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SPK Study in Afghanistan

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ClinicalTrials.gov Identifier: NCT01707199
Recruitment Status : Unknown
Verified August 2013 by University of Oxford.
Recruitment status was:  Recruiting
First Posted : October 16, 2012
Last Update Posted : August 28, 2013
World Health Organization
Information provided by (Responsible Party):
University of Oxford

Brief Summary:

In Afghanistan, studies over the past 15 years have shown a high degree of Plasmodium falciparum resistance to chloroquine. In 2003 the high failure rate of chloroquine against falciparum malaria led the national malaria treatment programme to switch its recommended first line drug treatment for uncomplicated Plasmodium falciparum malaria to artemisinin-based combination therapy (ACT) in the form of Artesunate/Sulphadoxine-Pyrimethamine (AS+SP). Second line drug treatment is oral quinine (7 days).

For operational reasons, prior to recent studies (manuscript in preparation) there have been no molecular data on P. falciparum SP resistance markers from within the borders of Afghanistan. These studies have revealed early evidence of increasing SP resistance (resistance polymorphisms with double DHFR & triple DHPS mutations). The aim of this study is to conduct a focused, prospective study in Kunar for monitoring of the efficacy of the AS+SP combination in this province, along with molecular studies of isolates from recruited patients.

Condition or disease Intervention/treatment
Uncomplicated P. Falciparum Malaria Drug: Artesunate + Sulphadoxine-pyrimethamine

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Detailed Description:

Afghanistan is a poor country that remains largely dependent on foreign aid. Life expectancy remains in the order of 60 years, with 30% of mortality due to communicable diseases.

Malaria is a large health burden, and antimalarial drug resistance poses a considerable threat to malaria control. Resistance to chloroquine was evident in Afghanistan by the late-1990s, with failure rates more than 60% for the country as a whole and as high as 90% for Jalalabad (Nangarhar province). The combination of artesunate with amodiaquine also proved to have low efficacy. In 2004 failure rates for SP for the treatment of P. falciparum were 10-15% consistent with comparable clinical data in Afghan refugees residing in Pakistan. Given this efficacy, the Ministry of Public Health, in consultation with WHO and other international partners, has implemented AS+SP as first-line treatment of slide confirmed P. falciparum malaria in Afghanistan. Quinine (7 days po) is second line treatment. CQ+SP has been the recommended treatment for patients with a presumptive diagnosis of malaria since 2003. Both artesunate and sulphadoxine-pyrimethamine are safe and well tolerated drugs and there is no evidence of an interaction between them.

Artesunate (AS) has been reported to be associated with mild gastrointestinal disturbances, dizziness and tinnitus although none of these associations are convincing. The only potentially serious adverse effect that has been reported with the artemisinin class of drugs in clinical trials is type I hypersensitivity reactions (about 1:3,000 patients). Transient reticulocytopenia, neutropenia, and elevated liver enzyme values have been reported but none have been clinically significant. The weight of evidence suggests these drugs have no significant adverse cardiovascular effects. A variety of clinical, neurophysiological, and pathologic studies in humans have not shown evidence of neurological toxicity. Because these drugs have not been evaluated extensively in early pregnancy in humans, they should be avoided in patients in the first trimester of pregnancy with uncomplicated malaria until more information is available (WHO guidelines 2006).

Sulphadoxine-pyrimethamine (SP) is a fixed combination of a long-acting sulfonamide and the antifolate pyrimethamine. These are synergistic against sensitive parasites. Minor adverse effects are unusual and serious sulfonamide toxicity is very unusual with a single-dose treatment of malaria. The anti-folate properties of pyrimethamine rarely produce toxicity.

The combination of AS + SP has been evaluated extensively in adults and children with uncomplicated malaria and is sufficiently efficacious in areas where 28-day cure rates with sulphadoxine-pyrimethamine alone exceed 80%. This ACT is currently being used in parts of South America, the Middle East, and South Asia where SP susceptibility remains high. Studies conducted between 2004-2006 to evaluate the efficacy of artesunate plus sulphadoxine-pyrimethamine (AS+SP) against P. falciparum showed high efficacy in terms of adequate clinical and parasitological response (Afghanistan National Malaria Strategic Plan).

The genetic determinants of in vitro resistance to the two drug components of SP individually are shown to be point mutations at seven sites in the dihydrofolate reductase gene (dhfr) causing resistance to pyrimethamine and five sites in the dihydropteroate synthase (dhps) gene causing resistance to sulphadoxine. Different combinations of mutations within each gene confer differing degrees of insensitivity. Due to administrative instability, until recently few molecular data relating to P. falciparum SP resistance markers have been available from within the borders of Afghanistan. However the investigators have obtained recent (submitted) data showing that in addition to two resistance polymorphisms in DHFR (C59R and S108N) that are well known to be at high frequency in the region, a small number of parasites in the Kunar province have three mutations (A437G, K540E and A581G) in DHPS.

This study is a prospective, open label, single arm clinical trial to test the PCR confirmed efficacy and tolerability of AS+SP for the treatment of uncomplicated falciparum malaria in Afghanistan. Follow-up will be for 42 days, in order to sensitively detect recrudescence. Recrudescence will be distinguished from re-infection by molecular techniques based on well characterized microsatellite markers msp1, msp2 and glurp will be used. Baseline and any recurrent parasites will be tested for DHFR and DHPS polymorphisms by RFLP as well as sequencing if indicated. The proposed study will provide accurate data and accurate evidences on efficacy of the current malaria treatment regimen in Afghanistan.

Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 100 participants
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Treatment
Official Title: Efficacy and Safety of Artesunate+Sulphadoxine-Pyrimethamine for the Treatment of Uncomplicated Plasmodium Falciparum Malaria in Malaria Control Center Asadabad in Kunar Province of Afghanistan
Study Start Date : October 2012
Estimated Primary Completion Date : December 2013
Estimated Study Completion Date : December 2013

Resource links provided by the National Library of Medicine

MedlinePlus related topics: Malaria
U.S. FDA Resources

Arm Intervention/treatment
Experimental: Artesunate + Sulphadoxine-pyrimethamine

AS+SP will be administered according to the patient's age, based on a dose of 4mg artesunate/kg body weight once daily for 3 days plus SP at a dose of 25mg sulphadoxine/kg body weight single dose on the first day.

One co-blister pack of Artecospe will be used per patient and obtained via WHO from Guilin Pharmaceutical Co. Ltd., Shanghai China, with appropriate expiry date.

Drug: Artesunate + Sulphadoxine-pyrimethamine

AS+SP will be administered according to the patient's age, based on a dose of 4mg artesunate/kg body weight once daily for 3 days plus SP at a dose of 25mg sulphadoxine/kg body weight single dose on the first day.

One co-blister pack of Artecospe will be used per patient and obtained via WHO from Guilin Pharmaceutical Co. Ltd., Shanghai China, with appropriate expiry date.

Primary Outcome Measures :
  1. Adequate clinical and parasitological response (ACPR) [ Time Frame: 42 days ]
    WHO defined ACPR

Secondary Outcome Measures :
  1. Adverse events [ Time Frame: 42 days ]
    The incidence of any adverse event will be documented. All patients will be asked routinely about previous symptoms and about symptoms that have emerged since the previous follow-up visit.

  2. Molecular markers for antimalarial drug resistance [ Time Frame: Baseline ]
    To study polymorphisms in PfDHFR, PfDHPS and copy number of PfGCH1 which are considered as markers of resistance to Sulphadoxine-pyrimethamine (SP) components.

Information from the National Library of Medicine

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Ages Eligible for Study:   4 Months and older   (Child, Adult, Senior)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • Males: age over 4 months;
  • Females: age 4 months - 11 years inclusive, or 18 years or older;
  • Infection with P. falciparum detected by microscopy at a level of 500-150,000/µL asexual forms;
  • Presence of axillary or tympanic temperature ≥ 37.5 °C or oral or rectal temperature of ≥ 38 °C or history of fever during the past 24 h;
  • ability to swallow oral medication;
  • ability and willingness to comply with the study protocol for the duration of the study and to comply with the study visit schedule; and
  • Informed consent from the patient or from a parent or guardian in the case of children under 16 years of age.

Exclusion Criteria:

  • Presence of general danger signs in children aged under 5 years or signs of severe falciparum malaria according to the definitions of WHO (Appendix 1);
  • Infection with another Plasmodium species detected by microscopy not mixed with falciparum;
  • Females 18 years or older: a positive pregnancy test or absence of a negative pregnancy test when a pregnancy test is not possible for cultural reasons;
  • Breastfeeding
  • Presence of severe malnutrition (defined as a child whose growth standard is below -3 z-score, has symmetrical oedema involving at least the feet or has a mid-upper arm circumference < 110 mm);
  • Presence of febrile conditions due to diseases other than malaria (e.g. measles, acute lower respiratory tract infection, severe diarrhoea with dehydration) or other known underlying chronic or severe diseases (e.g. cardiac, renal and hepatic diseases, HIV/AIDS);
  • Regular medication, which may interfere with antimalarial pharmacokinetics;
  • History of hypersensitivity reactions or contraindications to any of the study medications;

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT01707199

Contact: Charlie Woodrow, MD charlie@tropmedres.ac

Narang, Asadabad, Watapoor district health centres Recruiting
Kunar, Afghanistan
Contact: Ghulam Rahim Awab, MD       awabgr@yahoo.com   
Principal Investigator: Ghulam Rahim Awab, MD         
Sponsors and Collaborators
University of Oxford
World Health Organization
Principal Investigator: Ghulam Rahim Awab, MD Research Dept. Ministry of Public Health (MoPH) Afghanistan

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
Responsible Party: University of Oxford
ClinicalTrials.gov Identifier: NCT01707199     History of Changes
Other Study ID Numbers: SPK
First Posted: October 16, 2012    Key Record Dates
Last Update Posted: August 28, 2013
Last Verified: August 2013

Keywords provided by University of Oxford:
P. falciparum
Artemisinin Combination Therapy (ACT)

Additional relevant MeSH terms:
Malaria, Falciparum
Protozoan Infections
Parasitic Diseases
Fanasil, pyrimethamine drug combination
Antiprotozoal Agents
Antiparasitic Agents
Anti-Infective Agents
Folic Acid Antagonists
Enzyme Inhibitors
Molecular Mechanisms of Pharmacological Action
Anti-Infective Agents, Urinary
Renal Agents