Participant characteristics at baseline
The study was conducted between October 2012 and March 2013, with a total of 1555 patients screened because they complained of symptoms suspected to be of malaria and had not taken any antimalarial medication within the previous days. The study profile is shown in figure 1. At enrolment, the three treatment groups had similar demographic and clinical characteristics. Overall, 225 patients fulfilled the criteria for enrolment but 9 where either residents inaccessible areas to the study team or were on transit in the Cameroon Development Corporation company. A total 216 were randomized consisting of 72 patients on AL, 72 patients on ASMQ and 72 on DHAP. However, one patient who was lost during follow up, was reported dead in the group of AL. Two other patients in the same group of AL, 4 in ASMQ and 2 in the DHAP group defaulted as a result of withdrawal or loss to follow-up and/or protocol violation. The demographic and clinical characteristics of the patients are shown in table 1.
Table 1
Demographic and clinical characteristics of patients per treatment group, at enrolments (Day 0) CAMEROON DC, 2012-2013.
Characteristics
|
AL (N=72)
|
ASMQ (N=72)
|
DHAP (N=72)
|
P (1)
|
P (2)
|
Mean Age (months) SD
|
32.97 (16.4)
|
37.90 (16.7)
|
42.8 (14.6)
|
0.15
|
0.15
|
Mean Weight (Kg) SD
|
12.9 (2.8)
|
13.7 (3.1)
|
14.4 (2.6)
|
0.47
|
0.19
|
Sex-ratio Male / Female
|
1.8 (44/28)
|
1 (36/36 )
|
0.8 (32/40)
|
|
|
Mean Temperature (oC). SD (Range)
|
38.1(1.1)
(36-41)
|
38.4 (1.0)
(36.03-40.08)
|
38.2 (1.0)
(36.7-40.6)
|
0.50
|
0.13
|
Mean temperature ≥ 38oC (oC). SD (Range)
|
39.1 (1.0)
(38-41)
|
38.97 (0.8)
(38-40.8)
|
38.8 (0.9)
(38-39.8)
|
0.51
|
0.45
|
Mean temperature < 38 SD (Range)
|
37.3(0.45)
(36-37.9)
|
37.4 (0.4)
(36.3-37.9)
|
37.4(0.4)
(36.7-37.9)
|
0.70
|
0.90
|
Proportion ≥ to 40oC SD (range)
|
40.3(0.3)
(40-41)
|
40.2(0.3)
(40-40.2)
|
40.17(0.2)
(40-40.6)
|
0.23
|
0.90
|
Geometrical mean Parasite density (p/ul)SD (*CI%95)
|
27,061
(-6074-22192)
|
25135
(-13627-1747)
|
19002
(-6074-22192)
|
0.09
|
0.65
|
Geometrical mean≥100 000 (P/ul ) SD(CI%95)
|
198849.8
(-1840.5-138198.6)
|
185500.3
(-30969.6-140628.8)
|
130670.7
(-1840.5-38198.6)
|
0.5
|
0.2
|
Mean Hematocrite (%)SD (P>0.05)
|
33.2 (6.0)
|
32.8(6.0)
|
33.8(5.9)
|
0.56
|
0.13
|
Anemia between 15% et 29%
|
23/72
(31.9 %)
|
28/72
(38.9%)
|
19/72
(28.4)
|
|
|
* Confidence interval at 95 % (binomial exact method). (1) Compare DHAP vs AL. (2) Compare DHAP vs ASMF.
The 28 days follow up was completed for 209 (96.7%) patients and 207 (95.8%) subjects were evaluable for primary and secondary endpoint on day 42 consisting of 69/72 (95.8%) children treated with AL, 68/72 (94.4 %) children treated with ASMQ and 70/72 (97.2%). Of the patients recruited, 38.9 % (28/72) on AL, 50.0 % (36/72) on ASMQ and 55.5 % (40/72) on DHAP were female. The mean age was 32.97±16.41 months for AL, 32.97±16.41 for ASMQ and 42.78±14.57 months for DHAP with no significant (P=0.15) difference in the mean age between the treatment groups. The mean weight was 12.89±2.76 kg, 90±16.68Kg, 14.38±2.64 Kg for AL, ASMQ and DHAP treatment groups respectively. There was no statistical significant difference between the treatment group relative to the mean weight (P>0.05).The geometrical mean parasitaemia was comparable between the treatment groups: 27,061 parasites/μL for AL and 19002 parasites/μL for DHAP (AL vs DHAP CI95% (-6074-22192) and 25135 parasites/μL for ASMQ, (AL vs ASMQ CI95% (-13627-1747). The geometrical mean parasitaemia was higher in AL group compared with ASMQ and DHAP groups, but the differences were not significant (AL vs DHAP - P =0.09; AL vs ASMQ - P = 0.65). At the time of admission, 45.83% (33/72) of patients on AL, 66.67% (48/72) of patients on ASMQ and 55.55% (40/72) on DHAP were febrile (T≥38oC). A total of 12 patients showed a parasite density greater or equal to 100000 P/uL including 5 patients with the mean parasite density of 198849.8 P/uL ( CI 95% -1840.5-138198.6) in the AL group,3 patients with the mean parasite density of 185500.3 P/uL (IC% -30969.6-140628.8) in the ASMQ group and 4 with the mean parasite density of 130670.7 P/uL ( CI 95%-1840.5-138198.6) in the DHAP group. No statistical difference (P>0.05) was observed between the groups (table 1). Likewise, 2 patients in the AL group and one in the ASMQ had a parasite density count of greater or equal to 200000 P/uL of blood; they were enrolled because they had no sign and symptoms of severe malaria at inclusion. Values of vital signs (pulse rate and RR) evaluated at enrolment and during the study course were within the expected ranges. At enrolment, the pulse rates ranging from 108 to 115 b/m and RR from 24 to 26. There was no tachycardia and dyspnoea. The haematocrit values were between 36 % to 38 %. At base line 91 of 216 enrolled patient had rectal body temperature below 38oC with high parasitaemia reflecting a possible self-medication with analgesic before coming to the hospital or clinic.
The clinical and parasitological response to DHAP, ASMQ and AL
The outcomes of clinical and parasitological response are showed in Table 2. None of the patients in the three different treatment arms showed early treatment failure during the first three days after initiation of treatment. The drugs were tolerated; there was no report of significant Adverse Drug Reaction (ADR). Table 2 shows crude and PCR corrected treatment rates of the test drugs. It was observed in the course of this trial, that parasitaemia consisting of young trophozoites appeared on day 28 and 42 in 18 of the 68 ASMQ group, 22 of the 69 AL group and 12 in the 70 DHAP group. The parasitaemia was associated with increase in body temperature in 6, 4 and 3 patients in AL, ASMQ and DHAP treatment group respectively. Blood sample were collected to perform the Polymerase Chain Reaction (PCR) technique in order to infer whether it was as a result of recrudescence or of new infection.
Table 2
Clinical and parasitological therapeutic outcome after PCR correction
|
AL
|
ASMQ
|
DHAP
|
P (1)
|
P (2)
|
Per-protocol day 28
|
|
|
|
|
|
|
|
|
|
Before PCR corrections (%)
|
After PCR corrections (%)
|
Before PCR corrections (%)
|
After PCR corrections (%)
|
Before PCR corrections (%)
|
After PCR corrections (%)
|
|
|
ETF
|
0 (0.0)
|
0 (0.0)
|
0 (0.0)
|
0 (0.0)
|
0 (0.0)
|
0 (0.0)
|
|
|
LCF
|
2 (2.9)
|
1 (1.4)
|
4 (5.7)
|
2 (2.9)
|
1 (1.4)
|
1 (1.4)
|
|
|
LPF
|
7 (10.1)
|
1 (1.4)
|
3 (4.3)
|
0 (0.0)
|
4 (5.7)
|
0 (0.0)
|
|
|
ACPR (N; IC95%)*
|
60 (86.9) (IC95%; 85.3-88.5%)
|
67 (97.1) (IC95% 96.8-97.4%)
|
63 (90.0) (IC95%; 88.8 - 91.2%)
|
68 (97.1) (IC95%; 96.8-97.4%)
|
65 (92.9) (IC95%; 92.1 - 93.7%)
|
69 (98.6) (IC95%; 98.4-98.8%)
|
0.002
|
0.002
|
Total
|
69
|
69
|
70
|
70
|
70
|
70
|
|
|
Per-protocol day 42
|
|
|
|
|
|
|
|
|
LCF
|
4 (6.0)
|
1 (1.4)
|
0 (0.0)
|
0 (0.0)
|
1 (1.4)
|
0 (0.0)
|
|
|
LPF
|
9 (13.0)
|
3 (4.5)
|
11 (16.8)
|
2 (2.9)
|
5 (7.2)
|
0 (0.0)
|
|
|
ACPR (N; IC95%)*
|
56 (81.1)(IC95% 78.8-83.4%)
|
65 (94.2) (IC95%; 93.5 - 94.9%)
|
57 (83.8) (IC95%; 81.8-85.8%)
|
66 (97.1)(IC95%; 96.8-97.4%)
|
63 (91.3) (IC95%; 90.3 - 92.3%)
|
70 (100)
|
0.01
|
0.003
|
Total
|
69
|
69
|
68
|
68
|
70
|
70
|
|
|
ACPR
D7 - D42
|
84% (IC 95%; 83.3- 84.7%)
|
95.6% (IC95%; 95.3-96.0%)
|
86.9% (IC95%; 86.1-87.7%)
|
97.1% (IC95%; 96.8-97.4%)
|
92.1% (IC95%; 91.9-92.3%)
|
99.3% (IC95%; 99.1-99.6%)
|
0.004
|
0.003
|
Per-protocol efficacy: proportion of adequate clinical and parasitological response, * Confidence interval at 95 % (binomial exact method); (1) Compare DHAP vs AL; (2) Compare DHAP vs ASMF
The overall crude adequate clinical and parasitological response (ACPR) were 84% (95%IC; 83.3- 84.7), 86.9% (95% IC; 86.1-87.7%), 92.1% (95% IC; 91.9-92.3%) in AL, ASMQ, and DHAP arms respectively (table 2). The PCR-corrected cure rates were generally higher than crude cure rates. The AL, ASMQ and DHAP PCR-corrected percentage cure rates were 95.6% (95% IC; 95.3-96.0%), 97.1% (IC95%; 96.8-97.4%) and 99.3% (IC95%; 99.1-99.6%) respectively with a significantly higher cure rate (p < 0.01) recorded in DHAP compared to ASMQ and AL arms (table 2). The success rates, PCR-corrected for AL on D1, D2, D3, D7, D14, D28 and D42 were 88.90%, 99.97, 99.99, 100, 100, 97.10 and 94.20%, respectively. The success rates for the ASMQ group were 99.60, 99.93, 99.96, 100, 100, 97.10% and 97.10 %, respectively. The success rates for the DHAP group were 99.86, 99.98, 100, 100, 100, 100, 98.60 and 100% respectively.
Profile of parasite clearance time (PCT) and temperature clearance time (TCT)
Parasite clearance was slower in the AL group as compared to the ASMQ and DHAP treatment groups. However, proportions of aparasitaemic patients for the 42-day duration were similar for the AL, ASMQ and DHAP arms on days 7, 14 and 35 (figure 2). Importantly, 99.61% of DHAP-treated patients and 99.86% of ASMQ treated patients were aparasitaemic on day 1 and 100% of patients in DHAP arm were aparasitaemic on day 2 (figure 2).
The median time to parasite clearance for each treatment group is presented in table 3. The mean PCT was shorter in DHAP group 28.7± 9.64 hours as compared to AL, 34.33±18.40 hours (CI 95% 3.25-8.08;P=0.0001) and ASMQ 39.7± 21.4 hours (CI 95% 7.34-14.66; P=0.0001).
Table 3
Parasite and temperature clearance
Treatment Outcome
|
AL (N total=72)
|
ASMF (N total=72)
|
DHAP (N total=72)
|
Fever clearance Time (hours)
|
12.57h ± 3.50
|
11.25h±5.11
|
11.02h±2.33
|
Parasite Clearance time (hours) SD (CI95%)
|
34.3±18.4 ( 3.2-8.1;P=0.0001)
|
39.7± 21.4(7.3-14.7)P=0.0001)
|
28.7± 9.64 ( 3.2-8.1;P=0.0001)
|
Positive blood film at D1 (N (%))
|
18 (25)
|
21 (29.2)
|
14 (19.4)
|
Positive blood film at D2 (N (%))
|
11 (15.3)
|
13 (18.0)
|
11 (15..3)
|
Positive blood film at D3 (N (%))
|
2 (2.8)
|
1 (1.4)
|
0
|
Withdrawal/loss to follow-up (D1-D7)
|
0
|
0
|
0
|
Withdrawal/loss to follow-up (D7-14)
|
2
|
0
|
0
|
LTF(D7-14)
|
0
|
0
|
0
|
Analysed at D14
|
70
|
72
|
72
|
aAdequate clinical and Parasitological Response (ACPR) Day 14 (N, %)
|
70 (100)
|
72 (100 )
|
72 (100 )
|
Analysed at D28
|
69
|
70
|
70
|
Withdrawal/loss to follow up
|
1
|
2
|
2
|
LTF (D15-28)
|
2
|
4
|
1
|
Late parasitological failure (LPF) (N/total, %)
|
7
|
3
|
4
|
aAdequate clinical and Parasitological Response (ACPR) Day 28 (N, %)
|
60 (86.9) (IC95%; 85.3-88.5%)
|
63 (90.0) (IC95%; 88.8 - 91.2%)
|
65 (92.9) (IC95%; 92.1 - 93.7%)
|
Analysed at D42
|
69
|
68
|
70
|
Withdrawal/loss to follow-up
|
0
|
0
|
0
|
Late treatment failure on day 42
|
4
|
0
|
1
|
Late parasitological failure (LPF) (N/total, %)
|
9
|
11
|
5
|
aAdequate clinical and Parasitological Response (ACPR) Day 42 (N/total, %)
|
56 (81.1)(IC95% 78.8-83.4%)
|
57 (83.8) (IC95%; 81.8-85.8%)
|
63 (91.3) (IC95%; 90.3 - 92.3%)
|
Note: aPCR uncorrected.
Time for Parasite Clearance (PCT) in 72 patients of AL group was determined and it was observed that Parasitaemia completely cleared in 53 patients within 24hrs, 7 cleared in 4hrs while 12 patients were cleared in 72 h. Time for parasite clearance was 34.33±18.40 hours for the AL group. In AL group, the geometric mean parasite density of the 72 enrolled patients on day 0 was 27061.1 which decreased to 2988.4 on D1, therefore giving a percentage success rate of 88.9%. The success rates (using the geometric mean parasite densities) on day 2 and 3 were 88.90%, and 99.97respectively. In ASMQ group, the geometric mean parasite density of the 72 enrolled patients on day 0 was 25135.1 which reduced to 107.0 on D1 therefore giving a percentage success rate of 99.6 % on D1. The success rates on other days, using the geometric mean parasite density, were as follows: D2 (99.93%), D3 (99.96%). Hence, parasitaemia was cleared in 45 children within 24 h (D1), 7 children within 48hrs (D2) and in the remaining 20 children within 72 hrs (D3). Therefore the time to parasite clearance was calculated to be 39.7± 21.4hrs for the ASMQ group. In the DHAP group, the geometric mean parasite density of the 72 enrolled patients on day 0 was 19,002.4 which reduced to 26.70 on D1 therefore giving a percentage success rate of 99.86 % on D1. The success rates on other days, using the geometric mean parasite density, were as follows: D2 (99.98%), D3 (100%). One child showed a reappearance of parasite on day 28 and one on day 42 associated with high temperature (39-40oC) and they were given antipyretic and quinine tablets for 7 days since no sign and symptoms of severe malaria demanded referral. Parasitaemia had cleared in 58 children within 24hrs (D1), 3 children within 48 hrs (D2), 11 within 72hrs. Most Important, no child had residual parasitaemia on day 3 in DHAP recipients, giving a success rate of 100% within 72hrs (D3). Therefore the time to parasite clearance was calculated to be 28.7± 9.64h. Fever clearance time was shorter in DHAP (11.02±0.51hrs) and ASMF (11.25±4.7hrs) group as compare to the AL group (12.57±4.0hrs)
Overall, 122 patients 33 in AL group, 48 ASMQ group and 41 in DHAP group showed a temperature of above or equal to 38oC with a mean temperature of 38.13±1.15oC, 38.44±1.02oC and 38.18±1.01oC for the AL, ASMQ and DHAP group respectively with no statistical significant difference (P>0.05) between the treatment group (Table 1).
A total number of 31 patients including 10 in AL group, 13 in ASMQ group and 8 in DHAP group harboured a rectal body temperature of 40 oC and above with the mean temperature 40.35±0.32oC of in the AL treatment group; 40.05± 0.08 oC in ASMQ and 40.17 in DHAP group. Overall, there was a significant decrease of these temperature from D0 and throughout the follow period (figure 3) without any significant difference (P> 0. 05) between the treatment groups.
Tolerability and safety
Tolerability defines the overall profile of adverse drug reactions, whereas safety refers to potentially hazardous adverse drug reactions. In this trial tolerability and safety evaluations were based on measurement of vital signs, physical examination, recording of all adverse events, and haematology analysis. Patients were equally asked not leading questions on their health situation since the last intake of antimalarial drugs and answers were classified as mild, moderate and serious or life threatened.
(1) EFFECT OF TRIAL ANTIMALARIAL DRUGS ON ANEMIA
AL, ASMQ and DHAP, improved on severe anaemia (HCT < 25%) in two to four weeks. The increase of HCT was in the order of 2 % to 4 % on D14 and 5% to 8% D28, and 8% to 10 % on D42 as compare to baseline (Table 3, Figure 4). The mean haematocrit improved moderately from day 0 to day 28 by 3 to 5 % in AL group, by 4 to 8% in ASMQ group and 2 to 5% in DHAP treatment group. The mean Haematocrit recovery after day 28 was statically significant in all the treatment groups (p < 0.001). The mean Haematocrit value was 33.2±6.0 % for AL 32.8±6.0 % for ASMQ and 33.8±5.9 % for DHAP group. Only a few patients had HCT of over 40.0% at CDC Estates clinics on D0. The percentage of cases with mild anaemia (15–29%) reduced from 5.7%;2.8 % and 6.9% on day 14 to 0 % on days 28 and 42, compared to baseline 31.9%, 38.9 % and 28.4 respectively in the AL, ASMQ DHAP treatment groups
(2) ADVERSE EVENTS
The leading adverse reactions recorded during follow up were cough followed by abdominal discomfort, loss of appetite, weakness and pruritus. Overall, 114 of 216 patients complained of cough 62.5% in the AL group, 47.2% in the ASMQ group and 58.6% in the DHAP group. A total of 34 patients reported that they experienced abdominal pains 18.0% in AL group, 23.6% in ASMQ group and 5.5% in DHAP recipients (Table 4). In addition 4 (5.5) reported to experience dizziness and 2 (2.8%) complained of hallucination only in the ASMQ treatment group. There were blisters in the mouth and a case of serious skin rash in a child by day 35 in the AL treatment although this was not thought to be caused by the drug intake. There were also boils all over the body of a child in ASMQ group at D34 but not due to anti malaria drug intake. All other adverse effects showed no relevant to treatment groups. Patients treated with ASMQ harboured higher frequency of side effect recorded in this study including abdominal pains, body weakness, headache, late vomiting significantly (P<0.05) more frequent than those treated with AL and DHAP (Table 4).
Table 4
The frequency of adverse events mild to moderate grades from day 1 to day 42 (related or not) after treatment initiation
Symptomes (N(%))
|
AL (N=72)
|
ASMF (N=.72)
|
DHAP (N=.72)
|
P
|
(1) (2)
|
Weakness/Fatigue
|
13 (18.0)
|
14 (19.4)
|
8 (11.1)
|
0.0080
|
0.0100
|
Loss of appetite
|
12 (16.7)
|
14 (19.4.0)
|
4 (5.5)
|
0.0130
|
0.0160
|
Pruritus
|
10 (13.9)
|
11 (15.3)
|
2 (2.8)
|
0.0130
|
0.0144
|
Headache
|
2 (2.8)
|
9(12.5)
|
0
|
0.0030
|
0.0140
|
Dizziness
|
0
|
4 (5.5)
|
0
|
|
0.0064
|
Abdominal pain
|
13 (18.0)
|
17 (23.6)
|
4 (5.5)
|
0.0150
|
0.0210
|
Vomiting
|
8 (11.1)
|
15 (20.8)
|
3 (4.2)
|
0.0100
|
0.0200
|
Diarrhea
|
5 (6.9)
|
4 (5.5)
|
5 (6.9)
|
|
0.0020
|
Cough
|
45 (62.5)
|
34 (47.2)
|
35 (48.6)
|
0.016
|
0.016
|
Skin rash
|
8 (11.1)
|
6 (8.3)
|
2 (2.8)
|
0.0060
|
0.0060
|
Hallucination
|
0
|
2 (2.8)
|
0
|
|
0.0032
|
Insomnia
|
3 (4.2)
|
11 (15.3)
|
1 (1.4)
|
0.0032
|
0.0160
|
P value; (1) Compare DHAP vs AL; (2) Compare DHAP vs ASMF
Gametocyte carriage
A total of 23 (10.6%) patients had gametocytemia at baseline; 6 (8.3%) were in the AL group, 9 (12.5%) were in the ASMQ group, and 8 (11.1 %) were in the DHAP group. Of the 193(89.4%)patients without gametocytemia at baseline, 5 (15.27%) in the AL group, 2 (2.7%) in the ASMQ group, and 3 (4.2%) in the DHAP group developed gametocytemia post treatment as from D1 and throughout the weeks post treatment (Figure 5). The proportion of cases with gametocytes increased during the first two days of treatment but overall reduced during the first week of follow-up, from 8.3% to 1.4% in the group AL, from 12.5 % to 0 % in the ASMQ group and from 11.1% to 1.4 % in the DHAP on day 3. As for DHAP and ASMQ group, all the patients (100%) cleared their gametocytaemia by day 3. In the AL, ASMQ and DHAP groups, there was no patient with gametocytes at day 7. At day 28, 2 (2.8%)patients in the AL, 1 (1.4 %) patient in the ASMQ arm and 2 (2.8 %) patients in the DHAP arm showed reappearance of gametocytes in their peripheral blood and all of them cleared gametocytaemia by day 35 and 42.