Antimalarial chemoprophylaxis for forest goers in southeast Asia: an open-label, individually randomised controlled trial

• Published in: The Lancet infectious diseases 2023-01, Vol.23 (1), p.81-90
• Main Authors: Tripura, Rupam, von Seidlein, Lorenz, Sovannaroth, Siv, Peto, Thomas J, Callery, James J, Sokha, Meas, Ean, Mom, Heng, Chhouen, Conradis-Jansen, Franca, Madmanee, Wanassanan, Peerawaranun, Pimnara, Waithira, Naomi, Khonputsa, Panarasri, Jongdeepaisal, Monnaphat, Pongsoipetch, Kulchada, Chotthanawathit, Paphapisa, Soviet, Ung, Pell, Christopher, Duanguppama, Jureeporn, Rekol, Huy, Tarning, Joel, Imwong, Mallika, Mukaka, Mavuto, White, Nicholas J, Dondorp, Arjen M, Maude, Richard J
• Format: Article
• Language: English
• Subjects: Adverse events; Allocations; Antimalarial activity; Antimalarial agents; Antimalarials - adverse effects; Artemether; Artemether - therapeutic use; Artemether, Lumefantrine Drug Combination - therapeutic use; Artemisinins - therapeutic use; Cambodia - epidemiology; Chemoprevention; Clinical trials; Disease prevention; Dosage; Drug Combinations; Drug dosages; Drug resistance; Effectiveness; Ethanolamines - therapeutic use; Fluorenes - therapeutic use; Forests; Humans; Infectious diseases; Insecticides; Intervention; Lumefantrine - therapeutic use; Malaria; Malaria - drug therapy; Malaria - prevention & control; Malaria, Falciparum - complications; Malaria, Falciparum - drug therapy; Malaria, Falciparum - prevention & control; Microscopy; Parasites; Plasmodium falciparum; Population studies; Randomization; Research ethics; Risk; Risk groups; Subclinical infection; Vector-borne diseases
• ISSN: 1473-3099; 1474-4457
• DOI: 10.1016/S1473-3099(22)00492-3

Malaria in the eastern Greater Mekong subregion has declined to historic lows. Countries in the Greater Mekong subregion are accelerating malaria elimination in the context of increasing antimalarial drug resistance. Infections are now increasingly concentrated in remote, forested foci. No intervention has yet shown satisfactory efficacy against forest-acquired malaria. The aim of this study was to assess the efficacy of malaria chemoprophylaxis among forest goers in Cambodia. We conducted an open-label, individually randomised controlled trial in Cambodia, which recruited participants aged 16–65 years staying overnight in forests. Participants were randomly allocated 1:1 to antimalarial chemoprophylaxis, a 3-day course of twice-daily artemether–lumefantrine followed by the same daily dosing once a week while travelling in the forest and for a further 4 weeks after leaving the forest (four tablets per dose; 20 mg of artemether and 120 mg of lumefantrine per tablet), or a multivitamin with no antimalarial activity. Allocations were done according to a computer-generated randomisation schedule, and randomisation was in permuted blocks of size ten and stratified by village. Investigators and participants were not masked to drug allocation, but laboratory investigations were done without knowledge of allocation. The primary outcome was a composite endpoint of either clinical malaria with any Plasmodium species within 1–28, 29–56, or 57–84 days, or subclinical infection detected by PCR on days 28, 56, or 84 using complete-case analysis of the intention-to-treat population. Adherence to study drug was assessed primarily by self-reporting during follow-up visits. Adverse events were assessed in the intention-to-treat population as a secondary endpoint from self-reporting at any time, plus a physical examination and symptom questionnaire at follow-up. This trial is registered at ClinicalTrials.gov (NCT04041973) and is complete. Between March 11 and Nov 20, 2020, 1480 individuals were enrolled, of whom 738 were randomly assigned to artemether–lumefantrine and 742 to the multivitamin. 713 participants in the artemether–lumefantrine group and 714 in the multivitamin group had a PCR result or confirmed clinical malaria by rapid diagnostic test during follow-up. During follow-up, 19 (3%, 95% CI 2–4) of 713 participants had parasitaemia or clinical malaria in the artemether–lumefantrine group and 123 (17%, 15–20) of 714 in the multivitamin group (absolute risk differenc