Gestational malaria in Kisangani : Efficacy of Mefloquine vs Sulfadoxine-Pyrimethamine in Intermittent Preventive Treatment : A Study Protocol for a randomized controlled clinical trial CURRENT STATUS: POSTED

Background : In Prompt and effective case management. Nevertheless, several cases of resistance to Sulfadoxine-Pyrimethamine, used in intermittent preventive treatment, and to Chloroquine are reported in sub-Saharan Africa and in the Democratic Republic of the Congo. The prevalence of malaria among pregnant women remains high in Africa in general, and in the Democratic Republic of Congo in particular. This issue leads us to conduct this study, which aims at proposing an alternative to SP for preventing malaria in pregnant women. Materials and methods : From June 1 to October 31, 2019, we enrolled pregnant women from five health facilities in Kisangani for randomized, single-blind controlled clinical trials to compare the efficacy of two intermittent preventive treatment regimens in Kisangani pregnant women, selected before 18 th weeks of amenorrhea. The first regimen consists of 4 doses of SulfadoxinePyrimethamine starting at the selection time and spaced at least 4 weeks during pregnancy. Each dose is made of 3 tablets of 525 mg Sulfadoxine-Pyrimethamine. The second regimen consists of 2 doses of Mefloquine during pregnancy. The first dose is taken at the selection time and the second dose between the 28 th and 32 nd weeks of amenorrhea. Each dose is made of 3 tablets of 250 mg Mefloquine. The efficacy criteria for these two regimens are placental malaria parasitemia, low birth weight of newborn and maternal anemia at delivery. The safety criterion was the occurrence of major side effects. Discussion : There are not enough randomized clinical trials assessing the efficacy of Mefloquine for the intermittent preventive treatment of malaria in African pregnant women, hence the recommendation for clinical trials. The present study is the only one that conducts such assessment in a hyper-endemic area with resistance to Sulfadoxine-Pyrimethamine and Chloroquine. The findings are therefore intended to promote the use of Mefloquine as the best alternative to SulfadoxinePyrimethamine in the intermittent preventive treatment of malaria. Clinical trial registration :

However, for some time, the development of SP resistance in the world and in sub-Saharan Africa has been noted. Basuki S. et al. [13] identified cases of SP resistance in Indonesia. Several cases of SP resistance have been reported in Africa [14][15][16][17][18][19][20]. Nosten and Mc Gready [21] considered in 2015 that SP is a failure in various parts of Africa and that evidence for the beneficial effects of IPTp-SP was low.
Ruh et al. [22] also made these findings in the DRC. In DRC, in the city of Kisangani, Labama et al. [6] found that SP does not reduce the gestational malaria risk. This situation raises serious concerns regarding the use of this combination for IPTp [23]. Garner and Brabin [24], after a review of randomized controlled trials of IPT in malaria-endemic areas concluded that additional studies are required to establish whether IPT has benefits on prompt and effective management of clinical malaria. Thus, several alternative options to SP are currently being evaluated and proposed, SP plus Azithromycin or Artesunate, Chloroquine, SP plus Chloroquine, Mefloquine (MQ), SP plus Piperaquine, etc. [25][26][27][28]. The difficulty of administering some of these regimens is that resistance has developed for chloroquine, Piperaquine has been used like mass prophylaxis and curative treatment in China since 1978, Artesunate is used for curative treatment in combination with Amodiaquine in the DRC and Azithromycin happens to be costly [16,25]. Clerk et al. [20] reported that the effect of IPT with Artesunate-Amodiaquine or SP-Artesunate-Amodiaquine on maternal anemia and low birth weight newborns were comparable to the effects of IPTp-SP.
According to a study by Gosling et al. comparing the efficacy of SP, Chlorproguanil-Dapsone and MQ, it was noted that MQ had a more superior protective effect than the others. According to the Belgian Pharmaceutical Information Center [31], MQ is recommended for prophylaxis in areas with chloroquine resistance. Chloroquine resistance continues to persist in most countries affected by malaria [32], and the DRC is not spared. Indeed, after removing chloroquine from the DRC's malaria treatment policy 11 years ago, still, Juliao et al. [32] and Mvumbi et al. [33] have identified markers of chloroquine resistance.
In view of the above, we thought it was appropriate to compare MQ with SP for IPTp in Kisangani, an endemic malaria area with SP and Chloroquine high-level resistance.
In order to conduct this study, we considered the following research question: Will the prevalence of placental malaria, maternal anemia at delivery and low birth weight of newborns in Kisangani pregnant women who received MQ as IPTp be lower than in those who received SP.

Hypothesis
Since MQ has a long half-life, with a low rate of resistance in sub-Saharan Africa [26], the following result can be expected : MQ is more effective than SP in IPTp in Kisangani.

Objectives
This study aims to :

1.
To compare the efficacy of MQ versus SP in IPTp in Kisangani ;

2.
To compare the safety of MQ versus SP in Kisangani pregnant women.

Type, framework and period of study
The study is a single blind, randomized controlled clinical trial that compares two regimens of IPTp - River, in the municipality which bears the same name ; This geographical situation would not allow prompt and effective management of potential major side effects.

Study population
The study population is composed of pregnant women who live in Kisangani and the surrounding area for more than 2 weeks prior the selection and who attend antenatal care (ANC) in the selected health facilities during the period of June 1 to November 30, 2019.

Sample size
To calculate the sample size, we referred to González et al.

Inclusion criteria
Are included in the study pregnant women who: -begin their ANC in the selected health facilities, with gestational age under 18 weeks of amenorrhea ; -have not received IPTp yet ; -give their informed consent.

Exclusion criteria
Are excluded pregnant women with : -positive HIV serology ; -history of known sickle cell disease ; -history of neurological (e.g. epilepsy), psychiatric, renal or hepatic affections ; -history of allergy to sulfonamides or MQ ; -received an antimalarial or other medicine within 15 days of selection ; -have consumed medicinal herbal tea within 15 days prior to the selection.

Criteria for withdrawal from the study
Participants with at least one of the following criteria will be subsequently excluded: 1. withdrawal of consent ; 2. study medication's major side effect ; 3. failure to comply with the TPIp regimen ; 4. delivery out of the follow-up health facility.
All withdrawal details are recorded in the data collection sheet and the register of discarded cases.
Upon withdrawal, the ANCs will continue normally. Any details related to withdrawal or loss of followup will be recorded in the side effects sheets and notified to the study follow-up committee.

Recruitment and randomization of participants
Respondents are selected during the ANCs, since June 1 st and ongoing till October 31st, 2019.
When registering pregnant women, the investigators obtain their informed consent. During selection, each participant is given a unique code. This code comprises the initial of the health facility where the participant is selected, followed by a serial number. Each participant's code is recorded in a case register. Then the participants are randomized. Thus, the first selected receives SP while the second receives MQ.

Study medication
As study medication, we Before starting the trial, all the study medications were controlled by the quality assurance laboratory agitation, nightmares, uncontrollable vomiting, debilitating headache, coca-cola urine, jaundice and dyspnea. Redness of the skin, itching, rash (e.g. hives) are considered major side effects of SP.
The University's Ethics Committee will conduct a mid-term assessment of side-effect data and decide if trials can continue.
Participants will be followed until delivery, they will receive usual antenatal care, and information on clinical malaria, use of antimalarials, and potential side effects of study medications will be given to them. Participants who will develop clinical malaria during pregnancy will be treated according to the malaria treatment policy recommended in the DRC.

Schedule of enrolment, interventions, and assessments
To write the study protocol, we completed the SPIRIT checklist and we constructed a SPIRIT figure.

Data collection
Data collection is prospective.
Before starting the data collection, the investigators (midwives or nurses and medical After taking medication, respondents return to the hospital on day 1, day 2, day 3 and day 7. In hospital, participants are interviewed about the occurrence of side effects. Respondents with side effects also return to the hospital on day 14. All reported side effects are recorded in the data collection sheet and the register of side effects. Compliance with the dosage and methods of taking is also checked for participants who used Mefloquine.
During pregnancy, the respondents regularly follow the ANCs and all the events occurred are recorded in the data collection sheet.
At the time of delivery, upon admission of participants to the delivery room, nurses or midwives fully examine them and medical biotechnologists perform hemoglobin test. Then, maternal anemia at delivery will be considered to have a hemoglobin level of less than 11gr / dl. The results of examinations will be recorded in the data collection sheet or in the laboratory register.
Immediately after delivery, nurses or midwives will thoroughly examine newborns while weighing them using the SH-8008 electronic baby scale. The weight details will be confirmed after doublechecking (re-weigh) before being recorded in the data collection sheet and in the delivery register. A weight lower than 2500 gr at birth will be considered as low birth weight. The medical biotechnologists of the study will proceed to the preparation of the placental stamp BS. The slides will be read at the Provincial Public Health Laboratory (PPHL) in Kisangani and the results will be recorded in the laboratory register.
To ensure the reliability, the data collected by one investigator will first be counter-checked by another and then by the study supervisor. And for the quality control of the laboratory results, 10% of the randomly positive selected and 10% of the randomly negative selected PPHL samples will be transferred to the Institut National de Recherches Biomédicales in Kinshasa for the same analysis. The concordance rate of the BS results will be determined by calculating the Kappa number.
The data collected will be encoded by an independent data manager.

Blood sample -Training
Medical biotechnologists were briefed on hemoglobin assay techniques using the Hemocue Hb Hemoglobinometer according to the manufacturer's instructions, taking placental stamps, spreading blood smear on the slide and transporting slides according to the guidelines of the National Malaria Control Program (NMCP). They were also briefed on Determine HIV rapid test.
-Collecting blood from placental stamps Immediately after delivery, medical biotechnologists will clean the placenta ; they will superficially cut its maternal surface and will apply a blade on the incised placental surface.

Laboratory investigations -Placental parasitaemia
The study supervisor (1) will transport, according to the standards, the smear spread on slides to the Provincial Public Health Laboratory. The medical biotechnologists will stain the smear for 10 minutes to 10% diluted giemsa solution. After preparation, they will read the microscope 100X objective. The diagnosis of malaria will be considered when trophozoites or other plasmodium development stages are present in the sample.

Efficicacy criteria
Efficacy criteria will be primarily placental parasitaemia and secondly the low birth weight of the newborn (weight < 2500 g) and maternal anemia at delivery (hemoglobin <11g / dl).
The safety criterion is the occurrence or not of major side effects.

Data analysis
Only data of participants who will give birth in their follow-up health facilities with good compliance with IPTp regimen will be analyzed.
The collected data will be first encoded and then analyzed using the software EPI Info version 7.2.2.6 and Xlstat 2019.
To describe the sample, the frequency and percentage, the means and their standard deviations, the median and areas of variation will be calculated; To compare the proportions, Pearson's chi squared Fisher's or exact test at the significance level of < 0.05.
To compare the mean birth weights and mean mothers' hemoglobin levels, the ANOVA will be used.
The difference will be significant if the P-value is < 0.05 at the 95% threshold.
To measure the strength of the association, the relative risk and its 95% confidence interval will be determined.
To eliminate the confounding factors, a multivariate analysis with conditional logistic regression will be performed.

Discussion
In conducting a clinical trial, we intend to prove that MQ is the best alternative to replace SP in IPTp in