-lumefantrine versus 
dihydroartemisinin-piperaquine for treatment of malaria: a randomized trial. PLoS Clinical 
Trials 2007; 2(5): e20. 


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50. 
Yeka A, Dorsey G, Kamya MR, et al. Artemether-lumefantrine versus 
dihydroartemisinin-piperaquine for treating uncomplicated malaria: a randomized trial to guide 
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51. 
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of monthly versus bimonthly dihydroartemisinin-piperaquine chemoprevention in adults at high 
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Ismaili J, van der Sande M, Holland MJ, et al. Plasmodium falciparum infection of the 
placenta affects newborn immune responses. Clin Exp Immunol 2003; 133(3): 414-21. 
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Malhotra I, Mungai P, Muchiri E, et al. Distinct Th1- and Th2-Type prenatal cytokine 
responses to Plasmodium falciparum erythrocyte invasion ligands. Infect Immun 2005; 73(6): 
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Plasmodium falciparum antigens in a malaria-endemic region of Cameroon. J Immunol 2007; 
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mortality and morbidity. J Infect Dis 2011; 203(5): 691-9. 
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Mutabingwa TK, Bolla MC, Li JL, et al. Maternal malaria and gravidity interact to 
modify infant susceptibility to malaria. PLoS Med 2005; 2(12): e407. 
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Schwarz NG, Adegnika AA, Breitling LP, et al. Placental malaria increases malaria risk 
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65. 
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parasites under chloroquine cover induces cross-stage immunity against malaria liver stage. J 
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Plasmodium falciparum: what next? Trends Parasitol 2001; 17(12): 582-8. 
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75. 
Katrak S, Gasasira A, Arinaitwe E, et al. Safety and tolerability of artemether-
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76. 
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2010: a systematic analysis. Lancet 2012; 379(9814): 413-31. 
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Menendez C, Bardaji A, Sigauque B, et al. A randomized placebo-controlled trial of 
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78. 
Cisse B, Cairns M, Faye E, et al. Randomized trial of piperaquine with sulfadoxine-
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79. 
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pathogenesis and immunity. Lancet Infect Dis 2007; 7(2): 105-17. 
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Phillips-Howard PA, West LJ. Serious adverse drug reactions to pyrimethamine-
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84. 
Kayentao K, Garner P, van Eijk AM, et al. Intermittent preventive therapy for malaria 
during pregnancy using 2 vs 3 or more doses of sulfadoxine-pyrimethamine and risk of low birth 
weight in Africa: systematic review and meta-analysis. JAMA 2013; 309(6): 594-604. 
85. 
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dihydroartemisinin-piperaquine. Trans R Soc Trop Med Hyg 2007; 101(9): 858-66. 
86. 
Longo M, Zanoncelli S, Della Torre P, et al. Investigations of the effects of the 
antimalarial drug dihydroartemisinin (DHA) using the Frog Embryo Teratogenesis Assay-
Xenopus (FETAX). Reprod Toxicol 2008; 25(4): 433-41. 
87. 
Longo M, Zanoncelli S, Manera D, et al. Effects of the antimalarial drug 
dihydroartemisinin (DHA) on rat embryos in vitro. Reprod Toxicol 2006; 21(1): 83-93. 
88. 
Longo M, Zanoncelli S, Torre PD, et al. In vivo and in vitro investigations of the effects 
of the antimalarial drug dihydroartemisinin (DHA) on rat embryos. Reprod Toxicol 2006; 22(4): 
797-810. 
 
 


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15.  
APPENDICES 
 
Appendix A. Information Sheet  
A STUDY ON PREVENTING MALARIA IN PREGNANT WOMEN AND 
YOUNG CHILDREN 
 
 
Makerere University in Uganda and the University of California, San Francisco in 
the United States are combining efforts in Tororo to study new ways of using 
malaria drugs to prevent malaria in pregnant women and their babies.  
 
Malaria during pregnancy can have a harmful effect on you or your child. We 
want to study 2 different malaria drugs to see if they can be used to prevent 
malaria if taken during pregnancy. 
 
Our study clinic is located at Tororo District Hospital next to the antenatal clinic 
and is open every day from 8:00 am to 5:00 pm 
 
We want to enroll pregnant women who are at least 16 years old and follow them 
during pregnancy.  
 
We will then follow the child born  up to 3 years of age. We want to study the 
same 2 different malaria drugs to see if they can be used to prevent malaria in 
young children. 
 
Women and children in this study will receive free medical care  
 
We shall also give reimbursement for transport to and from our study clinic 
 
For more information, please come to our study clinic where our doctors will be 
happy to talk to you and see if you and your baby can be in the study. 
UCSF


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Appendix B.  Determination of Gestational Age 
 
Gestational age will be based on the first day of the last menstrual period (LMP) and the earliest 
available ultrasound performed at > 6 weeks gestation.  The estimated due date (EDD) is 
calculated as 280 days following the LMP. 
 
If the first available ultrasound is consistent with a gestational age of 6 to 12 weeks, and the 
ultrasound gestational age is within 7 days of that given LMP, then the LMP is used to 
determine gestational age.  However, if the ultrasound gestational age differs from the LMP 
gestational age by more than 7 days, then the ultrasound is used to determine gestational age. 
 
If the first available ultrasound is consistent with a gestational age of 13-24 weeks, and the 
ultrasound gestational age is within 14 days of that given by the LMP, then the LMP is used to 
determine gestational age.  However, if the ultrasound gestational age differs from the LMP by 
more than 14 days, then the ultrasound is used to determine gestational age. 
 
If the first available ultrasound is consistent with a gestational age of 25 weeks or more, and the 
ultrasound gestational age is within 21 days of that given by the LMP, then the LMP is used to 
determine gestational age.  However, if the ultrasound gestational age differs from the LMP by 
more than 21 days, then the ultrasound is used to determine gestational age.  Care here should 
be taken to rule out intrauterine growth restriction (IUGR). 
 
If the LMP is not known, then the earliest ultrasound performed at > 6 weeks should be used to 
determine gestational age. 


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Appendix C. Household survey 
 
The household survey will be administered through a completely paperless QDS software 
system using hand-held tablet computers. A list of questions that will be used in the survey is 
provided below.  
 
Ques. No. 
Variable Name 
Question 
Section 1: Identification 
1 
VISDATE 
Date of final visit 
2 
STARTIME 
Start time of interview 
4 
BC 
Birth Cohort Number 
3 
PPTIDA 
Study Participant ID 
5 
PPTID 
To ensure data integrity, please re-enter the Participant ID. 
7 
INTNUM 
Interviewer number 
8 
AGREE 
Are you going to conduct the interview with this household? 
Section 2: Household Characteristics 
9 
SWATER 
What is the main source of drinking water for members of your household? 
10 
OTHERSCS 
Specify other source of water 
11 
TFACLTY 
What kind of toilet facility do members of your household usually use? 
12 
OTHERFCY 
Specify other kind of toilet facilities 
13 
ELECTRIC 
Does your household have... 
 
...Electricity? 
14 
RADIO 
...Radio? 
15 
CASSETTE 
…Cassette player? 
16 
TV 
…Television? 
17 
MOBILE 
…Mobile phone? 
18 
PHONE 
…Fixed phone? 
19 
FRIDGE 
…Refrigerator? 
20 
TABLE 
…Table? 
21 
CHAIR 
…Chairs? 
22 
SOFA 
…Sofa set? 
23 
BED 
…Bed? 
24 
CUPBOARD 
…Cupboard? 
25 
CLOCK 
…Clock? 
26 
FUELTYPE 
What type of fuel does your household mainly use for cooking? 
27 
OTHERFUE 
Specify other type of fuel used 
28 
SENERGY 
What is the main source of energy for lighting in the household? 
29 
OTHERENG 
Specify other source of energy for lighting 
30 
MMFLOOR 
MAIN MATERIAL OF THE FLOOR  
  
 RECORD OBSERVATION. 
  
 MARK ONLY ONE. 
31 
OTHERMMF 
Specify other material of the floor 
32 
MMROOF 
MAIN MATERIAL OF THE ROOF. 
   
 RECORD OBSERVATION. 
   
 MARK ONLY ONE.  


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33 
OTHERMMR 
Specify other material of the roof 
34 
MMEWALLS 
MAIN MATERIAL OF THE EXTERIOR WALLS. 
   
 RECORD OBSERVATION. 
 
 MARK ONLY ONE.  
35 
OTHERMME 
Specify other material of the exterior walls 
36 
HHROOMS 
How many rooms in your household  are used for sleeping? 
 
(INCLUDING ROOMS OUTSIDE THE MAIN DWELLING) 
 
If there are 15 or more rooms, enter 15 
37 
HHSPACES 
How many sleeping spaces like mats, mattresses,  or beds are available in your household? 
 
If there are 25 or more sleeping places, enter 25 
38 
WATCH 
Does any member of your household own or have… 
 
 …A watch? 
39 
BICYCLE 
….A bicycle? 
40 
SCOOTER 
…A motorcycle or motor scooter? 
41 
CART 
…An animal-drawn cart? 
42 
CAR 
…A car or truck? 
43 
MBOAT 
…A boat with a motor? 
44 
NOMBOAT 
…A boat without a  motor? 
45 
BANKACCO 
…A bank account? 
46 
NUMALAND 
How many acres of agricultural land do members of this household own? 
47 
DMARKT 
How far is it to the nearest market place? 
48 
HHMEALS 
Now I would like to ask you about the food your household eats. 
How many meals does your household usually have per day? 
49 
HHNUMT 
In the past week, on how many days did the household eat meat? 
50 
HHPSF 
How often in the last year did you have problems in satisfying the  food needs of the 
household? 
51 
DHFCTY 
How far is it to the nearest health facility? 
52 
MTHFCTY 
If you were to go this facility,how would you most likely go there? 
53 
OTHERMTH 
Specify other means of transport to the health facility 
54 
PSPRAY 
At any time in the past 12 months, has anyone asked permission to come into your dwelling to 
spray the interior walls against mosquitoes? 
55 
GPSPRAY 
Did you grant them permission to spray the interior walls of your dwelling? 
56 
RGSPRAY 
What was the primary reason that you did not grant permission to spray the interior walls of 
your dwelling against mosquitoes? 
57 
OTHERRGS 
Specify other reasons for not granting permission to spray the interior walls of your dwelling 
against mosquitoes 
58 
TSPRAY 
How many months ago was the dwelling last sprayed? 
59 
WSPRAY 
Who sprayed the dwelling? 
60 
OTHERWSP 
Specify other people who sprayed the dwelling 
61 
DSPRAY 
Did you pay for the dwelling to be sprayed? 
62 
PPWALLS 
Since the spraying, have the walls in your dwelling been plastered or painted? 
63 
TPPWALLS 
How many months ago were the walls plastered or painted?  
 
 
64 
MSPRAY 
In the past 12 months, have you seen or heard any messages about spraying the interior walls 
of your dwelling against mosquitoes? 


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65 
MSGA 
Where did you hear or see message(s)? 
 
...Radio? 
66 
MSGB 
...TV? 
67 
MSGC 
...Newspaper/Leaflet? 
68 
MSGD 
…Health worker/CMD? 
69 
MSGE 
…Neighbour/Relative/Friend 
70 
MSGF 
...Community Leader? 
71 
MSGG 
…Village public adress system 
72 
MSGH 
...Don't know 
73 
MSGI 
…Other 
74 
OTHERMSG 
Specify other 
75 
AHWKER 
Is there a community health worker (community medicine distributor/CMD, village health 
team/VHT, community own resource person/CORP) who distributes malaria medicines in your 
village or community? 
76 
AMCHWKER 
Does the community health worker currently have malaria medicines available? 
Section 3: Study Participants Sleeping Area Characteristics All questions in this section will be repeated with variable names entopen1, entcov1 
, etc. for each entryway and window in the study participants room  
77 
SRENTRY 
OBSERVATION: How many entryways into the room are there? 
78 
ENTOPN1 
OBSERVATION: Does it open to the outside? 
79 
ENTCOV1 
OBSERVATION: Is the entry way covered? 
80 
ETMM1 
OBSERVATION: Main material is the covering made of. 
81 
OTHCOV1 
Specify Other covering type 
82 
SRWINDOW 
OBSERVATION: How many windows are in the room? 
83 
WNDCOV1 
OBSERVATION: Is the window covered? 
84 
WNDOPN1 
OBSERVATION: Does the window open to the outside 
85 
SREAVES 
OBSERVATION: Does the room have eaves? 
86 
EAVESCOV 
OBSERVATION: If room has eaves, are the eaves covered? 
87 
EAVESOPN 
OBSERVATION: Do the eaves open to the outside? 
88 
AIRBRICK 
OBSERVATION: Does the room have airbricks? 
89 
AIRBRCOV 
OBSERVATION: If the room has airbricks, are the airbricks covered? 
90 
AIRBROPN 
OBSERVATION: Do the airbricks open to the outside? 
91 
AIRBRNUM 
OBSERVATION: How many airbricks are in the room? 
92 
SLEEP 
Where does the study participant usually sleep? 
93 
OTHERSL 
Specify other sleeping area 
94 
SRSLNUM 
Usually, how many people sleep in the same room as the study participant (excluding the study 
participant)? 
95 
SRSLNUM5 
How many of those people are under 5 years old (excluding the study participant)? 
96 
SLAREAS 
How many sleeping areas are in the room where the study participant sleeps? 
97 
SASLNUM 
How many people sleep in the same bed/sleeping area as the study participant under the 
mosquito net (excluding the study participant)? 
98 
SASLNUM5 
How many of those people are under 5 years old (excluding the study participant)? 
Section 4: Bednets All questions in this section will be repeated with variable names obs2,mnths2,where2, etc. for each mosquito net in the 
household (hhnumnet) 
99 
HHAMNETS 
IMMEDIATELY BEFORE Enrollment, did your household have any mosquito nets that can be 
used while sleeping? 
100 
HNUMNETS 
IMMEDIATELY BEFORE study enrollment, How many mosquito nets did your household have? 
101 
OBS1 
May I have a look at (all) the net(s) to establish the brand? 
102 
MNTHS1 
How many months ago did your household obtain the mosquito net? 
 
 
103 
WHERE1 
Where did you get the mosquito net from? 


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104 
SPCFRO1 
Specify other sources of the mosquito net 
105 
BRAND1 
OBSERVE OR ASK THE BRAND OR TYPE OF MOSQUITO NET. 
106 
OTHERB1 
Specify other brands or types of mosquito net 
107 
SMNET1 
Since you got the mosquito net, was it ever soaked or dipped in a liquid to repel mosquitoes or 
bugs? 
108 
TSMNET1 
How many months ago was the net last soaked or dipped? 
109 
SLPNET1 
Did anyone sleep under this mosquito net last night? 
110 
NUSED1A 
What are some of the reasons why this net was not used? 
 
...Too hot 
111 
NUSED1B 
...Don't like smell 
112 
NUSED1C 
...No mosquitoes 
113 
NUSED1D 
...Net too old/too many holes 
114 
NUSED1E 
...Net not  hung 
115 
NUSED1F 
...Net too dirty 
116 
NUSED1G 
...Net no longer kill insects 
117 
NUSED1H 
...Don’t know 
118 
NUSED1I 
...Other 
119 
NTHUNG1 
If not hung, why not? 
120 
OTHRNT1 
Specify other reason why the net was not hung. 
Section 5: Interviewer Details 
122 
STOPTIME 
End time of interview 
123 
VSTATUS 
Result of Visit 
124 
OVSTATUS 
Specify other result 
125 
TOTVISIT 
Total number of visits 
126 
COMMENTS 
Interviewer's Comments 
 
 
 


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Appendix D. Administration of study drugs and placebos  
 
Timing of administration of study drugs during pregnancy 
Weeks of 
gestation 
3 dose SP  
(treatment arm A) 
3 dose DP  
(treatment arms B+C) 
Monthly DP  
(treatment arms D+E) 
16 
DP placebo + SP placebo 
DP placebo + SP placebo 
DP + SP placebo 
20 
SP + DP placebo 
DP + SP placebo 
DP + SP placebo 
24 
DP placebo + SP placebo 
DP placebo + SP placebo 
DP + SP placebo 
28 
SP + DP placebo 
DP + SP placebo 
DP + SP placebo 
32 
DP placebo + SP placebo 
DP placebo + SP placebo 
DP + SP placebo 
36 
SP + DP placebo 
DP + SP placebo 
DP + SP placebo 
40 
DP placebo + SP placebo 
DP placebo + SP placebo 
DP + SP placebo 
 
Timing of administration of study drugs during infancy 
Weeks of 
age 
3 monthly DP  
(treatment arms A+B+D) 
Monthly DP 
(treatment arms C+E) 
8 
DP 
DP  
12 
DP placebo 
DP 
16 
DP placebo  
DP 
20 
DP 
DP 
24 
DP placebo 
DP 
28 
DP placebo  
DP 
32 
DP 
DP 
36 
DP placebo 
DP  
40 
DP placebo  
DP 
44 
DP 
DP 
48 
DP placebo 
DP 
52 
DP placebo  
DP 
56 
DP 
DP 
60 
DP placebo 
DP 
64 
DP placebo  
DP  
68 
DP 
DP 
72 
DP placebo 
DP 
76 
DP placebo  
DP 
80 
DP 
DP 
84 
DP placebo 
DP 
88 
DP placebo  
DP 
92 
DP 
DP  
96 
DP placebo 
DP 
100 
DP placebo  
DP 
104 
DP 
DP 
 


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Appendix E. Weight-based dosing guidelines for DP during infancy 
 
Weight (kg) 
Dihydroartemisinin-Piperaquine (20mg/160mg tabs) 
monthly dosing given once a day for 3 consecutive days 
Day 1 
Day 2 
Day 3 
< 5.9 
½ tab 
½ tab 
½ tab 
6.0-10.9 
1 tab 
1 tab 
1 tab 
11.0-14.9 
1 ½ tab 
1 ½ tab 
1 ½ tab 
15.0-19.9 
2 tabs 
2 tabs 
2 tabs 
20.0-23.9 
2 ½ tab 
2 ½ tab 
2 ½ tab 
24.0-25.9 
3 tabs 
3 tabs 
3 tabs 
 


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Appendix F. WHO Criteria for Severe Malaria and Danger Signs 
 
Criteria for severe malaria 
 
Cerebral malaria - defined as unarousable coma not attributable to any other cause in a patient 
with falciparum malaria 
Generalized convulsions (> 3 convulsions over 24 hours period) 
Severe normocytic anemia (Hb < 5 gm/dL) 
Hypoglycemia 
Metabolic acidosis with respiratory distress 
Fluid and electrolyte disturbances 
Acute renal failure 
Acute pulmonary edema and adult respiratory distress syndrome (ARDS) 
Circulatory collapse, shock, septicemia ("algid malaria") 
Abnormal bleeding 
Jaundice 
 
Danger signs (in children only) 
 
Less than 3 convulsions over 24 hour period 
Inability to sit up or stand 
Vomiting everything 
Unable to breastfeed or drink 
Lethargy 
 


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Appendix G. Uganda Ministry of Health Guidelines for Routine Care of Pregnant and 
Postpartum Women, and Newborns 
 
In addition to receiving medical care as described above in the protocol, women and infants 
enrolled in the study will receive standard routine prenatal and postpartum care according to 
Uganda Ministry of Health guidelines. These standard procedures are subject to availability at 
Tororo District Hospital.  
 
Routine antenatal care. Women enrolled in the study will receive routine care as designated in 
the Uganda Ministry of Health Guidelines. Routine antenatal care includes screening and 
treating for syphilis and syndromic management of sexually transmitted infections (STIs).  
Pregnant women will receive iron and folic acid supplementation. In addition, women will be 
given multivitamins that will be given once daily. In addition, women receive mebendazole 
500mg as a single dose as early as possible after the 1st trimester. Each antenatal visit also 
includes blood pressure assessment and urine dip stick for proteinuria.  
 
Routine intrapartum/delivery care. Routine delivery care for in-hospital births will include 
labor management by the midwifery staff and management of obstetrical complications as per 
Ministry of Health guidelines. Immediate postpartum infant care will include polio and BCG 
immunization, ophthalmic tetracycline, and vitamin K. 
 
Routine postpartum care.  All postpartum women will receive vitamin A supplementation 
(200,000 IU) immediately following delivery. Depending on clinical circumstances and based on 
local standard of care, women may receive 2 weeks of multivitamins twice a day. Common 
indications for postpartum multivitamins include anemia, postpartum hemorrhage and 
prolonged labor. Women will be seen at 1 week after delivery as per Ugandan standards of 
care. Women also undergo a 6 weeks postpartum visit as part of routine care. These visits 
include an abdominal exam,  syndromic management of STIs,and follow-up on any obstetrical 
complications that occurred. In addition, women receive vitamin A at this visit, if not given 
immediately postpartum, and are continued on iron and folic acid supplementation. Pelvic and 
breast exam will be done if clinically indicated. Contraceptive counseling is performed at this 
visit as is a nutritional assessment and infant feeding and support. Screening for cervical cancer 
will be performed postpartum by clinical TDH staff if available at Tororo District Hospital. 
 
Routine infant care. Infants will be referred to the TDH antenatal clinic for routine 
immunizations at 6 weeks, 10 weeks, 14 weeks, 6 and 9 months of life.  
  


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Appendix H. Schedule of routine assessments and procedures in pregnant women 
Evaluations  and 
Interventions 
Enrollment 
Weeks of gestation 
Delivery 
1 and 6 weeks 
postpartum 
16* 
20 
24 
28 
32 
36 
40 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
HIV testing1 
X 
 
 
 
X 
 
 
 
X 
 
Pregnancy confirmation2 
X 
 
 
 
 
 
 
 
 
 
Obstetrical ultrasound3 
X 
 
 
 
 
 
 
 
 
 
Blood collected by 
phlebotomy for CBC, ALT, 
and immunology studies 
X 
 
X 
 
X 
 
X 
 
X 
 
Blood collected by finger 
prick for dried blood spot 
and plasma 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Routine assessment in the 
study clinic4 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
Administration of study 
drugs 
 
X 
X 
X 
X 
X 
X 
X 
 
 
Collection of cord blood 
and placental tissue 
 
 
 
 
 
 
 
 
X 
 
Labor and delivery 
documentation5 
 
 
 
 
 
 
 
 
X 
 
Standard Care 
Obstetrical exam6 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Syphilis screening 
X 
 
 
 
 
 
 
 
 
 
Iron and Folic Acid 
X 
X 
X 
X 
X 
X 
X 
X 
 
 
Prenatal vitamins 
X 
 
 
 
 
 
 
 
 
 
Mebendazole7 
 
X 
 
 
 
 
 
 
 
Screening for non-malarial 
parasitic infections8 
 
X 
 
 
 
 
 
 
 
Vitamin A9 
 
 
 
 
 
 
 
 
X 
 
Insecticide treated bednet 
X 
 
 
 
 
 
 
 
X 
 
* Only if study subject enrolled prior to 16 weeks gestation; If the woman is enrolled between 
18 or 20 weeks, then the week 20 phlebotomy will not be performed. 
 
Explanation of maternal schedule of events  
1. HIV test will be done at enrollment and documented. A repeat rapid HIV test will be done at 
delivery. HIV testing shall be done using standard rapid HIV-testing algorithm.   
2. Pregnancy confirmation by positive urine pregnancy test, or confirmed intrauterine 
pregnancy by ultrasound. A pregnancy test may be skipped if an intrauterine pregnancy has 
been noted on ultrasound at the screening visit. 
3. Ultrasound will be done to confirm intrauterine pregnancy and estimate gestational age at 
enrollment. See Appendix B for dating criteria. 
4. Targeted physical exam will include anthropometric measurements (e.g. weight) and vital 
signs (i.e. temperature, pulse, and blood pressure). Measurement of height at the 
enrollment visit only. 
5. Labor & Delivery documentation will include: Peripartum history, mode of delivery, Apgar 
scores (when available), weight, length, and head circumference of the child at birth, 
approximate gestational age, duration of labor, signs of fetal distress (presence of 
meconium), summary of events in first days of life (including feeding, breathing patterns, 


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
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jaundice, lethargy, or any additional abnormal findings), duration of admission if delivered in 
hospital. 
6. Obstetrical exam includes estimation of gestational age at study entry, fundal height 
measurement, fetal heart tones and urine dipstick for protein. A cervical exam will also be 
performed at screening and during antepartum study visits as clinically indicated. 
7. Mebendazole is typically given as 500mg as a single dose as early as possible after the 1st 
trimester (16 or 20 week visit). 
8. Screening for non-malarial parasitic infections will be done prior to administering 
Mebendazole and will include stool ova and parasite examination, circulating filarial 
antigens, and blood smear for microfilaremia.  
9. Vitamin A supplementation is dosed as 200,000 IU. 


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Appendix I. Schedule of routine assessments and procedures in children 
Weeks 
of age 
Blood collected by finger 
prick 
Blood collected by 
phlebotomy for 
CBC, and 
immunology 
studies 
Blood collected by 
phlebotomy for 
ALT 
Routine 
assessment in 
the study 
clinic 
Administration 
of study drugs 
Screening for 
non-malarial 
parasitic 
infections 
Blood 
smear 
Dried 
blood 
spots 
Plasma 
4 
X 
X 
X 
 
 
X 
 
 
8 
X 
X 
X 
X 
X 
X 
X 
 
12 
X 
X 
X 
 
 
X 
X 
 
16 
X 
X 
X 
 
 
X 
X 
 
20 
X 
X 
X 
 
 
X 
X 
 
24 
X 
X 
X 
X 
X 
X 
X 
 
28 
X 
X 
X 
 
 
X 
X 
 
32 
X 
X 
X 
 
 
X 
X 
 
36 
X 
X 
X 
 
 
X 
X 
 
40 
X 
X 
X 
X 
X 
X 
X 
 
44 
X 
X 
X 
 
 
X 
X 
 
48 
X 
X 
X 
 
 
X 
X 
 
52 
X 
X 
X 
 
 
X 
X 
 
56 
X 
X 
X 
X 
X 
X 
X 
X 
60 
X 
X 
X 
 
 
X 
X 
 
64 
X 
X 
X 
 
 
X 
X 
 
68 
X 
X 
X 
 
 
X 
X 
 
72 
X 
X 
X 
 
X 
X 
X 
 
76 
X 
X 
X 
 
 
X 
X 
 
80 
X 
X 
X 
 
 
X 
X 
 
84 
X 
X 
X 
 
 
X 
X 
 
88 
X 
X 
X 
X 
X 
X 
X 
 
92 
X 
X 
X 
 
 
X 
X 
 
96 
X 
X 
X 
 
 
X 
X 
 
100 
X 
X 
X 
 
 
X 
X 
 
104 
X 
X 
X 
X 
X 
X 
X 
 
108 
X 
X 
 
 
 
X 
 
 
112 
X 
X 
 
 
 
X 
 
 
116 
X 
X 
 
 
 
X 
 
 
120 
X 
X 
 
X 
 
X 
 
 
124 
X 
X 
 
 
 
X 
 
 
128 
X 
X 
 
 
 
X 
 
 
132 
X 
X 
 
 
 
X 
 
 
136 
X 
X 
 
X 
 
X 
 
 
140 
X 
X 
 
 
 
X 
 
 
144 
X 
X 
 
 
 
X 
 
 
148 
X 
X 
 
 
 
X 
 
 
152 
X 
X 
 
 
 
X 
 
 
156 
X 
X 
 
X 
 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Appendix J.    DAIDS Toxicity Table (Dec 2004, clarification Aug 2009)  
 
Division of AIDS Table for Grading the Severity of ADULT AND PEDIATRIC Adverse Events Version 1.0, 
December, 2004; clarification AUGUST 2009 
 
The Division of AIDS Table for Grading the Severity of Adult and Pediatric Adverse Events (“DAIDS AE 
Grading Table”) is a descriptive terminology which can be utilized for Adverse Event (AE) reporting. A 
grading (severity) scale is provided for each AE term. 
 
This clarification of the DAIDS Table for Grading the Severity of Adult and Pediatric AE’s provides 
additional explanation of the DAIDS AE Grading Table and clarifies some of the parameters.  
 
I. 
Instructions and Clarifications 
 
Grading Adult and Pediatric AEs 
The DAIDS AE Grading Table includes parameters for grading both Adult and Pediatric AEs.  When a 
single set of parameters is not appropriate for grading specific types of AEs for both Adult and Pediatric 
populations, separate sets of parameters for Adult and/or Pediatric populations (with specified 
respective age ranges) are given in the Table.  If there is no distinction in the Table between Adult and 
Pediatric values for a type of AE, then the single set of parameters listed is to be used for grading the 
severity of both Adult and Pediatric events of that type.   
Note: In the classification of adverse events, the term “severe” is not the same as “serious.” 
Severity is an indication of the intensity of a specific event (as in mild, moderate, or severe chest 
pain).  The term “serious” relates to a participant/event outcome or action criteria, usually 
associated with events that pose a threat to a participant’s life or functioning.  
 
Grade 5 
For any AE where the outcome is death, the severity of the AE is classified as Grade 5.  
 
Estimating Severity Grade for Parameters Not Identified in the Table 
In order to grade a clinical AE that is not identified in the DAIDS AE grading table, use the category 
“Estimating Severity Grade” located on Page 3. 
 
Determining Severity Grade for Parameters “Between Grades” 
If the severity of a clinical AE could fall under either one of two grades (e.g., the severity of an AE could 
be either Grade 2 or Grade 3), select the higher of the two grades for the AE. If a laboratory value that is 
graded as a multiple of the ULN or LLN falls between two grades, select the higher of the two grades for 
the AE. For example, Grade 1 is 2.5 x ULN and Grade 2 is 2.6 x ULN for a parameter. If the lab value is 
2.53 x ULN (which is between the two grades), the severity of this AE would be Grade 2, the higher of 
the two grades. 
 
Values Below Grade 1 
Any laboratory value that is between either the LLN or ULN and Grade 1 should not be graded. 
 
Determining Severity Grade when Local Laboratory Normal Values Overlap with Grade 1 Ranges  
In these situations, the severity grading is based on the ranges in the DAIDS AE Grading Table, even 
when there is a reference to the local lab LLN. 


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
76 
 
 
 
For example: Phosphate, Serum, Low, Adult and Pediatric > 14 years (Page 20) Grade 1 range is 2.50 
mg/dL - < LLN. A particular laboratory’s normal range for Phosphate is 2.1 – 3.8 mg/dL. A participant’s 
actual lab value is 2.5.   In this case, the value of 2.5 exceeds the LLN for the local lab, but will be graded 
as Grade 1 per DAIDS AE Grading Table. 
 
II. Definitions of terms used in the Table: 
 
Basic Self-care Functions 
Adult 
Activities such as bathing, dressing, toileting, transfer/movement, 
continence, and feeding. 
 
Young Children 
Activities that are age and culturally appropriate (e.g., feeding self 
with culturally appropriate eating implement). 
 
LLN 
Lower limit of normal 
 
Medical Intervention 
Use of pharmacologic or biologic agent(s) for treatment of an AE. 
 
NA 
Not Applicable 
 
Operative Intervention 
Surgical OR other invasive mechanical procedures. 
 
ULN 
Upper limit of normal 
 
Usual Social & Functional 
Activities 
Adult 
Adaptive tasks and desirable activities, such as going to work, 
shopping, cooking, use of transportation, pursuing a hobby, etc. 
 
Young Children 
Activities that are age and culturally appropriate (e.g., social 
interactions, play activities, learning tasks, etc.). 
 


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
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PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
GRADE 4 
POTENTIALLY 
LIFE-THREATENING 
ESTIMATING SEVERITY GRADE 
Clinical adverse event 
NOT identified 
elsewhere in this 
DAIDS AE Grading 
Table  
Symptoms causing no 
or minimal 
interference with 
usual social & 
functional activities 
Symptoms causing 
greater than minimal 
interference with usual 
social & functional 
activities 
Symptoms causing 
inability to perform usual 
social & functional 
activities 
Symptoms causing 
inability to perform basic 
self-care functions OR 
Medical or operative 
intervention indicated to 
prevent permanent 
impairment, persistent 
disability, or death  
SYSTEMIC 
Acute systemic 
allergic reaction  
Localized urticaria 
(wheals) with no 
medical intervention 
indicated 
Localized urticaria with 
medical intervention 
indicated OR Mild 
angioedema with no 
medical intervention 
indicated 
Generalized urticaria 
OR Angioedema with 
medical intervention 
indicated OR 
Symptomatic mild 
bronchospasm 
Acute anaphylaxis OR 
Life-threatening 
bronchospasm OR 
laryngeal edema 
Chills 
Symptoms causing no 
or minimal 
interference with 
usual social & 
functional activities 
Symptoms causing 
greater than minimal 
interference with usual 
social & functional 
activities  
Symptoms causing 
inability to perform usual 
social & functional 
activities 
NA 
Fatigue 
Malaise 
Symptoms causing no 
or minimal 
interference with 
usual social & 
functional activities 
Symptoms causing 
greater than minimal 
interference with usual 
social & functional 
activities 
Symptoms causing 
inability to perform usual 
social & functional 
activities 
Incapacitating fatigue/ 
malaise symptoms 
causing inability to 
perform basic self-care 
functions 
Fever (nonaxillary) 
37.7 – 38.6°C 
38.7 – 39.3°C 
39.4 – 40.5°C 
> 40.5°C  
Pain (indicate body 
site) 
DO NOT use for pain 
due to injection (See 
Injection Site 
Reactions: Injection 
site pain) 
See also Headache, 
Arthralgia, and 
Myalgia 
Pain causing no or 
minimal interference 
with usual social & 
functional activities 
Pain causing greater 
than minimal 
interference with usual 
social & functional 
activities 
Pain causing inability to 
perform usual social & 
functional activities 
Disabling pain causing 
inability to perform basic 
self-care functions OR 
Hospitalization (other 
than emergency room 
visit) indicated 
Unintentional weight 
loss 
NA 
5 – 9% loss in body 
weight from baseline 
10 – 19% loss in body 
weight from baseline 
≥ 20% loss in body 
weight from baseline OR  
Aggressive intervention 
indicated [e.g., tube 
feeding or total 
parenteral nutrition 
(TPN)] 


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
78 
 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
GRADE 4 
POTENTIALLY 
LIFE-THREATENING 
INFECTION 
Infection (any other 
than HIV infection) 
Localized, no 
systemic antimicrobial 
treatment indicated 
AND Symptoms 
causing no or minimal 
interference with 
usual social & 
functional activities 
Systemic antimicrobial 
treatment indicated 
OR Symptoms 
causing greater than 
minimal interference 
with usual social & 
functional activities 
Systemic antimicrobial 
treatment indicated 
AND Symptoms causing 
inability to perform usual 
social & functional 
activities OR Operative 
intervention (other than 
simple incision and 
drainage) indicated 
Life-threatening 
consequences (e.g., 
septic shock) 
INJECTION SITE REACTIONS 
Injection site pain 
(pain without touching) 
Or 
Tenderness (pain 
when area is touched)  
Pain/tenderness 
causing no or minimal 
limitation of use of 
limb 
Pain/tenderness 
limiting use of limb OR 
Pain/tenderness 
causing greater than 
minimal interference 
with usual social & 
functional activities 
 
Pain/tenderness 
causing inability to 
perform usual social & 
functional activities 
 
Pain/tenderness causing 
inability to perform basic 
self-care function OR 
Hospitalization (other 
than emergency room 
visit) indicated for 
management of 
pain/tenderness 
Injection site reaction (localized) 
Adult > 15 years 
 
Erythema OR 
Induration 
of 5x5 cm – 9x9 cm 
(or 25 cm2 – 81cm2) 
Erythema OR 
Induration OR Edema  
> 9 cm any diameter 
(or > 81 cm2) 
Ulceration OR 
Secondary infection OR 
Phlebitis OR Sterile 
abscess OR Drainage 
Necrosis (involving 
dermis and deeper 
tissue) 
 
Pediatric ≤ 15 
years 
Erythema OR 
Induration OR Edema 
present but ≤ 2.5 cm 
diameter 
Erythema OR 
Induration OR Edema 
> 2.5 cm diameter but 
< 50% surface area of 
the extremity segment 
(e.g., upper arm/thigh) 
Erythema OR Induration 
OR Edema involving  
≥ 50% surface area of 
the extremity segment 
(e.g., upper arm/thigh) 
OR Ulceration OR 
Secondary infection OR 
Phlebitis OR Sterile 
abscess OR Drainage 
Necrosis (involving 
dermis and deeper 
tissue) 
Pruritis associated 
with injection  
See also Skin: Pruritis 
(itching - no skin 
lesions) 
Itching localized to 
injection site AND 
Relieved 
spontaneously or with 
< 48 hours treatment  
Itching beyond the 
injection site but not 
generalized OR Itching 
localized to injection 
site requiring ≥ 48 
hours treatment  
Generalized itching 
causing inability to 
perform usual social & 
functional activities 
NA 
SKIN – DERMATOLOGICAL 
Alopecia 
Thinning detectable 
by study participant 
(or by caregiver for 
young children and 
disabled adults) 
Thinning or patchy hair 
loss detectable by 
health care provider 
Complete hair loss 
NA 


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
79 
 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
GRADE 4 
POTENTIALLY 
LIFE-THREATENING 
Cutaneous reaction – 
rash 
Localized macular 
rash  
Diffuse macular, 
maculopapular, or 
morbilliform rash OR 
Target lesions  
Diffuse macular, 
maculopapular, or 
morbilliform rash with 
vesicles or limited 
number of bullae OR 
Superficial ulcerations 
of mucous membrane 
limited to one site 
Extensive or generalized 
bullous lesions OR 
Stevens-Johnson 
syndrome OR Ulceration 
of mucous membrane 
involving two or more 
distinct mucosal sites 
OR Toxic epidermal 
necrolysis (TEN) 
Hyperpigmentation 
Slight or localized 
Marked or generalized 
NA 
NA 
Hypopigmentation 
Slight or localized  
Marked or generalized 
NA 
NA 
Pruritis (itching – no 
skin lesions)  
(See also Injection 
Site Reactions: 
Pruritis associated 
with injection) 
Itching causing no or 
minimal interference 
with usual social & 
functional activities 
Itching causing greater 
than minimal 
interference with usual 
social & functional 
activities 
Itching causing inability 
to perform usual social 
& functional activities  
NA 
 
CARDIOVASCULAR 
Cardiac arrhythmia 
(general) 
(By ECG or physical 
exam) 
Asymptomatic AND 
No intervention 
indicated 
Asymptomatic AND 
Non-urgent medical 
intervention indicated 
Symptomatic, non-life-
threatening AND Non-
urgent medical 
intervention indicated  
Life-threatening 
arrhythmia OR Urgent 
intervention indicated 
Cardiac-
ischemia/infarction 
NA 
NA 
Symptomatic ischemia 
(stable angina) OR 
Testing consistent with 
ischemia  
Unstable angina OR 
Acute myocardial 
infarction 
Hemorrhage 
(significant acute 
blood loss) 
NA 
Symptomatic AND No 
transfusion indicated 
Symptomatic AND 
Transfusion of ≤ 2 units 
packed RBCs (for 
children ≤ 10 cc/kg) 
indicated  
Life-threatening 
hypotension OR 
Transfusion of > 2 units 
packed RBCs (for 
children > 10 cc/kg) 
indicated 
Hypertension 
Adult > 17 years 
(with repeat testing 
at same visit) 
140 – 159 mmHg 
systolic 
OR 
90 – 99 mmHg 
diastolic 
160 – 179 mmHg 
systolic 
OR 
100 – 109 mmHg 
diastolic 
≥ 180 mmHg systolic 
OR 
≥ 110 mmHg diastolic 
 
Life-threatening 
consequences (e.g., 
malignant hypertension) 
OR Hospitalization 
indicated (other than 
emergency room visit) 
Correction: in Grade 2 to 160 - 179 from > 160-179 (systolic) and to ≥ 100 -109 from > 100-109 (diastolic) and  
in Grade 3 to  ≥ 180 from > 180 (systolic) and to  ≥ 110  from > 110 (diastolic). 
Pediatric ≤ 17 
years 
(with repeat 
testing at same 
visit) 
 
NA 
91st –  94th percentile 
adjusted for age, 
height, and gender 
(systolic and/or 
diastolic) 
≥ 95th percentile 
adjusted for age, height, 
and gender (systolic 
and/or diastolic) 
Life-threatening 
consequences (e.g., 
malignant hypertension) 
OR Hospitalization 
indicated (other than 
emergency room visit) 


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
80 
 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
GRADE 4 
POTENTIALLY 
LIFE-THREATENING 
Hypotension 
NA 
Symptomatic, 
corrected with oral 
fluid replacement 
Symptomatic, IV fluids 
indicated 
Shock requiring use of 
vasopressors or 
mechanical assistance 
to maintain blood 
pressure 
 
Pericardial effusion 
Asymptomatic, small 
effusion requiring no 
intervention 
 
Asymptomatic, 
moderate or larger 
effusion requiring no 
intervention 
 
Effusion with non-life 
threatening physiologic 
consequences OR 
Effusion with non-urgent 
intervention indicated 
Life-threatening 
consequences (e.g., 
tamponade) OR Urgent 
intervention indicated 
Thrombosis/embolism 
NA 
Deep vein thrombosis 
AND No intervention 
indicated (e.g., 
anticoagulation, lysis 
filter, invasive 
procedure)  
Deep vein thrombosis 
AND Intervention 
indicated (e.g., 
anticoagulation, lysis 
filter, invasive 
procedure)  
Embolic event (e.g., 
pulmonary embolism, 
life-threatening 
thrombus)  
Vasovagal episode 
(associated with a 
procedure of any kind) 
Present without loss 
of consciousness  
Present with transient 
loss of consciousness 
NA  
NA 
Ventricular 
dysfunction 
(congestive heart 
failure) 
NA 
Asymptomatic 
diagnostic finding AND 
intervention indicated 
New onset with 
symptoms OR 
Worsening symptomatic 
congestive heart failure 
Life-threatening 
congestive heart failure 
GASTROINTESTINAL 
Anorexia 
Loss of appetite 
without decreased 
oral intake 
Loss of appetite 
associated with 
decreased oral intake 
without significant 
weight loss 
Loss of appetite 
associated with 
significant weight loss 
Life-threatening 
consequences OR 
Aggressive intervention 
indicated [e.g., tube 
feeding or total 
parenteral nutrition 
(TPN)] 
Comment: Please note that, while the grading scale provided for Unintentional Weight Loss may be used as a guideline when 
grading anorexia, this is not a requirement and should not be used as a substitute for clinical judgment.  
Ascites 
Asymptomatic 
Symptomatic AND 
Intervention indicated 
(e.g., diuretics or 
therapeutic 
paracentesis) 
Symptomatic despite 
intervention 
Life-threatening 
consequences 
Cholecystitis 
NA 
Symptomatic AND 
Medical intervention 
indicated 
 
Radiologic, endoscopic, 
or operative intervention 
indicated 
Life-threatening 
consequences (e.g., 
sepsis or perforation)  
Constipation  
NA 
Persistent constipation 
requiring regular use 
of dietary 
modifications, 
laxatives, or enemas  
Obstipation with manual 
evacuation indicated 
Life-threatening 
consequences (e.g., 
obstruction) 


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
81 
 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
GRADE 4 
POTENTIALLY 
LIFE-THREATENING 
Diarrhea 
Adult and 
Pediatric ≥ 1 year 
Transient or 
intermittent episodes 
of unformed stools 
OR Increase of ≤ 3 
stools over baseline 
per 24-hour period 
Persistent episodes of 
unformed to watery 
stools OR Increase of 
4 – 6 stools over 
baseline per 24-hour 
period 
Bloody diarrhea OR 
Increase of ≥ 7 stools 
per 24-hour period OR 
IV fluid replacement 
indicated 
Life-threatening 
consequences (e.g., 
hypotensive shock) 
Pediatric < 1 year 
Liquid stools (more 
unformed than usual) 
but usual number of 
stools 
Liquid stools with 
increased number of 
stools OR Mild 
dehydration 
Liquid stools with 
moderate dehydration 
Liquid stools resulting in 
severe dehydration with 
aggressive rehydration 
indicated OR 
Hypotensive shock 
Dysphagia-
Odynophagia  
Symptomatic but able 
to eat usual diet 
Symptoms causing 
altered dietary intake 
without medical 
intervention indicated 
Symptoms causing 
severely altered dietary 
intake with medical 
intervention indicated 
Life-threatening 
reduction in oral intake 
Mucositis/stomatitis  
(clinical exam) 
Indicate site (e.g., 
larynx, oral) 
See Genitourinary for 
Vulvovaginitis  
See also Dysphagia-
Odynophagia and 
Proctitis 
Erythema of the 
mucosa 
Patchy 
pseudomembranes or 
ulcerations  
Confluent 
pseudomembranes or 
ulcerations OR Mucosal 
bleeding with minor 
trauma 
Tissue necrosis OR 
Diffuse spontaneous 
mucosal bleeding OR 
Life-threatening 
consequences (e.g., 
aspiration, choking) 
Nausea  
Transient (< 24 hours) 
or intermittent nausea 
with no or minimal 
interference with oral 
intake 
Persistent nausea 
resulting in decreased 
oral intake for 24 – 48 
hours 
Persistent nausea 
resulting in minimal oral 
intake for > 48 hours 
OR Aggressive 
rehydration indicated 
(e.g., IV fluids) 
Life-threatening 
consequences (e.g., 
hypotensive shock) 
Pancreatitis 
NA 
Symptomatic AND 
Hospitalization not 
indicated (other than 
emergency room visit) 
Symptomatic AND 
Hospitalization indicated 
(other than emergency 
room visit) 
Life-threatening 
consequences (e.g., 
circulatory failure, 
hemorrhage, sepsis) 
Proctitis (functional- 
symptomatic) 
Also see 
Mucositis/stomatitis  
for clinical exam 
 
 
Rectal discomfort 
AND No intervention 
indicated 
 
Symptoms causing 
greater than minimal 
interference with usual 
social & functional 
activities OR Medical 
intervention indicated  
Symptoms causing 
inability to perform usual 
social & functional 
activities OR Operative 
intervention indicated  
Life-threatening 
consequences (e.g., 
perforation) 
 
Vomiting 
Transient or 
intermittent vomiting 
with no or minimal 
interference with oral 
intake 
Frequent episodes of 
vomiting with no or 
mild dehydration 
Persistent vomiting 
resulting in orthostatic 
hypotension OR 
Aggressive rehydration 
indicated (e.g., IV fluids) 
Life-threatening 
consequences (e.g., 
hypotensive shock) 


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82 
 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
GRADE 4 
POTENTIALLY 
LIFE-THREATENING 
NEUROLOGIC 
Alteration in 
personality-behavior 
or in mood (e.g., 
agitation, anxiety, 
depression, mania, 
psychosis) 
Alteration causing no 
or minimal 
interference with 
usual social & 
functional activities  
Alteration causing 
greater than minimal 
interference with usual 
social & functional 
activities  
Alteration causing 
inability to perform usual 
social & functional 
activities  
Behavior potentially 
harmful to self or others 
(e.g., suicidal and 
homicidal ideation or 
attempt, acute 
psychosis) OR Causing 
inability to perform basic 
self-care functions  
Altered Mental Status  
For Dementia, see 
Cognitive and 
behavioral/attentional 
disturbance (including 
dementia and 
attention deficit 
disorder) 
Changes causing no 
or minimal 
interference with 
usual social & 
functional activities 
Mild lethargy or 
somnolence causing 
greater than minimal 
interference with usual 
social & functional 
activities 
Confusion, memory 
impairment, lethargy, or 
somnolence causing 
inability to perform usual 
social & functional 
activities 
Delirium OR 
obtundation, OR coma 
Ataxia  
Asymptomatic ataxia 
detectable on exam 
OR Minimal ataxia 
causing no or minimal 
interference with 
usual social & 
functional activities 
Symptomatic ataxia 
causing greater than 
minimal interference 
with usual social & 
functional activities 
Symptomatic ataxia 
causing inability to 
perform usual social & 
functional activities  
Disabling ataxia causing 
inability to perform basic 
self-care functions 
Cognitive and 
behavioral/attentional 
disturbance (including 
dementia and 
attention deficit 
disorder)  
Disability causing no 
or minimal 
interference with 
usual social & 
functional activities 
OR Specialized 
resources not 
indicated 
Disability causing 
greater than minimal 
interference with usual 
social & functional 
activities OR 
Specialized resources 
on part-time basis 
indicated 
Disability causing 
inability to perform usual 
social & functional 
activities OR 
Specialized resources 
on a full-time basis 
indicated 
Disability causing 
inability to perform basic 
self-care functions OR 
Institutionalization 
indicated 
CNS ischemia 
(acute) 
NA 
NA 
Transient ischemic 
attack 
Cerebral vascular 
accident (CVA, stroke) 
with neurological deficit  
Developmental delay 
– Pediatric ≤ 16 
years 
Mild developmental 
delay, either motor or 
cognitive, as 
determined by 
comparison with a 
developmental 
screening tool 
appropriate for the 
setting  
Moderate 
developmental delay,  
either motor or 
cognitive, as 
determined by 
comparison with a 
developmental 
screening tool 
appropriate for the 
setting  
Severe developmental 
delay, either motor or 
cognitive, as determined 
by comparison with a 
developmental 
screening tool 
appropriate for the 
setting  
Developmental 
regression, either motor 
or cognitive, as 
determined by 
comparison with a 
developmental 
screening tool 
appropriate for the 
setting 


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
83 
 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
GRADE 4 
POTENTIALLY 
LIFE-THREATENING 
Headache  
Symptoms causing no 
or minimal 
interference with 
usual social & 
functional activities 
Symptoms causing 
greater than minimal 
interference with usual 
social & functional 
activities 
Symptoms causing 
inability to perform usual 
social & functional 
activities 
Symptoms causing 
inability to perform basic 
self-care functions OR 
Hospitalization indicated 
(other than emergency 
room visit) OR 
Headache with 
significant impairment of 
alertness or other 
neurologic function  
Insomnia 
NA 
Difficulty sleeping 
causing greater than 
minimal interference 
with usual social & 
functional activities 
Difficulty sleeping 
causing inability to 
perform usual social & 
functional activities 
Disabling insomnia 
causing inability to 
perform basic self-care 
functions 
Neuromuscular 
weakness  
(including myopathy & 
neuropathy)  
Asymptomatic with 
decreased strength 
on exam OR Minimal 
muscle weakness 
causing no or minimal 
interference with 
usual social & 
functional activities 
Muscle weakness 
causing greater than 
minimal interference 
with usual social & 
functional activities 
Muscle weakness 
causing inability to 
perform usual social & 
functional activities  
Disabling muscle 
weakness causing 
inability to perform basic 
self-care functions OR 
Respiratory muscle 
weakness impairing 
ventilation 
Neurosensory 
alteration (including 
paresthesia and 
painful neuropathy) 
Asymptomatic with 
sensory alteration on 
exam or minimal 
paresthesia causing 
no or minimal 
interference with 
usual social & 
functional activities  
Sensory alteration or 
paresthesia causing 
greater than minimal 
interference with usual 
social & functional 
activities  
Sensory alteration or 
paresthesia causing 
inability to perform usual 
social & functional 
activities 
Disabling sensory 
alteration or paresthesia 
causing inability to 
perform basic self-care 
functions 
 
Seizure: (new onset)  
– Adult ≥ 18 years 
See also Seizure: 
(known pre-existing 
seizure disorder) 
NA 
1 seizure  
2 – 4 seizures  
Seizures of any kind 
which are prolonged, 
repetitive (e.g., status 
epilepticus), or difficult 
to control (e.g., 
refractory epilepsy) 
Seizure: (known pre-
existing seizure 
disorder)  
– Adult ≥ 18 years 
For worsening of 
existing epilepsy the 
grades should be 
based on an increase 
from previous level of 
control to any of these 
levels. 
NA 
Increased frequency of 
pre-existing seizures 
(non-repetitive) without 
change in seizure 
character OR 
Infrequent break-
through seizures while 
on stable medication 
in a previously 
controlled seizure 
disorder 
Change in seizure 
character from baseline 
either in duration or 
quality (e.g., severity or  
focality)  
Seizures of any kind 
which are prolonged, 
repetitive (e.g., status 
epilepticus), or difficult 
to control (e.g., 
refractory epilepsy) 


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
84 
 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
GRADE 4 
POTENTIALLY 
LIFE-THREATENING 
Seizure  
– Pediatric < 18 
years 
Seizure, generalized 
onset with or without 
secondary 
generalization, lasting 
< 5 minutes with < 24 
hours post ictal state 
Seizure, generalized 
onset with or without 
secondary 
generalization, lasting 
5 – 20 minutes with  
< 24 hours post ictal 
state 
Seizure, generalized 
onset with or without 
secondary 
generalization, lasting  
> 20 minutes  
Seizure, generalized 
onset with or without 
secondary 
generalization, requiring 
intubation and sedation 
Syncope (not 
associated with a 
procedure) 
NA 
Present 
NA 
NA 
Vertigo 
Vertigo causing no or 
minimal interference 
with usual social & 
functional activities 
Vertigo causing 
greater than minimal 
interference with usual 
social & functional 
activities  
Vertigo causing inability 
to perform usual social 
& functional activities 
Disabling vertigo 
causing inability to 
perform basic self-care 
functions 
RESPIRATORY 
Bronchospasm (acute) 
FEV1 or peak flow 
reduced to  
70 – 80% 
FEV1 or peak flow  
50 – 69% 
FEV1 or peak flow  
25 – 49%  
Cyanosis OR FEV1 or 
peak flow < 25% OR 
Intubation 
Dyspnea or respiratory distress 
Adult ≥ 14 years 
Dyspnea on exertion 
with no or minimal 
interference with 
usual social & 
functional activities  
Dyspnea on exertion 
causing greater than 
minimal interference 
with usual social & 
functional activities  
Dyspnea at rest causing 
inability to perform usual 
social & functional 
activities  
Respiratory failure with 
ventilatory support 
indicated 
Pediatric < 14 
years 
Wheezing OR 
minimal increase in 
respiratory rate for 
age 
Nasal flaring OR 
Intercostal retractions 
OR Pulse oximetry 90 
– 95% 
Dyspnea at rest causing 
inability to perform usual 
social & functional 
activities OR Pulse 
oximetry < 90% 
Respiratory failure with 
ventilatory support 
indicated 
MUSCULOSKELETAL 
Arthralgia 
See also Arthritis 
Joint pain causing no 
or minimal 
interference with 
usual social & 
functional activities 
Joint pain causing 
greater than minimal 
interference with usual 
social & functional 
activities 
Joint pain causing 
inability to perform usual 
social & functional 
activities 
Disabling joint pain 
causing inability to 
perform basic self-care 
functions 
Arthritis 
See also Arthralgia 
Stiffness or joint 
swelling causing no or 
minimal interference 
with usual social & 
functional activities 
Stiffness or joint 
swelling causing 
greater than minimal 
interference with usual 
social & functional 
activities 
Stiffness or joint 
swelling causing 
inability to perform usual 
social & functional 
activities 
Disabling joint stiffness 
or swelling causing 
inability to perform basic 
self-care functions  
Bone Mineral Loss 
Adult ≥ 21 years 
BMD t-score  
-2.5 to -1.0  
BMD t-score < -2.5 
Pathological fracture 
(including loss of 
vertebral height) 
Pathologic fracture 
causing life-threatening 
consequences  


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
85 
 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
GRADE 4 
POTENTIALLY 
LIFE-THREATENING 
Pediatric < 21 
years 
BMD z-score  
-2.5 to -1.0 
BMD z-score < -2.5 
Pathological fracture 
(including loss of 
vertebral height) 
Pathologic fracture 
causing life-threatening 
consequences  
Myalgia 
(non-injection site) 
Muscle pain causing 
no or minimal 
interference with 
usual social & 
functional activities 
Muscle pain causing 
greater than minimal 
interference with usual 
social & functional 
activities 
Muscle pain causing 
inability to perform usual 
social & functional 
activities 
Disabling muscle pain 
causing inability to 
perform basic self-care 
functions 
Osteonecrosis 
NA 
Asymptomatic with 
radiographic findings 
AND No operative 
intervention indicated 
Symptomatic bone pain 
with radiographic 
findings OR Operative 
intervention indicated 
Disabling bone pain with 
radiographic findings 
causing inability to 
perform basic self-care 
functions 
GENITOURINARY 
Cervicitis  
(symptoms) 
(For use in studies 
evaluating topical  
study agents)  
For other cervicitis see 
Infection: Infection 
(any other than HIV 
infection)  
Symptoms causing no 
or minimal 
interference with 
usual social & 
functional activities  
Symptoms causing 
greater than minimal 
interference with usual 
social & functional 
activities  
Symptoms causing 
inability to perform usual 
social & functional 
activities  
 
Symptoms causing 
inability to perform basic 
self-care functions  
Cervicitis  
(clinical exam) 
(For use in studies 
evaluating topical  
study agents)  
For other cervicitis see 
Infection: Infection 
(any other than HIV 
infection)  
Minimal cervical 
abnormalities on 
examination 
(erythema, 
mucopurulent 
discharge, or friability) 
OR Epithelial 
disruption  
< 25% of total surface 
Moderate cervical 
abnormalities on 
examination 
(erythema, 
mucopurulent 
discharge, or friability) 
OR Epithelial 
disruption of 25 – 49% 
total surface 
Severe cervical 
abnormalities on 
examination (erythema, 
mucopurulent 
discharge, or friability) 
OR Epithelial disruption  
50 – 75% total surface 
Epithelial disruption  
> 75% total surface 
Inter-menstrual 
bleeding (IMB) 
Spotting observed by 
participant OR 
Minimal blood 
observed during 
clinical or colposcopic 
examination 
Inter-menstrual 
bleeding not greater in 
duration or amount 
than usual menstrual 
cycle 
Inter-menstrual bleeding 
greater in duration or 
amount than usual 
menstrual cycle 
Hemorrhage with life-
threatening hypotension 
OR Operative 
intervention indicated 
Urinary tract 
obstruction (e.g., 
stone) 
NA 
Signs or symptoms of 
urinary tract 
obstruction without  
hydronephrosis or 
renal dysfunction 
Signs or symptoms of 
urinary tract obstruction 
with hydronephrosis or 
renal dysfunction 
Obstruction causing life-
threatening 
consequences 


PROMOTE Birth Cohort 1, Protocol Version 6.0  25th October 2017,  
86 
 
 
PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
GRADE 4 
POTENTIALLY 
LIFE-THREATENING 
Vulvovaginitis  
(symptoms) 
(Use in studies 
evaluating topical 
study agents)  
For other 
vulvovaginitis see 
Infection: Infection 
(any other than HIV 
infection) 
Symptoms causing no 
or minimal 
interference with 
usual social & 
functional activities  
Symptoms causing 
greater than minimal 
interference with usual 
social & functional 
activities  
Symptoms causing 
inability to perform usual 
social & functional 
activities  
 
Symptoms causing 
inability to perform basic 
self-care functions  
Vulvovaginitis  
(clinical exam) 
(Use in studies 
evaluating topical 
study agents)  
For other 
vulvovaginitis see 
Infection: Infection 
(any other than HIV 
infection) 
Minimal vaginal 
abnormalities on 
examination OR 
Epithelial disruption  
< 25% of total surface 
Moderate vaginal 
abnormalities on 
examination OR 
Epithelial disruption of 
25 - 49% total surface 
Severe vaginal 
abnormalities on 
examination OR 
Epithelial disruption  
50 - 75% total surface 
Vaginal perforation OR 
Epithelial disruption 
> 75% total surface 
OCULAR/VISUAL 
Uveitis 
Asymptomatic but 
detectable on exam 
Symptomatic anterior 
uveitis OR Medical 
intervention indicated 
Posterior or pan-uveitis 
OR Operative 
intervention indicated 
Disabling visual loss in 
affected eye(s)  
Visual changes (from 
baseline) 
Visual changes 
causing no or minimal 
interference with 
usual social & 
functional activities 
Visual changes 
causing greater than 
minimal interference 
with usual social & 
functional activities 
Visual changes causing 
inability to perform usual 
social & functional 
activities 
Disabling visual loss in 
affected eye(s) 
ENDOCRINE/METABOLIC 
Abnormal fat 
accumulation 
(e.g., back of neck, 
breasts, abdomen) 
Detectable by study 
participant (or by 
caregiver for young 
children and disabled 
adults) 
Detectable on physical 
exam by health care 
provider 
Disfiguring OR Obvious 
changes on casual 
visual inspection 
NA 
Diabetes mellitus 
NA 
New onset without 
need to initiate 
medication OR 
Modification of current 
medications to regain 
glucose control 
New onset with initiation 
of medication indicated 
OR Diabetes 
uncontrolled despite 
treatment modification 
Life-threatening 
consequences (e.g., 
ketoacidosis, 
hyperosmolar non-
ketotic coma)  
Gynecomastia 
Detectable by study 
participant or 
caregiver (for young 
children and disabled 
adults) 
Detectable on physical 
exam by health care 
provider 
Disfiguring OR Obvious 
on casual visual 
inspection 
NA 


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PARAMETER 
GRADE 1 
MILD 
GRADE 2 
MODERATE 
GRADE 3 
SEVERE 
GRADE 4 
POTENTIALLY 
LIFE-THREATENING 
Hyperthyroidism  
Asymptomatic 
 
Symptomatic causing 
greater than minimal 
interference with usual 
social & functional 
activities OR Thyroid 
suppression therapy 
indicated 
Symptoms causing 
inability to perform usual 
social & functional 
activities OR 
Uncontrolled despite 
treatment modification  
Life-threatening 
consequences (e.g., 
thyroid storm) 
Hypothyroidism 
Asymptomatic 
Symptomatic causing 
greater than minimal 
interference with usual 
social & functional 
activities OR Thyroid 
replacement therapy 
indicated 
Symptoms causing 
inability to perform usual 
social & functional 
activities OR 
Uncontrolled despite 
treatment modification  
Life-threatening 
consequences (e.g., 
myxedema coma) 
Lipoatrophy 
(e.g., fat loss from the 
face, extremities, 
buttocks) 
Detectable by study 
participant (or by 
caregiver for young 
children and disabled 
adults) 
Detectable on physical 
exam by health care 
provider 
Disfiguring OR Obvious 
on casual visual 
inspection 
NA 
 
 


 
 
 
 
Adult Laboratory Toxicity Tables  
Routine Tests 
PARAMETER 
Grade 1 
MILD 
Grade 2 
MODERATE 
Grade 3 
SEVERE 
Grade 4 
LIFE THREATENING 
HEMATOLOGY 
WBC, decreased 
2,000 – 2,500/mm3 
1,500 – 1,999/mm3 
1,000 – 1,499/mm3 
< 1,000/mm3 
Absolute neutrophil count (ANC) 
1,000 – 1,300/mm3 
750 – 999/mm3 
500 – 749/mm3 
< 500/mm3 
Hemoglobin (Hb) 
10.0 – 10.9 g/dL 
9.0 – 9.9 g/dL 
7.0 – 8.9 g/dL 
< 7.0 g/dL 
Platelets, decreased 
100,000 –  
124,999/mm3 
50,000 –  
99,999/mm3 
25,000 –  
49,999/mm3 
< 25,000/mm3 
 
AST (SGOT) 
 
1.25 – 2.5 x ULN 
56 – 113 U/L 
2.6 – 5.0 x ULN 
114 – 225 U/L 
5.1 – 10.0 x ULN 
226 – 450 U/L 
10.0 x ULN 
> 450 U/L 
Non-routine tests available 
PARAMETER 
Grade 1 
MILD 
Grade 2 
MODERATE 
Grade 3 
SEVERE 
Grade 4 
LIFE THREATENING 
ALT (SGPT) 
 
1.25 – 2.5 x ULN 
56 – 113 U/L 
2.6 – 5.0 x ULN 
114 – 225 U/L 
5.1 – 10.0 x ULN 
226 – 450 U/L 
> 10.0 x ULN 
> 450 U/L 
Bilirubin (Total) 
 
1.1 – 1.5 x ULN 
1.6 – 2.5 x ULN 
2.6 – 5.0 x ULN 
> 5.0 x ULN 
Creatinine  
 
1.1 – 1.3 x ULN 
1.4 – 1.8 x ULN 
1.9 – 3.4 x ULN 
≥ 3.5 x ULN 
Hyperglycemia 
116 – 160 mg/dL 
6.44 – 8.88 mmol/L 
161 – 250 mg/dL 
8.89 – 13.88 mmol/L 
251 – 500 mg/dL 
13.89 – 27.75 mmol/L 
> 500 mg/dL 
> 27.75 mmol/L 
Hypoglycemia 
55 – 64 mg/dL 
3.05 – 3.55 mmol/L 
40 – 54 mg/dL 
2.22 – 3.06 mmol/L 
30 – 39 mg/dL 
1.67 – 2.23 mmol/L 
< 30 mg/dL 
< 1.67 mmol/L 
Potassium, serum, high 
 
5.6 – 6.0 mEq/L 
5.6 – 6.0 mmol/L 
6.1 – 6.5 mEq/L 
6.1 – 6.5 mmol/L 
6.6 – 7.0 mEq/L 
6.6 – 7.0 mmol/L 
> 7.0 mEq/L 
> 7.0 mmol/L 
Potassium, serum, low 
 
3.0 – 3.4 mEq/L 
3.0 – 3.4 mmol/L 
2.5 – 2.9 mEq/L 
2.5 – 2.9 mmol/L 
2.0 – 2.4 mEq/L 
2.0 – 2.4 mmol/L 
< 2.0 mEq/L 
< 2.0 mmol/L 
Sodium, serum, high 
 
146 – 150 mEq/L 
146 – 150 mmol/L 
151 – 154 mEq/L 
151 – 154 mmol/L 
155 – 159 mEq/L 
155 – 159 mmol/L 
≥ 160 mEq/L 
≥ 160 mmol/L 
Sodium, serum, low 
 
130 – 135 mEq/L 
130 – 135 mmol/L 
125 – 129 mEq/L 
125 – 129 mmol/L 
121 – 124 mEq/L 
121 – 124 mmol/L 
≤ 120 mEq/L 
≤ 120 mmol/L 
Urinalysis 
 
Hematuria (microscopic) 
 
 6 – 10 RBC/HPF 
> 10 RBC/HPF 
Gross, with or 
without clots OR 
with RBC casts 
Transfusion indicated 
Proteinuria, random 
collection 
1 + (30 mg/dL) 
2 – 3 + (100-300 
mg/dL) 
4 + (2000 mg/dL) 
NA 
 
 


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Pediatric Laboratory Toxicity Tables  
Routine Tests 
PARAMETER 
Grade 1 
MILD 
Grade 2 
MODERATE 
Grade 3 
SEVERE 
Grade 4 
LIFE THREATENING 
HEMATOLOGY 
WBC, decreased 
2,000 – 2,500/mm3 
1,500 – 1,999/mm3 
 
1,000 – 1,499/mm3 
 
< 1,000/mm3 
 
Absolute neutrophil count (ANC) 
750-1200/mm3 
400-749/mm3 
250-399/mm3 
< 250/mm3 
Hemoglobin (Hb) 
8.5 – 10.0 g/dL 
7.5 – 8.4 g/dL 
6.50 – 7.4 g/dL 
< 6.5 g/dL 
Platelets, decreased 
100,000 –  
124,999/mm3 
50,000 –  
99,999/mm3 
25,000 –  
49,999/mm3 
< 25,000/mm3 
 
AST (SGOT) 
 
1.1-<2.0 x ULN 
 
2.0-<3.0 x ULN 
 
3.0-8.0 x ULN 
 
> 8.0 x ULN 
 
Non-routine tests available 
PARAMETER 
Grade 1 
MILD 
Grade 2 
MODERATE 
Grade 3 
SEVERE 
Grade 4 
LIFE THREATENING 
ALT (SGPT) 
 
1.25 – 2.5 x ULN 
56 – 113 U/L 
2.6 – 5.0 x ULN 
114 – 225 U/L 
5.1 – 10.0 x ULN 
226 – 450 U/L 
> 10.0 x ULN 
> 450 U/L 
Bilirubin (Total) 
 
1.1-<1.5 x ULN 
 
1.5-<2.0 x ULN 
 
2.0-3.0 x ULN 
 
> 3.0 x ULN 
 
Creatinine 3 months-2 years 
 
0.6-0.8 x ULN 
0.9-1.1 x ULN 
1.2-1.5 x ULN 
> 1.5 x ULN 
Creatinine 2-12 years 
 
0.7-1.0 x ULN 
1.1-1.6 x ULN 
1.7-2.0 x ULN 
> 2.0 x ULN 
Hyperglycemia 
116 – 159 mg/dL 
 
160 – 249 mg/dL 
 
250 – 500 mg/dL 
 
> 400 mg/dL 
 
Hypoglycemia 
55-65 mg/dL 
40-54 mg/dL 
30-39 mg/dL 
<30 mg/dL or abnormal 
glucose and mental status 
changes 
Potassium, serum, high 
 
5.0 – 5.9 mEq/L 
 
6.0 – 6.4 mEq/L 
 
6.5 – 7.0 mEq/L 
 
> 7.0 mEq/L 
 
Potassium, serum, low 
 
3.0 – 3.5 mEq/L 
 
2.5 – 2.9 mEq/L 
 
2.0 – 2.4 mEq/L 
 
< 2.0 mEq/L 
 
Sodium, serum, high 
 
- 
145 – 149 mEq/L 
 
150 – 155 mEq/L 
 
> 155 mEq/L 
 
Sodium, serum, low 
 
- 
130 – 135 mEq/L 
 
124 – 129 mEq/L 
 
< 124 mEq/L 
 
Urinalysis 
 
Hematuria (microscopic) 
 
< 25 RBC/HPF 
> 25 RBC/HPF 
- 
Gross Hematuria 
Proteinuria, random 
collection 
1 + 
2 + 
3 + 
4 + 
 
 
 
 


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Appendix K. List of drugs associated with known risk of torsades de pointes 
 
Substantial evidence supports the conclusion that these drugs prolong the QT interval AND are clearly associated 
with a risk of TdP, even when taken as directed in official labeling.  
Reference: https://www.crediblemeds.org/  
    


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Appendix L. List of drugs that potentially inhibit the metabolism of piperaquine 
 
 
Chloramphenicol 
Clarithromycin 
Diltiazem 
Erythromycin 
Fluconazole 
Itraconazole  
Ketoconazole   
Verapamil 
 

SAP_000.pdf: 
Statistical Analysis Plan PROMOTE-II Birth Cohort 1 – Pregnant women 
SAP version 1.1: PROMOTE-II Birth Cohort 1 Pregnant women 08-May-2015 
Page 1 of 32 
 
Statistical Analysis Plan – Pregnant 
women 
 
TRIAL FULL TITLE 
Reducing the Burden of Malaria in HIV-uninfected 
Pregnant Women and Infants – “Birth Cohort 1” 
ClinicalTrials.gov 
Identifier: 
NCT02163447 
SAP VERSION 
1.1 
SAP VERSION DATE 
08-May-2015 
TRIAL STATISTICIAN 
Edwin D. Charlebois, MPH PhD 
TRIAL PRINCIPAL 
INVESTIGATORS 
Grant Dorsey, MD, PhD 
Moses Kamya, MBChB, MMed, PhD 
Diane Havlir, MD 
Abel Kakuru, MBChB, MSc 
Maggie Feeney, MD, MSc 
SAP AUTHOR 
Edwin D. Charlebois, MPH PhD 
 
 
 


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Table of Contents 
Table of Contents.................................................................................................... 2 
1 
Abbreviations and Definitions ............................................................................ 4 
2 
Introduction....................................................................................................... 5 
2.1 
Preface ........................................................................................................ 5 
2.2 
Purpose of the analyses ............................................................................... 6 
3 
Study Objectives and Endpoints ......................................................................... 6 
3.1 
Study Objectives .......................................................................................... 7 
3.2 
Endpoints .................................................................................................... 7 
3.3 
Derived variables ......................................................................................... 8 
4 
Study Methods ................................................................................................... 8 
4.1 
General Study Design and Plan .................................................................... 8 
4.2 
Equivalence or Non-Inferiority Studies ......................................................... 9 
4.3 
Inclusion-Exclusion Criteria and General Study Population .......................... 9 
4.4 
Randomization and Blinding ...................................................................... 10 
4.5 
Study Variables .......................................................................................... 11 
5 
Sample Size ..................................................................................................... 12 
6 
General Considerations .................................................................................... 14 
6.1 
Timing of Analyses .................................................................................... 14 
6.2 
Analysis Populations .................................................................................. 14 
6.2.1 
Full Analysis Population ....................................................................... 14 
6.2.2 
Per Protocol Population ....................................................................... 14 
6.3 
Covariates and Subgroups ......................................................................... 15 
6.5 
Interim Analyses and Data Monitoring ....................................................... 15 
6.5.1 
Purpose of Interim Analyses ................................................................ 15 
6.5.2 
Planned Schedule of Interim Analyses .................................................. 15 
6.5.3 
Scope of Adaptations........................................................................... 16 
6.5.4 
Stopping Rules .................................................................................... 16 


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6.5.5 
Adjustment of Confidence Intervals and p-values ................................ 16 
6.5.6 
Interim Analysis for Sample Size Adjustment ....................................... 16 
6.5.7 
Practical Measures to Minimize Bias ..................................................... 16 
6.5.8 
Documentation of Interim Analyses ..................................................... 17 
6.6 
Multi-center Studies .................................................................................. 17 
6.7 
Multiple Testing ........................................................................................ 17 
7 
Summary of Study Data ................................................................................... 17 
7.1 
Trial Prolie ................................................................................................. 17 
7.2 
Baseline Characteristics ............................................................................. 18 
7.3 
Treatment Adherence ................................................................................ 19 
8 
Efficacy Analyses ............................................................................................. 21 
8.1 
Efficacy outcomes ...................................................................................... 21 
8.2 
Primary Efficacy Analysis ........................................................................... 23 
8.3 
Secondary Efficacy Analyses ...................................................................... 23 
9 
Safety and Tolerability Analyses ....................................................................... 27 
9.1 
Adverse Events .......................................................................................... 27 
9.2 
Serious Adverse Events .............................................................................. 27 
9.3 
Analytical Methods .................................................................................... 27 
10 
References ..................................................................................................... 30 
 
 
 


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1 Abbreviations and Definitions 
ACT 
Artemisinin-based combination therapy 
AE 
Adverse Event 
AL 
Artemether-lumefantrine 
ALT 
Alanine transaminase (SGPT)  
CAB 
Community advisory board 
CBC 
CBC Complete blood cell 
CRF 
Case Report Form 
DP 
Dihydroartemisinin-piperaquine  
DSMB 
Data and Safety Monitoring Board 
IDRC 
Infectious Diseases Research 
Collaboration 
IPT 
Intermittent preventive therapy 
IPTp 
Intermittent preventive therapy in 
pregnancy  
IRB 
Institutional review board 
ITN 
Insecticide treated net  
MOH 
Ministry of Health 
MU 
Makerere University  
NICHD 
National Institute of Child Health and 
Human Development 
NIH 
National Institute of Health  
SAE 
Serious adverse event 
SAP 
Statistical Analysis Plan 
SP 
Sulfadoxine-pyrimethamine  
TDH  
Tororo District Hospital 
UCSF  
University California San Francisco  
WHO 
WHO World Health Organization  
 
 
 


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2 Introduction 
2.1 Preface 
In sub-Saharan Africa approximately 25 million pregnant women are at risk of P. 
falciparum infection every year and 25% have evidence of placental infection.1 
Among pregnant women living in areas of stable transmission few infections lead to 
symptomatic malaria, however, infection is associated with maternal morbidity, 
such as anemia, and adverse birth outcomes including abortions, stillbirth, preterm 
delivery, low birth weight (LBW), and infant mortality.2,3  
In Africa the only widely available tools for the prevention of malaria in pregnancy 
are insecticide treated bednets (ITNs) and intermittent preventive therapy (IPTp) 
with sulfadoxine-pyrimethamine (SP). Older studies demonstrated the efficacy of 
IPTp with SP in reducing the risk of placental malaria and LBW.4-8 However, there are 
now concerns about the continued efficacy of IPTp given the spread of antifolate 
resistance. A 2007 review suggested that IPTp with SP remained beneficial in areas 
with antifolate resistance, however, this conclusion was based on communities 
where SP treatment failure rates in children remained at moderate levels.9 More 
recently, reports from East Africa have documented SP failure rates over 65% in 
children when used for treatment10 or prevention11, and near saturation of common 
SP resistance alleles.12,13 In a recent study from Tanzania IPTp with SP was not 
associated with a decreased risk of placental malaria, maternal anemia, or LBW, and 
unexpectedly associated with an increased risk of fetal anemia.14 In a recent study 
from Uganda there was no significant difference in the risk of maternal infection, 
maternal anemia, and LBW for pregnant women receiving IPTp with SP plus ITNs vs. 
ITNs alone.15 In addition, most IPTp studies have defined placental malaria on the 
basis of placental blood smears, which dramatically underestimate the true 
prevalence of placental malaria. In summary, there are several lines of evidence 
suggesting that IPTp with SP is no longer effective in areas of East Africa with 
widespread antifolate resistance. New interventions to reduce the burden of malaria 
in pregnancy in this region are desperately needed. 
The artemisinin-based combination therapy (ACT) class of drugs offers an attractive 
alternative to SP for use in pregnancy. In a recent systematic review of 
parasitological efficacy for the treatment and prevention of falciparum malaria in 
pregnancy, placenta-positive rates were unacceptably high in a majority of SP trial 
arms and ACTs provided the lowest parasitological failure rates.16 The authors 


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recommended that SP should no longer be used for treatment or prevention of 
malaria in pregnancy and that ACTs provide the most efficacious and safe 
alternative therapy. Two studies of the ACT artesunate (AS) + SP from Africa 
concluded that this drug was safe for the treatment of malaria in pregnant 
women.17,18 More recent studies have focused on artemether-lumefantrine (AL), 
considering efficacy, pharmacokinetics, and safety. In a prospective study from 
Zambia, 495 pregnant women exposed to AL (including 156 in the 1st trimester) had 
similar risks of adverse maternal and infant outcomes compared to pregnant 
women exposed to SP.19  In a recent study from Uganda, pregnant women in their 
2nd or 3rd trimester with peripheral parasitemia treated with AL had a cure rate of 
99%.20 Dihydroartemisinin-piperaquine (DP) has also been safely used for the 
treatment of uncomplicated malaria in pregnancy in studies from Asia.21,22 In two 
recent studies on the treatment of uncomplicated malaria with DP in pregnant and 
non-pregnant women, one concluded that there were no clinically important 
differences in piperaquine pharmacokinetics in pregnancy 23 and another concluded 
that pregnancy was associated with an unaltered total exposure to piperaquine but 
a shorter terminal elimination half-life.24 
In summary, most African countries continue to recommend IPTp with SP, however, 
there are serious concerns about the efficacy of SP given widespread resistance, 
especially in East Africa. Available data have shown that ACTs are effective and safe 
for the treatment of malaria in pregnancy and are now recommended by the WHO 
as 1st line therapy for pregnant women in their 2nd or 3rd trimester.25 However, there 
are no published studies evaluating the safety and efficacy of ACTs for use as 
preventive therapy in pregnant women.  
2.2 Purpose of the analyses 
This proposal will be the first clinical trial we are aware of to evaluate the efficacy 
and safety of DP for the prevention of malaria in pregnant women. We will perform 
a randomized, double-blinded, controlled trial to compare 2 dosing strategies of 
this novel intervention with the current standard of care of IPTp with SP in an area 
of high transmission intensity and widespread antifolate resistance. The primary 
outcome will be based on placental histopathology; in addition, pregnant women 
will undergo monthly blood sampling using a highly sensitive loop-mediated 
isothermal amplification (LAMP) assay to better define the timing and frequency of 
malaria infection during pregnancy. 


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3 Study Objectives and Endpoints 
3.1 Study Objectives 
(ICH E3; 8.) 
We will test the hypothesis that IPT with DP will significantly reduce the burden of 
malaria in pregnancy. The specific study objectives are as follows: 
3.1.1. Objective 1 
To compare the risk of placental malaria among HIV uninfected pregnant women 
randomized to receive IPTp with 3 dose SP vs. 3 dose DP vs. monthly DP. We will 
test the hypothesis that pregnant women who receive IPTp with either 3 doses of DP 
or monthly DP will have a lower risk of placental malaria defined by histopathology 
compared to those who receive 3 doses of SP. Secondary outcomes will include 
maternal and fetal clinical outcomes. We will also compare the two different dosing 
strategies of DP. 
3.2 Endpoints 
(ICH E9; 2.2.2) 
3.2.1.  Primary Outcomes 
The primary outcome for pregnant women will be the prevalence of placental 
malaria based on placental histopathology and dichotomized into any evidence of 
placental infection (parasites or pigment) vs. no evidence of placental infection. We 
will also evaluate placental malaria defined by histopathology as a categorical 
variable (active-acute, active-chronic, and past infection) based on the criteria 
developed by Rogerson et al.26 
 
3.2.2. Secondary Outcomes 
• 
Prevalence of placental parasitemia: Proportion of placental blood samples 
positive for parasites by microscopy or LAMP 
• 
Incidence of maternal malaria: Episodes of fever and positive blood smear by 
microscopy  


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• 
Prevalence of adverse birth outcomes: Proportions of birth outcomes that 
include congenital malformations, preterm delivery, late spontaneous 
abortion, LBW (<2500g), stillbirth, or a composite of all of these 
• 
Incidence of adverse events:  Adverse events stratified by type, severity score 
and relationship to study drugs 
• 
Prevalence of anemia: Proportion of routine hemoglobin measurements < 11 
g/dL & < 8 g/dL 
• 
Prevalence of asymptomatic parasitemia: Proportion of routine monthly 
samples positive for parasites by LAMP  
3.3 Derived Variables 
Composite adverse birth outcome will be a derived variable defined as the presence 
of any preterm delivery, congenital malformations, spontaneous abortion, low birth 
weight (<2500g), or stillbirth.  
4 Study Methods 
4.1 General Study Design and Plan 
(ICH E3;9) 
This will be a double-blinded randomized controlled phase III trial of 300 HIV 
uninfected pregnant women and the children born to them. The study 
interventions will be divided into two phases. In the first phase, HIV uninfected 
women enrolled at 12-20 weeks gestation will be randomized in equal 
proportions to one of three IPTp treatment arms: 1) 3 doses of SP, 2) 3 doses of 
DP, or 3) monthly DP. All three interventions arms will have either SP or DP 
placebo to ensure adequate blinding is achieved in the study. Follow-up for the 
pregnant women will end approximately 6 weeks after giving birth. In the 
second phase of the study, all children born to pregnant women enrolled in the 
study will be followed from birth until they reach 36 months of age. Children 
born to women randomized to receive 3 doses of SP during pregnancy will 
receive DP every 3 months between 2-24 months of age. Children born to 
women randomized to receive 3 doses of DP or monthly DP during pregnancy 
will receive either DP every 3 months or monthly DP between 2-24 months of 
age. To ensure adequate blinding, children who will receive DP every 3 months 
will be given DP placebo during the months they will not be taking DP. Children 


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will then be followed an additional year between 24-36 months of age following 
the interventions.  
The details outlined in this statistical analyses plan will only focus on Phase I of 
the study involving pregnant women.  
4.2 Equivalence or Non-Inferiority Studies 
(ICH E3; 9.2, 9.7.1, 11.4.2.7. ICH E9; 3.3.2) 
N/A - This trial is designed as a superiority trial. 
4.3 Inclusion-Exclusion Criteria and General Study Population 
(ICH E3;9.3. ICH E9;2.2.1) 
4.3.1. Inclusion Criteria 
1) Pregnancy confirmed by positive urine pregnancy test or intrauterine 
pregnancy by ultrasound 
2) Estimated gestational age between 12-20 weeks 
3) Confirmed to be HIV uninfected by rapid test 
4) 16 years of age or older 
5) Residency within 30km of the study clinic 
6) Provision of informed consent by the pregnant woman for herself and her 
unborn child 
7) Agreement to come to the study clinic for any febrile episode or other 
illness and avoid medications given outside the study protocol 
8) Plan to deliver in the hospital 
4.3.2. Exclusion Criteria 
1) History of serious adverse event to SP or DP 
2) Active medical problem requiring inpatient evaluation at the time of 
screening 
3) Intention of moving more than 30km from the study clinic 


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4) Chronic medical condition requiring frequent medical attention 
5) Prior SP preventive therapy or any other antimalarial therapy during this 
pregnancy 
6) Early or active labor (documented by cervical change with uterine 
contractions) 
4.4 Randomization and Blinding 
(ICH E3; 9.4.3, 9.4.6. ICH E9; 2.3.1, 2.3.2) 
Treatment Group Assignments 
There will be 5 treatment arms which include both the intervention for the woman 
during pregnancy and her unborn child(ren) during infancy (Table 1). Non-singleton 
births from the same mother will be assigned to the same intervention. We will use 
a 2:1:1:1:1 randomization scheme targeting 100, 50, 50, 50, 50 pregnant women in 
treatment arms A-E respectively. This randomization scheme will result in a target 
of 100 women for each of the 3 different treatment arms during pregnancy. A 
randomization list will be computer generated by a member of the project who will 
not be directly involved in the conduct of the study. The randomization list will 
include consecutive treatment numbers with corresponding random treatment 
assignments. Randomized codes will correspond to the 5 treatment groups using 
permuted variable sized blocks of 6 and 12 (to account for treatment group A being 
represented twice as often as the other 4 treatment groups). Sealed copies of the 
original randomization list and documentation of the procedure used to generate 
the lists will be stored in the project administrative offices in San Francisco and 
Kampala. Prior to the onset of the study, a set of sequentially numbered, opaque, 
sealed envelopes will be prepared. Each envelope will be marked on the outside 
with the treatment allocation number. The inside of the envelope will contain a 
piece of paper with the treatment allocation number and treatment group 
assignment along with a piece of carbon paper. 
Table 1. Treatment arms with assignment of study drugs during pregnancy and infancy 
Phase of 
intervention 
Treatment arm (target number) 
A 
B 
C 
D 
E 
During pregnancy 
3 dose SP (100) 
3 dose DP (100) 
Monthly DP (100) 
During infancy 
3 monthly DP (100) 
3 monthly DP (50) 
Monthly DP (50) 
3 monthly DP (50) 
Monthly DP (50) 


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4.5 Study Variables 
(ICH E3; 9.5.1. ICH E9; 2.2.2) 
See Data Dictionary Excel file for complete list of study variables. 
Table 2. Schedule of routine assessments and procedures in pregnant women 
Evaluations  and 
Interventions 
Enrollment 
Weeks of gestation 
Delivery 
1 and 6 
weeks 
postpartum 
16* 
20 
24 
28 
32 
36 
40 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
HIV testing1 
X 
 
 
 
X 
 
 
 
X 
 
Pregnancy confirmation2 
X 
 
 
 
 
 
 
 
 
 
Obstetrical ultrasound3 
X 
 
 
 
 
 
 
 
 
 
Blood collected by 
phlebotomy for CBC, ALT, 
and immunology studies 
X 
 
X 
 
X 
 
X 
 
X 
 
Blood collected by finger 
prick for dried blood spot 
and plasma 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Routine assessment in the 
study clinic4 
X 
X 
X 
X 
X 
X 
X 
X 
 
X 
Administration of study 
drugs 
 
X 
X 
X 
X 
X 
X 
X 
 
 
Collection of cord blood 
and placental tissue 
 
 
 
 
 
 
 
 
X 
 
Labor and delivery 
documentation5 
 
 
 
 
 
 
 
 
X 
 
* Only if study subject enrolled prior to 16 weeks gestation; If the woman is enrolled between 18-20 
weeks, then the week 20 phlebotomy will not be performed. 
Explanation of maternal schedule of events  
1. HIV test will be done at enrollment and documented. A repeat rapid HIV test will be done at 
delivery. HIV testing shall be done using standard rapid HIV-testing algorithm.   
2. Pregnancy confirmation by positive urine pregnancy test, or confirmed intrauterine pregnancy by 
ultrasound. A pregnancy test may be skipped if an intrauterine pregnancy has been noted on 
ultrasound at the screening visit. 
3. Ultrasound will be done to confirm intrauterine pregnancy and estimate gestational age at 
enrollment. See Appendix B for dating criteria. 
4. Targeted physical exam will include anthropometric measurements (e.g. weight) and vital signs 
(i.e. temperature, pulse, and blood pressure). Measurement of height at the enrollment visit only. 
5. Labor & Delivery documentation will include: Peripartum history, mode of delivery, Apgar scores 
(when available), weight, length, and head circumference of the child at birth, approximate 
gestational age, duration of labor, signs of fetal distress (presence of meconium), summary of 
events in first days of life (including feeding, breathing patterns, jaundice, lethargy, or any 
additional abnormal findings), duration of admission if delivered in hospital. 
 
 
 


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Table 3.  Study Case Report Forms 
CRF# 
Form/Questionnaire 
1 
BC-1 Screening 
2 
BC-1 Enrollment 
3 
BC-1 Clinic Visit Form 
4 
BC-1 Subject Hospital Admission 
5 
BC-1 Missed Visit Form 
6 
BC-1 Subject Death Record Form 
7 
BC-1 Mothers Delivery Form 
8 
BC-1 Postpartum Visit Form 
9 
BC-1 Child's Delivery Form 
10 
BC-1 Study Drug Dispensing Forms 
11 
BC-1 AE Forms 
12 
BC-1 Subject Withdrawal or Study Completion Form 
13 
BC-1 Household Survey Questionnaire 
14 
BC-1 GPS Coordinates 
15 
BC-1 Placental Histopathology 
 
5 Sample Size  
(ICH E3; 9.7.2. ICH E9; 3.5) 
The number of pregnant women enrolled and the number of study participants 
reaching the various endpoints will determine the samples sizes for each of the 
primary outcomes of our study aims (Table 4). The 3 primary hypotheses for the 
complete study are as follows: 1) We will test the hypothesis that pregnant women 
who receive IPTp with either 3 dose DP or monthly DP will have a lower risk of 
placental malaria defined by histopathology compared to those who receive 3 doses 
of SP. We will also compare the two different dosing strategies of DP. 2) We will test 
the hypothesis that infants randomized to receive monthly DP between 2-24 
months of age will have a lower incidence of malaria during the first 24 months of 
life compared to infants randomized to receive q 3 monthly DP. 3) We will test the 
hypotheses that a) infants born to mothers randomized to receive IPTp with 3 dose 
DP or monthly DP will have a lower incidence of malaria during the first 24 months 
of life compared to infants born to mothers who were randomized to receive IPTp 
with 3 doses of SP, and b) infants randomized to receive monthly DP between 2-24 


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months of age will have a lower incidence of malaria between 24-36 months of age 
after the intervention is stopped compared to infants randomized q 3 monthly DP 
between 2-24 months of age. The primary determinant of our target sample size 
was based on testing hypotheses 3 given that the magnitude of differences 
anticipated for this hypothesis would be smaller than those anticipated for 
hypothesis 1 and 2. We conservatively estimate that 90% of pregnant women 
enrolled will reach the primary study endpoint and we will lose 5% of follow-up time 
per year in the infants. The minimum relative differences detectable for the primary 
outcomes of the 3 hypotheses given our estimated sample sizes are summarized in 
Table 5 below. For hypotheses 1, we will be powered to detect a 33% relative 
difference in the prevalence of placental malaria in the 3 dose DP arm or the 
monthly DP arm compared to the 3 dose SP arm assuming a prevalence of placental 
malaria of 62% in the 3 dose SP arm based on prior data. We will also be powered to 
detect a 41-70% relative difference in the prevalence of placental malaria in the 
monthly DP arm compared to the 3 dose DP arm assuming a prevalence of placental 
malaria in the 3 dose DP arm ranging from 20-50%. For hypothesis 2, we will be 
powered to detect an 18-23% relative difference in the incidence of malaria between 
0-24 months of age in the monthly DP arm compared to the q 3 monthly DP arm 
assuming an incidence of malaria in the q 3 monthly DP arm ranging from 3-5 
episodes PPY. For hypothesis 3A, we will be powered to detect a 22-28% relative 
difference in the incidence of malaria between 0-24 months of age among children 
assigned to receive q 3 monthly DP when comparing those born to women who 
received 3 dose SP to those born to women who received 3 dose DP or monthly DP 
assuming an incidence of malaria in the control group ranging from 3-5 episodes 
PPY. For hypothesis 3B, we will also be powered to detect a 16-21% relative 
difference in the incidence of malaria between 24-36 months of age among 
children assigned to receive monthly DP during infancy compared to those who 
received q 3 monthly DP during infancy assuming an incidence of malaria in the 
control group ranging from 3-5 episodes PPY.    
 
Table 4. Intervention arms during pregnancy and infancy 
Study populations 
Intervention arms 
Assigned treatment arms in pregnant women 
3 doses of SP 
3 doses of DP 
monthly DP 
Estimated number of pregnant women enrolled 
100 
100 
100 
Estimated number with placental outcomes 
90 
90 
90 
Assigned treatment arms in infants 
q 3 monthly DP 
q 3 monthly DP 
monthly  DP 
q 3 monthly DP 
monthly DP 
Estimated number of infants enrolled 
90 
45 
45 
45 
45 
Estimated number of infants reaching 24 months of age 
81 
41 
41 
41 
41 
 
 


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Table 5. Minimum relative differences in outcomes detectable given estimated effective sample sizes 
Hypothesis 
Analysis population 
Control group and 
estimated sample size 
Comparison group and 
estimated sample size 
Estimated outcome 
measure in control 
group 
Minimum 
relative 
difference 
detectable* 
1 
Pregnant women with placental 
malaria measured by 
histopathology at birth 
3 dose SP 
(n=90) 
3 dose DP or monthly DP 
(n=90 each) 
Prevalence of 
placental malaria = 
62% 
33% 
3 dose DP 
(n=90) 
monthly DP 
(n=90) 
Prevalence of 
placental malaria = 20-
50% 
41-70% 
2 
Infants 0-24 months of age born to 
women assigned to receive IPTp 
with 3 dose DP or monthly DP 
Infants assigned q 3 
monthly DP (n=90) 
Infants assigned monthly 
DP (n=90) 
Incidence of malaria = 
3-5 episode PPY 
18-23% 
 
3 
Infants 0-24 months of age 
randomized to q 3 monthly DP  
Infants of women 
assigned 3 dose SP 
(n=90) 
Infants of women assigned 
3 dose DP or monthly DP 
(n=45 each) 
Incidence of malaria = 
3-5 episodes PPY 
22-28% 
Infants 24-36 months of age after 
chemoprevention stopped 
Infants assigned q 3 
monthly DP (n=163) 
Infants assigned monthly 
DP (n=82) 
Incidence of malaria = 
3-5 episodes PPY 
16-21% 
* Relative difference = (estimated outcome in control arm – estimated outcome in the comparison arm) / 
estimated outcome on the control arm (two-sided alpha = 0.05, power = 80%). 
6 General Considerations 
6.1 Timing of Analyses 
The final trial analysis for Phase I of the study will be performed after the last 
enrolled woman has given birth and all outcome measures have been assessed.  
Prior to the final analysis we will perform an interim safety analysis when ~ ½ of the 
study subjects have given birth.  The interim safety analyses will compare the 
incidence rate ratio of significant adverse events (grade 3/4 & SAEs).   
6.2 Analysis Populations 
(ICH E3; 9.7.1, 11.4.2.5. ICH E9; 5.2) 
A modified intention-to-treat approach will be used for all analyses, including all 
women who were randomized and received at least one dose of study drugs, and 
who have evaluable data on specific outcomes regardless of whether the 
intervention was not given for any reason.  
6.2.1 Full Analysis Population 
• 
All subjects who were randomized and received at least one dose of study 
drugs 
• 
All subjects with evaluable data on specific outcomes 
6.2.2 Per Protocol Population 
A per protocol analysis is not planned. 


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6.3 Covariates and Subgroups 
(ICH E3; 9.7.1, 11.4.2.1. ICH E9; 5.7) 
Covariates of interest will include baseline measures of maternal age, gestational 
age at enrollment, gravidity, bednet ownership, socio-economic status as estimated 
by a household wealth index, and prevalence of malaria parasites using LAMP. 
Sub-group analyses will be performed based on categories of maternal age, 
gravidity, and gestational age at the time study drugs were first administered.   
6.4 Missing Data 
(ICH E3; 9.7.1, 11.4.2.2. ICH E9;5.3. EMA Guideline on Missing Data in Confirmatory 
Clinical Trials) 
Women in the trial who are prematurely withdrawn from the study or are not able to 
provide data for specific outcomes will be considered un-evaluable and will not be 
included in the primary trial analysis.   For some outcomes missing data will be 
imputed based on other information (see details in Table 10 below).  
6.5 Interim Analyses and Data Monitoring 
(ICH E3; 9.7.1, 11.4.2.3. ICH E9; 4.1, FDA Feb 2010 “Guidance for Industry Adaptive 
Design Clinical Trials for Drugs and Biologics”) 
6.5.1 Purpose of Interim Analyses 
Over the course of the trial, we will perform an interim safety analysis in addition to 
a final safety analysis for a total of two sequential evaluations of study safety. The 
interim safety analyses will compare the incidence rate ratio of significant adverse 
events (grade 3/4 & SAEs).   
6.5.2 Planned Schedule of Interim Analyses 
The interim safety analysis for pregnant women will be performed when ~ ½ of the 
study subjects have given birth. A standardized test statistic will be calculated for 
the adverse event incidence rate ratio. If this statistic exceeds the nominal critical 
value calculated using the error spending function (Table 6), then a statistically 
significant result will have been achieved at the time of the analysis.  In that event, 
the sponsor will be notified and a report submitted for review by the Data Safety 
Monitoring Board (DSMB). For the interim safety analysis, the study team will 


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present information on recruitment and the results of interim safety analyses to the 
DSMB, which will review the data and recommend a course of action.  
Table 6. Schedule of interim safety analysis and boundaries to monitor study outcome 
Number of Evaluable Subjects Accrued  
or % of Total Accrual Time 
Test Statistic 
Alpha 
Cumulative  
Alpha 
Lower Bound Upper Bound 
N=150 or 50% of accrual time 
-2.51 
2.51 
0.00601 
0.01210 
N=300 or 100% of accrual time 
-1.99 
1.99 
0.02313 
0.05000 
This analysis assumes α=0.05 (two-sided test), O’Brien-Fleming boundaries (DeMets error-
spending function) and 300 trial participants. We will utilize Programs for Computing Group 
Sequential Boundaries Using the Lan-DeMets Method. 
6.5.3 Scope of Adaptations 
At the time of the interim analysis, the DSMB may decide to continue, stop, or 
modify the trial based on the interim safety analysis. This may include the 
discontinuation of a study arm and re-randomization or cessation of subject 
participation in the stopped arm. 
6.5.4 Stopping Rules 
The DSMB will determine whether to stop the study for early evidence of 
intervention safety problems after a thorough review of interim data. Interim 
reports will provide cumulative enrollment figures and cumulative adverse birth 
outcomes, serious adverse events (classified according to grade), sorted by study 
arm. Brief clinical descriptions of key events will also be provided. The PI will be 
responsible for immediately reporting to the funding agency any temporary or 
permanent suspension of the project and the reason for the suspension.  
6.5.5 Adjustment of Confidence Intervals and p-values 
As appropriate we will adjust p-values and confidence intervals taking into account 
the specified error spending functions and interim evaluation of the data.  
6.5.6 Interim Analysis for Sample Size Adjustment 
The sample size will not be adjusted based on the results of the interim analysis. 
6.5.7 Practical Measures to Minimize Bias 
The study will establish and control who will have access to what information at 
each stage of the trial. Uncontrolled reporting of interim analyses to study 
investigators responsible for recruiting subjects will not occur.  
The following measure will be taken to minimize bias: 


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• 
Only the study statistician and assistant statistician will perform the interim 
analysis. 
• 
Only the statisticians and the DSMB will see any data or analyses at the 
interim analysis 
• 
No information will be publically available following an interim analysis 
• 
Information will be provided to the sponsor and investigators as per 
recommendation of the study DSMB. 
• 
Only the statisticians will be unblinded at for the interim analysis 
6.5.8 Documentation of Interim Analyses 
Snapshots of the data available at each interim analysis will be preserved, as will all 
documentation of analysis plans, programming code and reporting provided at the 
interim analysis.  
6.6 Multi-center Studies 
(ICH E3;9.7.1, 11.4.2.4. ICH E9; 3.2) 
This is a single center study. 
6.7 Multiple Testing 
(ICH E3; 9.7.1, 11.4.2.5. ICH E9; 2.2.5) 
This study has one primary endpoint. The preservation of the overall significance 
level is of importance and as there are more than two treatment groups, secondary 
analyses comparing multiple groups may require adjustment of p-values and 
confidence intervals. 
7 Summary of Study Data 
All continuous variables will be summarized using the following descriptive 
statistics: n (non-missing sample size), mean, standard deviation, median, 
maximum and minimum. The frequency and percentages (based on the non-
missing sample size) of observed levels will be reported for all categorical 
measures. All summary tables will be structured with a column for each 
treatment and will be annotated with the total population size relevant to that 
table/treatment, including any missing observations. 
 


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7.1 Trial Profile 
The overall study profile will be presented as a figure following CONSORT 
guidelines. The total numbers of women screened, excluded during screening 
(including criteria for exclusion) and enrolled will be presented. The numbers of 
women enrolled in each treatment arm and followed through each stage of the trial 
profile are presented in skeleton Table 7 below. 
Table 7. Trial profile 
 
Treatment arm 
3 dose SP 
3 dose DP 
Monthly DP 
Enrolled and randomized 
### 
### 
### 
Withdrawn before 1st dose of study drugs* 
### 
### 
### 
Received at least 1 dose of study drugs 
### 
### 
### 
Withdrawn before delivery*  
### 
### 
### 
Delivered 
### 
### 
### 
Withdrawn after delivery* 
### 
### 
### 
Completed 6 week post-partum visit 
### 
### 
### 
* Specific reasons for premature study withdrawal will be reported 
 


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7.2 Baseline Characteristics 
Skeleton table of all baseline variables collected on the day of enrollment that will 
be presented are provided in Table 8 below.  
Table 8. Baseline characteristics of study participants randomized to IPTp 
Characteristic 
Treatment arm 
3 dose SP 
(n=XXX) 
3 dose DP 
(n=XXX) 
Monthly DP 
(n=XXX) 
Age in years, mean (SD) 
 
 
 
Gestational age in weeks, mean (SD) 
 
 
 
Gestational age categories, n (%) 
   12-16 weeks 
   >16-20 weeks 
 
 
 
Previous pregnancies, n (%) 
   0 
   1  
   > 2 
 
 
 
Bednet ownership, n (%) 
   None 
   Untreated net 
   ITN 
 
 
 
Household wealth index, n (%) 
   Lowest tertile 
   Middle tertile 
   Highest tertile 
 
 
 
Weight in kg, mean (SD) 
 
 
 
Height in cm, mean (SD) 
 
 
 
Laboratory values, mean (SD) 
   WBC count per mm3 
    Neutrophil count per mm3 
    Platelet count per mm3 
    Hemoglobin g/dL 
   ALT IU/L 
 
 
 
Detection of malaria parasites by 
LAMP, n (%) 
 
 
 
 
7.3 Treatment Adherence 
During pregnancy, women will be given 1 of 3 treatment regimens: 1) SP given 3 
times during pregnancy, 2) DP given 3 times during pregnancy, or 3) DP given every 


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4 weeks during pregnancy. Each treatment with SP will be given as a single dose 
consisting of 3 full strength tablets. Each treatment with DP will consist of 3 full 
strength tablets given once a day for 3 consecutive days. In addition, placebos will 
be used to mimic the identical dosing strategy such that every 4 weeks women will 
receive two drugs on day 1 (SP and placebo, DP and placebo, or two placebos) 
followed by one drug on days 2 and 3 (DP or placebo). Two placebos will be used, 
one that mimics the appearance of SP and one that mimics the appearance of DP. 
Administration of all study drugs will be double blinded. All doses of study drugs 
will be pre-packaged by a study pharmacist and administered by a study nurse 
blinded to the study participant’s treatment regimen. All doses of SP (or SP placebo) 
administered will be directly observed in the clinic. For DP (or DP placebo), the first 
of the 3 daily doses will be directly observed in the clinic and the 2nd and 3rd daily 
doses will be administered at home using pre-packaged study drugs in opaque 
envelopes with dosing instructions written on the outside. For doses of study drugs 
administered in the clinic, if a study participant vomits the study drug within 30 
minutes of administration, the drug will be re-administered. For doses of study 
drugs administered at home, if a study participant vomits the study drug within 30 
minutes of administration or study drug is lost, the study participant will be 
instructed to come to the study clinic as soon as possible where the study drug will 
be re-administered/replaced. Measures of treatment adherence are summarized in 
skeleton Table 9 below. 
Table 9. Measures of treatment adherence 
 
Treatment arm 
3 dose SP 
3 dose DP 
Monthly DP 
At the level of each individual woman receiving at least one dose of study drugs 
At least one dose of study drug held for adverse event 
n/N (%) 
n/N (%) 
n/N (%) 
Missed at least 1 course of study drugs (all 3 doses) 
n/N (%) 
n/N (%) 
n/N (%) 
Reported not taking at least 1 dose of study drug at home 
n/N (%) 
n/N (%) 
n/N (%) 
At the level of each scheduled dose of study drug 
Study drugs (all 3 doses) held for adverse event 
n/N (%) 
n/N (%) 
n/N (%) 
Study drugs (all 3 doses) missed 
n/N (%) 
n/N (%) 
n/N (%) 
Reported not taking day 2 dose of study drugs at home 
n/N (%) 
n/N (%) 
n/N (%) 
Reported not taking day 3 dose of study drugs at home 
n/N (%) 
n/N (%) 
n/N (%) 
 
 
 


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8 
Efficacy Analyses 
8.1 Efficacy outcomes 
Definitions and criteria used to generate estimates of all primary and secondary efficacy outcomes are presented in Table 10 below. For 
women with non-singleton birth (i.e. twins), dichotomous delivery outcomes at the level of the individual child/placenta will be based 
on whether the outcome was present in either child/placenta.  
 
Table 10. Primary and secondary outcomes 
Outcome 
Category 
Type of 
measurement 
Timing of 
measurement 
Numerator 
Denominator 
Missing data 
Imputation 
Placental malaria by 
histopathology 
Primary 
outcome 
Proportion 
At delivery 
Placental tissue samples with 
parasites or pigment detected 
Number of placentas 
examined 
No placental  tissue 
sample collected 
None 
Placental parasitemia using 
microscopy 
Secondary 
outcome 
Proportion 
At delivery 
Placental blood samples with 
parasites detected by microscopy  
Number of placental blood 
samples examined 
No placental blood 
sample collected 
None 
Placental parasitemia using 
LAMP 
Secondary 
outcome 
Proportion 
At delivery 
Placental blood samples with 
parasites detected by LAMP  
Number of placental blood 
samples examined 
No placental blood 
sample collected 
None 
Maternal parasitemia using 
microscopy 
Secondary 
outcome 
Proportion 
At delivery 
Maternal blood samples with 
parasites detected by microscopy  
Number of maternal blood 
samples examined 
No maternal blood 
sample collected 
None 
Maternal parasitemia using 
LAMP 
Secondary 
outcome 
Proportion 
At delivery 
Maternal blood samples with 
parasites detected by LAMP  
Number of maternal blood 
samples examined 
No maternal blood 
sample collected 
None 
Cord blood parasitemia 
using microscopy 
Secondary 
outcome 
Proportion 
At delivery 
Cord blood samples with parasites 
detected by microscopy  
Number of cord blood 
samples examined 
No cord blood sample 
collected 
None 
Cord blood parasitemia 
using LAMP 
Secondary 
outcome 
Proportion 
At delivery 
Cord blood samples with parasites 
detected by LAMP  
Number of cord blood 
samples examined 
No cord blood sample 
collected 
None 
Spontaneous abortion 
Secondary 
outcome 
Proportion 
At delivery 
Delivery at < 28 weeks gestational 
age 
All deliveries 
Withdrawn prior to 
delivery 
None 
Stillbirth 
Secondary 
outcome 
Proportion 
At delivery 
Infant born deceased 
Deliveries > 28 weeks 
gestational age 
Withdrawn prior to 
delivery or < 28 weeks 
gestational age 
None 


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Low birth weight 
Secondary 
outcome 
Proportion 
At delivery 
Birth weight < 2500 gm 
Deliveries > 28 weeks 
gestational age 
Withdrawn prior to 
delivery or < 28 weeks 
gestational age or no 
birth weight 
Inferred if no 
birth weight but 
weight available 
with 7 days of 
birth 
Preterm delivery 
Secondary 
outcome 
Proportion 
At delivery 
Gestational age < 37 weeks 
Deliveries > 28 weeks 
gestational age 
Withdrawn prior to 
delivery or < 28 weeks 
gestational age 
None 
Congenital malformation 
Secondary 
outcome 
Proportion 
At delivery 
Any congenital malformation 
documented on exam 
Deliveries > 28 weeks 
gestational age 
Withdrawn prior to 
delivery or < 28 weeks 
gestational age or 
infant unavailable for 
examination 
None 
Composite adverse birth 
outcome 
Secondary 
outcome 
Proportion 
At delivery 
Any of the following: spontaneous 
abortion, stillbirth, low birth weight, 
preterm delivery, or congenital 
malformation 
All deliveries 
Withdrawn prior to 
delivery 
None 
Symptomatic malaria 
during pregnancy 
Secondary 
outcome 
Incidence 
Time at risk 
during 
pregnancy 
Number of episodes of fever and 
positive blood smear by microscopy 
Duration of observation 
from day following 1st dose 
of study drugs to delivery or 
premature study withdrawal 
None 
None 
Parasitemia during 
pregnancy detected by 
LAMP 
Secondary 
outcome 
Proportion 
At the time of 
each routine 
visit 
Maternal blood samples with 
parasites detected by LAMP 
Routine visits at 20, 24, 28, 
32, 36, and 40 weeks of 
gestational age following 1st 
dose of study drugs to 
delivery or premature study 
withdrawal 
Missed routine visits or 
samples not collected 
None 
Maternal anemia  
Secondary 
outcome 
Proportion 
At the time of 
each routine 
visit and at 
delivery when 
phlebotomy 
done 
Hemoglobin level < 11 g/dL 
Routine visits at 20,28, 36 
weeks of gestational age 
following 1st dose of study 
drugs to delivery or 
premature study withdrawal 
Missed routine visits or 
sample not collected 
when scheduled for 
phlebotomy 
None 
 


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8.2 Primary Efficacy Analysis 
We will test the hypothesis that pregnant women who receive IPTp with either 3 
dose DP or monthly DP will have a lower risk of placental malaria defined by 
histopathology compared to those who receive 3 doses of SP. We will also compare 
the two different dosing strategies of DP. 
Primary Outcome: The primary outcome will be the prevalence of placental malaria 
based on placental histopathology and dichotomized into any evidence of placental 
infection (parasites or pigment) vs. no evidence of placental infection. We will also 
evaluate placental malaria defined by histopathology as a categorical variable 
(active-acute, active-chronic, and past infection) based on the criteria developed by 
Rogerson et al.26  
Analysis Method: A modified intention-to-treat approach to all will be used, 
including all study participants randomized to therapy with the primary outcome 
measured, regardless of whether the intervention was not given for any reason.  
Primary analysis. We will compare the prevalence of placental malaria defined by 
histopathology at birth between the study arms using the Chi-Square or Fisher’s 
exact test for all pair-wise comparisons and presented as the risk ratio (RR) or 
reduction of the RR (1-RR x 100%) if the RR is lower than 1. We will explore for any 
differences of potential confounders between the treatment arms and if necessary 
adjust our analysis using multivariate logistic regression. 
8.3  Secondary Efficacy Analyses 
Secondary Outcomes: Secondary outcomes will include maternal outcomes during 
pregnancy and birth outcomes as listed in Table 10. 
Analysis Method: A modified intention-to-treat approach will be used, including all 
study participants randomized to therapy with data on the secondary outcomes, 
regardless of whether the intervention was not given for any reason.  
Secondary analyses. We will compare proportions between the study arms using the 
Chi-Square or Fisher’s exact test for all pair-wise comparisons and presented as 
the risk ratio (RR) or reduction of the RR (1-RR x 100%) if the RR is lower than 1. For 
repeated measures in the same study participant (maternal parasitemia and anemia 
during pregnancy) we will use generalized estimating equations with a log-binomial 
family and robust standard errors. We will compare the incidence of symptomatic 


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malaria during pregnancy using Poisson or negative binomial regression models. 
The Poisson models will include the logarithm of the follow-up time as an offset. 
We will translate the fitted coefficients and their confidence bounds into percentage 
effects with the formula 100*[exp(coefficient)-1]. This approach is closely related to 
exponential survival models for analyzing events per follow-up time, but is better 
able to adjust for violated assumptions. Testing for overdispersion in the Poisson 
regression can detect violations of these assumptions, and variances can be 
adjusted accordingly to produce valid p-values and confidence intervals.  If 
significant deviations from required distributions in study data are detected, we will 
employ negative-binomial or zero-inflated negative-binomial models to account for 
the observed pattern of data. If necessary, multivariate analyses will be performed 
to adjust for potential confounders and effect modifiers. Comparisons of incidence 
measures will be expressed at the incidence rate ratio (IRR) or the protective 
efficacy (PE = 1-IRR x 100%).  
 
Skeleton tables for the presentation of primary and secondary efficacy outcomes are 
presented in Tables 11 and 12 below. 
 


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Table 11. Outcomes assessed at the time of delivery 
Outcome 
Treatment arm 
3 dose SPa 
3 dose DP 
Monthly DP 
Prevalence Prevalence 
RR (95% CI) 
p-
value 
Prevalence 
RR (95% CI) 
p-
value 
Malaria positivity, by test 
   Histopathology 
   Placental blood by microscopy 
   Placental blood by LAMP 
   Maternal blood by microscopy 
   Maternal blood by LAMP 
   Cord blood by microscopy 
   Cord blood by LAMP 
 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
 
 
 
 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
 
 
Birth outcomes 
   Spontaneous abortion 
   Stillbirthb 
   Low birth weightb 
   Preterm deliveryb 
   Congenital anomalyb 
   Composite adverse birth outcome 
 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
 
 
 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
 
 
a Reference group 
b Only includes those at least 28 weeks gestational age 
 
 
 
 


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Table 12. Longitudinal outcomes assessed during pregnancy 
Outcome 
Treatment arm 
3 dose SPa 
3 dose DP 
Monthly DP 
Incidence measures 
Eventsb 
Eventsb 
IRR (95% CI) 
p-value 
Eventsb 
IRR (95% CI) 
p-value 
Symptomatic malaria 
xx (x.xx) 
xx (x.xx) 
 
 
xx (x.xx) 
 
 
Prevalence measures 
Prevalence 
Prevalence 
RR (95% CI) 
p-value 
Prevalence 
RR (95% CI) 
p-value 
Detection of malaria parasites by LAMP 
   All routine visits 
   20 weeks gestational age 
   24 weeks gestational age 
   28 weeks gestational age 
   32 weeks gestational age 
   36 weeks gestational age 
   40 weeks gestational age 
 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
 
 
 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
 
 
Anemia defined as hemoglobin level < 11 g/dL 
   All routine visits and delivery 
   20 weeks gestational age 
   28 weeks gestational age 
   36 weeks gestational age 
   At the time of delivery 
 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
 
 
 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
n/N (%) 
 
 
a Reference group 
b Number of events (incidence per person year at risk) 
 
 
 


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9 Safety and Tolerability Analyses 
Safety and tolerability will be evaluated during the period following the 1st dose of 
study drug administration through the end of the observation period (6 weeks post-
partum) or premature study withdrawal.  
9.1 Adverse Events 
An adverse event will be defined as "any untoward medical occurrence in a patient 
or clinical investigation subject administered a pharmaceutical product that does 
not necessarily have a causal relationship with this treatment" (ICH Guidelines E2A).  
An adverse event can further be broadly defined as any untoward deviation from 
baseline health, which includes:  
• 
Worsening of conditions present at the onset of the study 
• 
Deterioration due to the primary disease 
• 
Intercurrent illness 
• 
Events related or possibly related to concomitant medications  
(International Centers for Tropical Disease Research Network Investigator Manual, 
Monitoring and Reporting Adverse Events, 2003).    
At each scheduled and unscheduled visit to the clinic, study clinicians will assess 
patients according to a standardized case record form.  A severity grading scale, 
based on toxicity grading scales developed by the NIH Divisions of AIDS (DAIDS) 
and the Division of Microbiology and Infectious Diseases (DMID) Pediatric Toxicity 
Tables, will be used to grade severity of all symptoms, physical exam findings, and 
laboratory results.  All participants, regardless of treatment arm, will be assessed 
using the same standardized case record form.  Adverse event monitoring will occur 
during the period when study drugs are given and up to 6 weeks following delivery. 
Data will be captured on the incidence of all adverse events, regardless of severity. 
For each adverse event identified as severity grade 3-4 or a serious adverse event 
(SAE), an additional adverse event report form will be completed.   
 
9.2  Serious Adverse Events 
A Serious Adverse Event (SAE) will be define as any adverse event that results in any 
of the following outcomes:  
• Death 


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• Life-threatening adverse experience 
• Inpatient hospitalization or prolongation of existing hospitalization  
• Persistent or significant disability/incapacity 
• Congenital malformation/birth defect 
• Any other experience that suggests a significant hazard, contraindication, 
side effect or precaution that may require medical or surgical intervention to 
prevent one of the outcomes listed above 
• Event that changes the risk/benefit ratio of the study 
9.3 
Analytical Methods 
We will test the hypothesis that pregnant women who receive IPTp with either 3 
dose DP or monthly DP will have a lower incidence of adverse events and better 
tolerability compared to those who receive 3 doses of SP. A modified intention-to-
treat approach to all will be used, including all study participants who received at 
least one dose of study drugs, regardless of whether subsequently the intervention 
was not given for any reason. We will compare the proportions of study participants 
with vomiting following each dose of study drugs using generalized estimating 
equations with a log-binomial family and robust standard errors to account for 
repeated measures in the same study participant. We will compare the incidence of 
various adverse events using Poisson or negative binomial regression models. The 
Poisson models will include the logarithm of the follow-up time as an offset. We will 
translate the fitted coefficients and their confidence bounds into percentage effects 
with the formula 100*[exp(coefficient)-1]. This approach is closely related to 
exponential survival models for analyzing events per follow-up time, but is better 
able to adjust for violated assumptions. Testing for overdispersion in the Poisson 
regression can detect violations of these assumptions, and variances can be 
adjusted accordingly to produce valid p-values and confidence interval.  If 
significant deviations from required distributions in study data are detected, we will 
employ negative-binomial or zero-inflated negative-binomial models to account for 
the observed pattern of data. Comparisons of incidence measures will be expressed 
at the incidence rate ratio (IRR) or the protective efficacy (PE = 1-IRR x 100%). A 
skeleton table for the presentation of safety and tolerability outcomes are presented 
in Tables 13 below. 
 
 


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Table 13. Measures of safety and tolerability  
Outcome 
Treatment arm 
3 dose SPa 
3 dose DP 
Monthly DP 
Prevalence measures 
Prevalence 
Prevalence 
RR (95% CI) 
p-value 
Prevalence 
RR (95% CI) 
p-value 
Vomiting following administration of study drugs 
   Observed after administration of 1st dose in clinic 
   Reported after administration of 2nd dose at home 
   Reported after administration of 3rd dose at home 
 
n/N (%) 
n/N (%) 
n/N (%) 
 
n/N (%) 
n/N (%) 
n/N (%) 
 
 
 
n/N (%) 
n/N (%) 
n/N (%) 
 
 
Incidence measures 
Eventsb 
Eventsb 
IRR (95% CI) 
p-value 
Eventsb 
IRR (95% CI) 
p-value 
Individual adverse events of any severityc 
   XXXX 
   XXXX 
   XXXX 
   XXXX 
   XXXX 
 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
 
 
 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
 
 
Individual grade 3-4 adverse eventsc 
   XXXX 
   XXXX 
   XXXX 
   XXXX 
   XXXX 
 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
 
 
 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
xx (x.xx) 
 
 
All grade 3-4 adverse events 
xx (x.xx) 
xx (x.xx) 
 
 
xx (x.xx) 
 
 
Grade 3-4 adverse events possibly related to stud drugs 
xx (x.xx) 
xx (x.xx) 
 
 
xx (x.xx) 
 
 
All serious adverse events 
xx (x.xx) 
xx (x.xx) 
 
 
xx (x.xx) 
 
 
a Reference group 
b Number of events (incidence per person year at risk) 
c Includes only those categories with at least five total events 
 


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