<clinical_study>
  <!-- This xml conforms to an XML Schema at:
    https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
  <required_header>
    <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
    <link_text>Link to the current ClinicalTrials.gov record.</link_text>
    <url>https://clinicaltrials.gov/ct2/show/NCT04419766</url>
  </required_header>
  <id_info>
    <org_study_id>REPELMALARIA</org_study_id>
    <nct_id>NCT04419766</nct_id>
  </id_info>
  <brief_title>Evaluation of IR3535 as a Spatial Repellent for Malaria Control.</brief_title>
  <acronym>REPELMALARIA</acronym>
  <official_title>Evaluation of IR3535 as a Spatial Repellent for Malaria Control. (Avaliação da eficácia do Repelente Ambiental 3-(N-acetyl-n-butyl) Aminopropionic Acid Ethyl Ester (IR3535) Como Ferramenta Para o Controlo da malária).</official_title>
  <sponsors>
    <lead_sponsor>
      <agency>Universidade Nova de Lisboa</agency>
      <agency_class>Other</agency_class>
    </lead_sponsor>
    <collaborator>
      <agency>Centro de Investigação Operacional da Beira, Mozambique</agency>
      <agency_class>Other</agency_class>
    </collaborator>
    <collaborator>
      <agency>Fundação Belmiro de Azevedo, Portugal</agency>
      <agency_class>Other</agency_class>
    </collaborator>
  </sponsors>
  <source>Universidade Nova de Lisboa</source>
  <oversight_info>
    <has_dmc>No</has_dmc>
    <is_fda_regulated_drug>No</is_fda_regulated_drug>
    <is_fda_regulated_device>No</is_fda_regulated_device>
    <is_us_export>No</is_us_export>
  </oversight_info>
  <brief_summary>
    <textblock>
      Mozambique contributes with 5% of global malaria cases, and despite control efforts the&#xD;
      Sofala province continues to experience a high burden of malaria. The resistance to&#xD;
      insecticides and changes in vector habits can compromise the use of common vector control&#xD;
      tools. The use of spatial repellents is thus an interesting alternative, as it does not exert&#xD;
      selective pressure on resistance genes or eliminate other insects with impact on&#xD;
      biodiversity. IR3535 is a non-toxic repellent and if used at community level can extend&#xD;
      protection to outdoor biting.&#xD;
&#xD;
      Hypothesis: Using the IR3535 repellent for indoor and outdoor spraying will reduce the&#xD;
      prevalence of malaria and reduce vector density and infection.&#xD;
&#xD;
      An experimental Before-After-Control-Intervention will be carried out with two groups: a)&#xD;
      Intervention (Tambai Q2 and Q6): with intra and extra-household spraying with IR3535 and b)&#xD;
      Control (Tambai Q3 and Q4): without spraying. Tambai is acommunity of Bebedo, Nhamatanda,&#xD;
      Sofala, Mozambique. The mosquito distribution, diversity, density and sporozoite rate will be&#xD;
      monitored indoors and outdoors in both communities for 2 years. The prevalence of malaria&#xD;
      will be determined in under five years old children at the beginning, the end of the 1st year&#xD;
      and at the end of the study. Additionally, cross-sectional studies with a mixed approach&#xD;
      assessing the community knowledge, attitudes and practices (KAP) will be carried out to&#xD;
      detect gaps that persist at the community level. Heads of households and health professionals&#xD;
      will be interviewed at the beginning of the study, the end of 1st year and at the end of the&#xD;
      study. The data will be analyzed using SPSS and R software packages. For matching situations&#xD;
      (before and after), the McNemar test will be used to ascertain statistical significance.&#xD;
      Generalized Linear Models (GLM) will be used to jointly analyze several explanatory&#xD;
      variables. Linear Mixed Models (LMM) and Generalized Estimation Equation (GEE) models will be&#xD;
      used to compare longitudinal data. The prevalence of malaria and entomological indices&#xD;
      relevant for transmission are expected to decrease with the intervention while community&#xD;
      knowledge on malaria and its control are expected to increase.&#xD;
    </textblock>
  </brief_summary>
  <detailed_description>
    <textblock>
      Study area and population&#xD;
&#xD;
      The study will be carried out in the communities of Tambai, locality of Bebedo, district of&#xD;
      Nhamatanda, Sofala province, Mozambique. The community is covered by the Mutondo Health&#xD;
      Center.&#xD;
&#xD;
      Study design&#xD;
&#xD;
      A prospective experimental Before-After-Control-Intervention test will be carried out with&#xD;
      two groups: a) Intervention (community of Tambai quarters 2 (Q2) and 6 (Q6)): with indoors&#xD;
      and outdoors spraying with IR3535 (3-(N-acetyl-N-butyl) aminopropionic acid ethyl ester) and&#xD;
      b) Control (community of Tambai quarters 3 (Q3) and 4 (Q4)): without spraying. This&#xD;
      longitudinal study will last for 2 years. Mosquitoes will be captured indoors and outdoors to&#xD;
      determine entomological indicators relevant to transmission. Mosquito breeding sites in the&#xD;
      communities will be mapped using &quot;Participatory Mapping&quot;. The prevalence of malaria in&#xD;
      children under five will be determined in the control and in the intervention communities, at&#xD;
      the beginning, middle and end of study. A KAP survey on malaria to Tambai householders (Q2,&#xD;
      Q3, Q4; Q6) and health professionals and key community actors.&#xD;
&#xD;
      Population interventions and procedures&#xD;
&#xD;
      Initially, the Beira Operational Research Center (CIOB) and the Institute of Hygiene and&#xD;
      Tropical Medicine of the Nova University Lisbon (IHMT-NOVA), in collaboration with the&#xD;
      Mutondo health center, Provincial Directorate of Health of Sofala and the Directorate&#xD;
      district health district of Nhamatanda and the Gorongosa National Park, will present the&#xD;
      intervention in a participatory manner and explain the approach directed to the community in&#xD;
      order to guarantee its appropriation by the community from the beginning of the study. Before&#xD;
      conducting the study, communities will be informed, and the local structures will be briefed&#xD;
      in order for the community to understand the objectives of the study.&#xD;
&#xD;
      Surveys on community knowledge, attitudes and practices (KAP).&#xD;
&#xD;
      Three KAP surveys will be carried out, at the start (baseline), at the end of the first year&#xD;
      and at the end of the second year. The study population will comprise all households from Q2,&#xD;
      Q3, Q4 and Q6 of Tambai. Household data will be collected using a questionnaire designed for&#xD;
      tablets, with Android system, through the ODK application. Interviews to the head of&#xD;
      household will take place at their homes or at a location proposed by them. The KAP about&#xD;
      malaria and the different aspects related to the acceptability of the use of repellents will&#xD;
      be complemented by focus groups and interviews to local key actors. The collection of the&#xD;
      data will be carried out based on two techniques: a) semi-structured interviews (Flick, 2006)&#xD;
      to health professionals at the Vinho Health Center (a Maternal and Child Health Nurse and a&#xD;
      preventive medicine professional), two activists and local leaders; b) focus groups (Flick,&#xD;
      2006) with matrons and practitioners of traditional medicine from the two communities under&#xD;
      study. All participants in this component of the study will be selected intentionally&#xD;
      (Hancock, Ockleford and Windridge, 2009). Participation will be made by signing the informed&#xD;
      consent.&#xD;
&#xD;
      Malaria prevalence&#xD;
&#xD;
      The malaria prevalence will be determined in children under 5 years of age in both locations&#xD;
      Tambai Q2 and Q6 (intervention) and Tambai Q3 and Q4 (control) at the beginning of the study,&#xD;
      at the beginning of the second year and at the end of the second year (end of the project).&#xD;
      Consent will be requested to the legal guardian. Capillary blood will be collected using a&#xD;
      sterile pipette and individual lancet from all children in the study aged 6-59 months of age&#xD;
      for: a) Rapid Diagnostic Test (RDT) for Plasmodium falciparum; b) blood drop smears and c)&#xD;
      filter paper for nucleic acids extraction (FTA Cards ThermoFisher). The samples will be&#xD;
      coded, and information about the coordinates of the associated household will be recorded.&#xD;
      The initial sample processing will be carried out at the laboratory of the Health Center of&#xD;
      Ponta Gea - Beira, and the molecular analyzes at IHMT-NOVA - Lisbon, as defined in the MTA.&#xD;
      Identification of Plasmodium will be done by PCR and genotyping by whole genome sequencing&#xD;
      (Ocholla et al. 2014). Children who are diagnosed with malaria by RDT during the study will&#xD;
      be referred to the Mutondo Health Center for treatment.&#xD;
&#xD;
      House Spraying with repellent&#xD;
&#xD;
      The spraying with IR3535 will start at the beginning of the study and will be performed&#xD;
      monthly during the first 3 months, bimonthly during the next 6 months and then quarterly&#xD;
      thereafter. The spraying will be carried out inside and outside the houses during the&#xD;
      morning. Spraying will only be carried out in intervention quarters, while there will be no&#xD;
      spraying in control quarters.&#xD;
&#xD;
      Entomology&#xD;
&#xD;
      For entomological study households will be randomly selected. In case of failure of satellite&#xD;
      imagery and geographical analysis (Wampler et al. 2013, Escamilla et al. 2014), a classic&#xD;
      approach based on household inventories in each community will be used manually. Using local&#xD;
      mapping and numbering, two lists of numbered households will be created. After a random&#xD;
      number generator (e.g., Random.org) will be used to randomly select the households from each&#xD;
      list (Wampler et al. 2013). Mosquitoes will be collected twice a month inside and outside the&#xD;
      houses at the selected households for 2 years in the intervention and the control quarters.&#xD;
      Inside each household, resting mosquitoes that fed the previous night will be collected using&#xD;
      a Prokopak aspirator. Outside the residences, CDC- light traps will be placed in the early&#xD;
      evening and collected at the following morning. The traps will be placed outdoors, in places&#xD;
      equidistant from the buildings (houses) that compose the household. The physiological state&#xD;
      of the mosquitoes will be determined, and the females classified as unfed, partially fed,&#xD;
      fed, semi-gravid or gravid (Detinova, 1962). Mosquito females will be identified&#xD;
      morphologically and confirmed by the PCR (Abilio et al. 2015). The density of mosquitoes&#xD;
      caught in the control and intervention communities will be estimated using Williams'&#xD;
      geometric mean. GEE and LMM will be explored to compare the two groups along time. The rate&#xD;
      of infection will be determined by detecting and quantifying sporozoites in mosquitoes. The&#xD;
      mosquitoes' heads and thorax will be removed and prepared to isolate DNA (Abilio et al.&#xD;
      2011). Sporozoites will be detected and quantified by quantitative PCR (qPCR) as described in&#xD;
      (Marie et al. 2013).&#xD;
&#xD;
      Breeding sites mapping&#xD;
&#xD;
      The mosquito breeding sites will be mapped using the &quot;participatory mapping&quot; approach (Dickin&#xD;
      et al. 2014). The method will be used to identify the spatial perceptions of malaria risk in&#xD;
      the community, based on the spatial identification of existing breeding sites. Interview&#xD;
      participants and focus groups will be invited to draw a map of the areas they associate with&#xD;
      breeding in communities and describe the important features of the map. These maps can then&#xD;
      be digitized on a geographic information system (GIS) to create a georeferenced map of&#xD;
      community knowledge.&#xD;
&#xD;
      Malaria cases in the community&#xD;
&#xD;
      During the study, cases of malaria in Tambai will be monitored through patients who visit the&#xD;
      Mutondo Health Center. Patients of all ages from the communities with suspected malaria will&#xD;
      be recruited. A questionnaire will be administered. A RDT, a thick drop and blood smear will&#xD;
      be performed, and a drop of blood collected for subsequent molecular diagnosis by PCR (as&#xD;
      described above). Enrolment and consent will be asked after the patients have received all&#xD;
      the care they need in the health unit. Written informed consent will be obtained from the&#xD;
      participants or their legal representatives for patients under 18 years old.&#xD;
&#xD;
      Study variables&#xD;
&#xD;
      The study variables can be divided into variables from the survey (questionnaire) and&#xD;
      semi-structured interviews. Variables can be grouped into the following categories:&#xD;
&#xD;
        -  Socio-demographic variables: Age; Sex; Marital status; Profession; Education level;&#xD;
           Degree of kinship to the householder; Household size (nº of houses, area); Number of&#xD;
           rooms in the house; nº of people per division; Type of construction.&#xD;
&#xD;
        -  Ownership and use of mosquito nets: Ownership of mosquito nets; Use of mosquito nets;&#xD;
           Mobility and activities of household members.&#xD;
&#xD;
        -  Malaria knowledge, attitudes and practices: Malaria knowledge level; Malaria attitudes;&#xD;
           Mosquito control and bites; Ownership, conservation and use of mosquito nets; Knowledge&#xD;
           about repellents; After analyzing the questionnaire data, the variables are deduced;&#xD;
           Level of knowledge, attitude and practices about malaria (score categorized as: bad (&gt;&#xD;
           50%), medium (50% -74%) and high (≥75%)).&#xD;
&#xD;
      Variables of the study will also be those resulting from the collection of biological&#xD;
      material (peripheral blood and mosquitoes):&#xD;
&#xD;
        -  Malaria cases in children under five (RDT, optical microscopy and PCR);&#xD;
&#xD;
        -  Malaria cases attending the Vinho Health Center;&#xD;
&#xD;
        -  Mosquito density inside and outside homes; Percentage of infected mosquitoes;&#xD;
           Distribution of mosquito species inside and outside homes;&#xD;
&#xD;
        -  Breeding site (participatory mapping)&#xD;
&#xD;
      Sample size for KAP&#xD;
&#xD;
      Approximately 126 householders will be surveyed (according to the National Institute of&#xD;
      Statistics of Moçambique (INE) report, 2017) corresponding to the total number of households&#xD;
      in the communities under study. The chosen locations are comprised of only 126 households,&#xD;
      therefore everyone contacted will be included to participate in order to guarantee a maximum&#xD;
      power for the study.&#xD;
&#xD;
      Prevalence of malaria in the intervention and control community&#xD;
&#xD;
      According to the INE report, 2017, the total number of the population in the two study areas&#xD;
      is 630 inhabitants. To calculate the number of children under 5 years of age, the total&#xD;
      population was multiplied by 17.5%, so the sample will consist of about 110 children. The&#xD;
      attempt to include all children aims to try to obtain a sample size that guarantees us the&#xD;
      highest possible power.&#xD;
&#xD;
      Sample size and statistical power for entomological indicators&#xD;
&#xD;
      Different scenarios and programs were explored to calculate the sample size. Initially, a&#xD;
      scenario corresponding to a sample size of 40 households (20 in each community) followed for&#xD;
      48 moments was considered as being feasible. The statistical power was calculated using the G&#xD;
      * Power v.3.2 program (Faul et al. 2007, 2009), with a correlation between measurements made&#xD;
      at different times 0.2; with effect of size f = 0.25; a type I error probability equal to&#xD;
      0.05. A statistical power of 91.1% was estimated. Conversely, for the same parameter values,&#xD;
      fixing the power at 95%, in the perspective of using ANOVA for repeated measurements, 24&#xD;
      aggregates were obtained in each community. However, if the assumptions of ANOVA for repeated&#xD;
      measurements fail, LMM or GEE models will be used, so it is important to have an idea of the&#xD;
      statistical power for these models. Using the Longpower package&#xD;
      (https://www.rdocumentation.org/packages/longpower/versions/1.0-19/topics/longpower-package)&#xD;
      of the R software, the power associated with the GEE and LMM models, for the previous&#xD;
      scenario (24 households), would not be satisfactory. Considering the possibility of missing&#xD;
      values (up to 20% in the last visit), a more realistic autoregressive correlation matrix for&#xD;
      measurements in each visit, several scenarios were explored in Longpower to guarantee at&#xD;
      least powers of 80%, for the various types of models. Thus, also keeping the budget and human&#xD;
      resources available, we have 40 households in each location (80 households in total), with a&#xD;
      single monthly visit to each household.&#xD;
&#xD;
      Data analysis&#xD;
&#xD;
      The data will be analyzed using SPSS version 25.0 and R package. Initially, descriptive&#xD;
      statistics and exploratory analysis will be performed. Parametric and non-parametric tests&#xD;
      will be used, either for independent samples (for example, comparing the two communities at a&#xD;
      given time), or for paired samples (comparing each community at the beginning, middle and end&#xD;
      of the study). The Chi-square or Fisher's test will be used to test the association between&#xD;
      qualitative variables or to compare proportions between independent groups. For paired&#xD;
      qualitative data, the McNemar test and Cochran's Q test (for binary data) will be applied.&#xD;
      For quantitative variables, the comparison of two independent groups will be performed using&#xD;
      the T-Student test, in case of compliance with the assumptions of normality and homogeneity&#xD;
      of variances, or alternatively the Mann-Whitney-Wilcoxon test. ANOVA or Kruskal-Wallis test&#xD;
      will be used for more than two groups. Signs, Wilcoxon and Friedman tests will be used to&#xD;
      compare two or more paired samples. If the sample sizes allow, generalized linear models can&#xD;
      be used to jointly analyze several explanatory variables for some events of interest (for&#xD;
      example, use of repellent). For the longitudinal comparison between the intervention and&#xD;
      control groups, as for entomological indices, Mixed Linear Models and Generalized Estimation&#xD;
      Equation Model or a Nonparametric Analysis of Longitudinal Data in Factorial Experiments&#xD;
      (nparLD) approach will be applied, using several packages of the R. software. The&#xD;
      (CONsolidated Standards of Reporting Trials) CONSORT2010 standards, an intention-to-treat&#xD;
      (IT) analysis will be used, and there may be a need to proceed previously with a treatment&#xD;
      for missing values. Differences and associations will be considered statistically significant&#xD;
      when p &lt;0.05. In order to estimate the prevalence or other proportions of interest, 95%&#xD;
      confidence intervals will be obtained by Wald method or alternatively the Wilson or Jeffreys&#xD;
      methods.&#xD;
&#xD;
      The sporozoite rate (% of mosquitoes with sporozoites in the salivary glands) will be&#xD;
      compared between the control and intervention community and the percentage of reduction&#xD;
      determined. The temporal and spatial distribution of the different mosquito species and their&#xD;
      densities will be explored using ArcGIS 10 with Spatial Analysis and Statistical Tools) and&#xD;
      compared between the 2 locations (control x intervention).&#xD;
&#xD;
      In the qualitative component, after recording the interviews, their full transcription will&#xD;
      be carried out. Data processing and analysis will be manual, using the content analysis&#xD;
      technique.&#xD;
&#xD;
      Data management - Questionnaires&#xD;
&#xD;
      The Open Data Kit (ODK) will be used for data collection and its quality control. The&#xD;
      supervisor will review the interviews on a daily basis, before sending them to the secure&#xD;
      server located at the CIOB for storing. The server will be accessible only to the data&#xD;
      manager and the team of researchers. The transferred data does not include the names of&#xD;
      participants, only their codes. The data manager will clean and validate the data daily and&#xD;
      provide feedback to the field staff. All physical documents such as informed consents, data&#xD;
      collection forms and electronic devices (GPS and tablets) will be stored and only accessible&#xD;
      to the CIOB Principal Investigator. The paper documents will be kept for 5 years after the&#xD;
      study is completed and then destroyed.&#xD;
&#xD;
      Data Management - Prevalence and entomology&#xD;
&#xD;
      The data will be collected through a paper data collection form. Every day, each data&#xD;
      collector must enter all data in a database available on a computer and send it to the data&#xD;
      manager, after a careful revision by responsible of the team. After the data manager receives&#xD;
      the data, she/he can create a password protected folder to archive the data on a daily basis.&#xD;
&#xD;
      Quality control and monitoring - Training of staff&#xD;
&#xD;
      Study personnel will be properly trained by the study's research team. The field team will be&#xD;
      subdivided into three (3) groups:&#xD;
&#xD;
        -  Collecting blood samples and administering the survey to householders and conducting&#xD;
           interviews with health professionals. The team will consist of 3 health technicians with&#xD;
           experience in research.&#xD;
&#xD;
        -  Mosquitoes collection and breeding sites mapping. The team will consist of 2 entomology&#xD;
           technicians.&#xD;
&#xD;
        -  Sprayers that will be spraying houses with repellent. The team will consist of 4 people.&#xD;
&#xD;
      The training will be focused on ethical aspects, selection of households, children aged 6-59&#xD;
      months, conducting interviews, blood sampling procedures, good clinical and laboratory&#xD;
      practices, mosquito collection, manipulation, identification, processing and storing,&#xD;
      breeding mapping and spraying techniques and safety.&#xD;
&#xD;
      Quality control and monitoring - Supervision of field work&#xD;
&#xD;
      The teams will have a field coordinator who will be responsible for monitoring the field work&#xD;
      and ensuring data quality. During the study, a team of supervisors will periodically visit&#xD;
      the field teams to ensure proper practices. The quality control (QC) of the data will start&#xD;
      in the pilot phase, with the identification and replacement of unclear terms and study&#xD;
      questions. The field coordinator will also continuously assess compliance with standard&#xD;
      operating procedures (SOP) and ethical principles.&#xD;
&#xD;
      Data quality and quality assurance&#xD;
&#xD;
      The baseline study will include a pilot that will be conducted during training in a community&#xD;
      that is not part of the study. The pilot will have the following objectives (i) to evaluate&#xD;
      and validate the contents of the data collection instruments, (ii) to ensure compliance with&#xD;
      the ethical aspects related to the study. The pilot will help to identify the difficulties&#xD;
      and omissions during the questionnaire. The pilot will analyze the fieldwork strategy, team&#xD;
      composition, staff responsibilities and time required to complete all activities.&#xD;
&#xD;
      The field coordinator will do the quality control of the inquiries made before they are sent&#xD;
      to the CIOB and in addition to the quality control done by the field coordinator, the main&#xD;
      investigators will also do the supervision to guarantee the quality of the data.&#xD;
&#xD;
      Storage of Data&#xD;
&#xD;
      The data will be stored at the CIOB. Study documents and data collection instruments,&#xD;
      including informed consent in physical format, that will be placed in file folders and kept&#xD;
      locked, with restricted access to researchers. All documents related to the research will be&#xD;
      filed according to the rules of the legislation and will be kept at CIOB for a period of 5&#xD;
      years.&#xD;
&#xD;
      Storage of Biological samples&#xD;
&#xD;
      Part of the blood and mosquito sample will be processed in the laboratory of IHMT-NOVA,&#xD;
      Portugal, for that purpose a material transfer agreement (MTA) has been signed between CIOB&#xD;
      and IHMT-NOVA, Portugal. Part of the blood sample will be kept in the CIOB for future&#xD;
      analysis in the scope of PhDs and/or Master programs, explicitly referring to the present&#xD;
      project. The samples will be kept in a freezer at CIOB at -80 ° C, for 5 years after the end&#xD;
      of the study. Biological samples that will not be used for further analysis will be destroyed&#xD;
      at the end of the analysis within the study.&#xD;
&#xD;
      Ethical review&#xD;
&#xD;
      This study protocol has been submitted for ethical approval to the Institutional Committee on&#xD;
      Bioethics for Health of the National Institute of Health (CIBS-INS) and to the National&#xD;
      Committee on Bioethics for Health (CNBS) - Clearance Ref. 63/CNBS/20 and Addendum Ref.&#xD;
      11/CNBS/21. The study will be carried out in accordance with the rules of &quot;good clinical&#xD;
      practice (GCP)&quot;, &quot;good clinical and laboratory practice (GCLP)&quot; and all applicable regulatory&#xD;
      requirements, such as the Declaration of Helsinki 2013, at its 64th General Assembly.&#xD;
&#xD;
      Informed consent&#xD;
&#xD;
      The consent from the heads of households, parents or legal representatives of the children&#xD;
      and health professionals selected for the study will be obtained by trained interviewers.&#xD;
      They will be fluent in the local languages (Sena and Ndau) or accompanied by an interpreter&#xD;
      during the request for informed consent and interviews. All participants will be informed&#xD;
      about the objectives of the study, procedures to be performed during the study and potential&#xD;
      associated inconveniences, as well as the possibility of leaving the study even after signing&#xD;
      the informed consent without any implications for them.&#xD;
&#xD;
      The participant will have the right to privacy during the moment of the interview, it will be&#xD;
      held in a place where the participant feels comfortable, explaining that all the information&#xD;
      provided by him will be confidential, authorization for audio recording of the interview will&#xD;
      be specifically requested. Permission from the householder will be ask, for the collection of&#xD;
      a finger prick blood sample from the children in the household aged 6-59 months. If the&#xD;
      child's legal representative is different from the head of household, informed consent will&#xD;
      also be administered to her/him. If the child's parent/legal guardian is under 18, informed&#xD;
      consent will be administered to authorize the child to participate.&#xD;
&#xD;
      Authorizations for periodic visits throughout the study will be requested while explaining&#xD;
      the importance of the procedures for:&#xD;
&#xD;
        -  spraying of their homes (indoor and outdoor) with mosquito repellent (monthly). Only in&#xD;
           Tambai Q2 and Q6;&#xD;
&#xD;
        -  collection of mosquitoes from the interior and exterior of their houses (twice a month)&#xD;
           in two localities.&#xD;
&#xD;
      The inquirers and each participant will sign 2 copies of the informed consent form, in which&#xD;
      one copy will remain with the participant and the other will remain with the inquirer for&#xD;
      later filing in the study folder. The contact of the principal investigator of the study is&#xD;
      an integral part of the document. The informed consent form will serve as proof that the&#xD;
      participant accepted to be part of the study by their own free will. In order to guarantee&#xD;
      confidentiality, each participant will be assigned an identification code for the&#xD;
      questionnaire. Each questionnaire made will have a code corresponding to consent.&#xD;
&#xD;
      Participation risks&#xD;
&#xD;
      The risks of participation are minimal, but in the event that a participant feels&#xD;
      uncomfortable during the interview with any question, they can ask to pass the question on.&#xD;
      During the blood sample collection, there may be same risk of bleeding or inflammation from&#xD;
      the collection site. To minimize that adequate material will be provided to collect capillary&#xD;
      blood (sterilized lancets and disposable gloves) through health professionals trained for&#xD;
      that specific activity. Regarding the spraying of houses with repellent, participants will be&#xD;
      informed about potential rare adverse effects. If someone in the residence, where the&#xD;
      spraying was carried out, has any reaction, which is suspected to be associated with the&#xD;
      product, the spraying will be interrupted in that residence and the individual referred to&#xD;
      the health service.&#xD;
&#xD;
      Benefits of participation&#xD;
&#xD;
      Frequently, after carrying out interviews, an increase of knowledge in the communities is&#xD;
      noted. This is due to the fact that often those who apply the questionnaire can alert to best&#xD;
      practices, which can contribute to improvements in the health of the community. One of the&#xD;
      benefits will be knowing whether or not you have malaria, plus children diagnosed with&#xD;
      malaria will be able to benefit from treatment.&#xD;
    </textblock>
  </detailed_description>
  <overall_status>Active, not recruiting</overall_status>
  <start_date type="Actual">April 28, 2021</start_date>
  <completion_date type="Anticipated">December 30, 2023</completion_date>
  <primary_completion_date type="Anticipated">June 30, 2023</primary_completion_date>
  <phase>N/A</phase>
  <study_type>Interventional</study_type>
  <has_expanded_access>No</has_expanded_access>
  <study_design_info>
    <allocation>Randomized</allocation>
    <intervention_model>Parallel Assignment</intervention_model>
    <intervention_model_description>A prospective experimental Before-After-Control-Intervention test will be carried out with two groups: a) Intervention (community of Tambai): with indoors and outdoors spraying with IR3535 (3-(N-acetyl-N-butyl) aminopropionic acid ethyl ester) and b) Control (community of Micheu 1): without spraying.</intervention_model_description>
    <primary_purpose>Prevention</primary_purpose>
    <masking>None (Open Label)</masking>
  </study_design_info>
  <primary_outcome>
    <measure>Changes from baseline in malaria prevalence in children under 5 years at 1st year</measure>
    <time_frame>Month 1, Month 12</time_frame>
    <description>Malaria cases in children aged 6 to 59 months</description>
  </primary_outcome>
  <primary_outcome>
    <measure>Changes from baseline in malaria prevalence in children under 5 years at 2nd year</measure>
    <time_frame>Month 1, Month 24</time_frame>
    <description>Malaria cases in children aged 6 to 59 months</description>
  </primary_outcome>
  <primary_outcome>
    <measure>Monthly changes of indoor Anopheles mosquito density from baseline to month 24</measure>
    <time_frame>1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 19, 20, 21, 22, 23, 24 Months</time_frame>
    <description>Mosquitoes resting inside the houses will be collected by aspiration</description>
  </primary_outcome>
  <primary_outcome>
    <measure>Monthly changes of outdoor Anopheles mosquito density from baseline to month 24</measure>
    <time_frame>1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 19, 20, 21, 22, 23, 24 Months</time_frame>
    <description>Outside mosquitoes collected overnight using CDC-light traps</description>
  </primary_outcome>
  <primary_outcome>
    <measure>Monthly changes of Anopheles mosquito sporozoite rate</measure>
    <time_frame>1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 19, 20, 21, 22, 23, 24 Months</time_frame>
    <description>Number of infected mosquitoes determined by PCR</description>
  </primary_outcome>
  <primary_outcome>
    <measure>Change from Baseline in Knowledge, attitudes and practices - KAP score at 1st year</measure>
    <time_frame>Month 1, Month 12</time_frame>
    <description>An evaluation scale will be defined with the attribution of points for correct answers, and whoever has &lt;50% will be considered a participant with a bad level of knowledge, attitudes and practices and whoever has 50% -74% and ≥75% will be considered medium and high level of knowledge, attitudes or practices respectively</description>
  </primary_outcome>
  <primary_outcome>
    <measure>Change from Baseline in Knowledge, attitudes and practices - KAP score at 2nd</measure>
    <time_frame>Month 1, Month 24</time_frame>
    <description>An evaluation scale will be defined with the attribution of points for correct answers, and whoever has &lt;50% will be considered a participant with a bad level of knowledge, attitudes and practices and whoever has 50% -74% and ≥75% will be considered medium and high level of knowledge, attitudes or practices respectively</description>
  </primary_outcome>
  <secondary_outcome>
    <measure>Mosquito breeding sites mapping</measure>
    <time_frame>continuous for the 2 years</time_frame>
    <description>The mosquito breeding sites will be mapped using the &quot;participatory mapping&quot; approach (Dickin et al. 2014). Community generated maps will be digitized on a GIS to create a georeferenced map of community knowledge.</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>Prevalence of symptomatic malaria cases in the area covered by the Vinho health center</measure>
    <time_frame>continuous for the 2 years</time_frame>
    <description>Malaria cases in the locality of Bebedo will be monitored through patients of all ages with suspected malaria, attending the Vinho Health Center. Blood will be collected, for blood-smears and PCR.</description>
  </secondary_outcome>
  <number_of_arms>2</number_of_arms>
  <enrollment type="Actual">166</enrollment>
  <condition>Malaria</condition>
  <arm_group>
    <arm_group_label>intervention</arm_group_label>
    <arm_group_type>Experimental</arm_group_type>
    <description>Community of Tambai: Indoors and outdoors spraying with IR3535 (3-(N-acetyl-N-butyl) aminopropionic acid ethyl ester)</description>
  </arm_group>
  <arm_group>
    <arm_group_label>Control</arm_group_label>
    <arm_group_type>No Intervention</arm_group_type>
    <description>Community of Micheu 1: Without spraying.</description>
  </arm_group>
  <intervention>
    <intervention_type>Other</intervention_type>
    <intervention_name>IR3535 (3-(N-acetyl-N-butyl) aminopropionic acid ethyl ester) house spraying</intervention_name>
    <description>The spraying will be performed monthly during the first 3 months, bimonthly during the next 6 months and then quarterly thereafter. The spraying will be carried out inside and outside the houses during the morning.</description>
    <arm_group_label>intervention</arm_group_label>
  </intervention>
  <eligibility>
    <criteria>
      <textblock>
        Inclusion Criteria for children:&#xD;
&#xD;
          -  aged 6 to 59 months&#xD;
&#xD;
          -  resident in the communities under study&#xD;
&#xD;
          -  to give informed consent for participation by parents or legal representatives&#xD;
&#xD;
          -  availability on the day of the study.&#xD;
&#xD;
        Exclusion Criteria for children:&#xD;
&#xD;
          -  aged below 6 months and older than 59 months&#xD;
&#xD;
          -  being infected with or having undergone malaria treatment for up to one month&#xD;
&#xD;
          -  lack of consent from parents or legal representatives.&#xD;
&#xD;
        Inclusion Criteria for heads of household and health professionals:&#xD;
&#xD;
          -  Be the head of household or someone appointed by her/him and a resident at the place&#xD;
             of study&#xD;
&#xD;
          -  Be a health professional in the area of Vinho health center&#xD;
&#xD;
          -  Be available on the day of the interview&#xD;
&#xD;
          -  Have consented to participate in the study&#xD;
&#xD;
        Exclusion Criteria for heads of household and health professionals:&#xD;
&#xD;
        • Having a mental illness or having a change in behavior&#xD;
      </textblock>
    </criteria>
    <gender>All</gender>
    <minimum_age>6 Months</minimum_age>
    <maximum_age>N/A</maximum_age>
    <healthy_volunteers>Accepts Healthy Volunteers</healthy_volunteers>
  </eligibility>
  <overall_official>
    <last_name>Henrique Silveira, PhD</last_name>
    <role>Principal Investigator</role>
    <affiliation>Universidade Nova de Lisboa, Portugal</affiliation>
  </overall_official>
  <overall_official>
    <last_name>Joaquim Lequechane, Lic</last_name>
    <role>Principal Investigator</role>
    <affiliation>Centro de Investigação Operacional da Beira, INS, MISAU, Mozambique</affiliation>
  </overall_official>
  <location>
    <facility>
      <name>Centro de Investigação Operacional da Beira, Instituto Nacional de Saúde, Ministério de Saúde, Mozambique</name>
      <address>
        <city>Beira</city>
        <state>Sofala</state>
        <zip>Bairro Ponta Gêa</zip>
        <country>Mozambique</country>
      </address>
    </facility>
  </location>
  <location_countries>
    <country>Mozambique</country>
  </location_countries>
  <reference>
    <citation>Abilio AP, Kleinschmidt I, Rehman AM, Cuamba N, Ramdeen V, Mthembu DS, Coetzer S, Maharaj R, Wilding CS, Steven A, Coleman M, Hemingway J, Coleman M. The emergence of insecticide resistance in central Mozambique and potential threat to the successful indoor residual spraying malaria control programme. Malar J. 2011 May 2;10:110. doi: 10.1186/1475-2875-10-110.</citation>
    <PMID>21535872</PMID>
  </reference>
  <reference>
    <citation>Abilio AP, Marrune P, de Deus N, Mbofana F, Muianga P, Kampango A. Bio-efficacy of new long-lasting insecticide-treated bed nets against Anopheles funestus and Anopheles gambiae from central and northern Mozambique. Malar J. 2015 Sep 17;14:352. doi: 10.1186/s12936-015-0885-y.</citation>
    <PMID>26377825</PMID>
  </reference>
  <reference>
    <citation>DETINOVA TS. Age-grouping methods in Diptera of medical importance with special reference to some vectors of malaria. Monogr Ser World Health Organ. 1962;47:13-191. No abstract available.</citation>
    <PMID>13885800</PMID>
  </reference>
  <reference>
    <citation>Dickin SK, Schuster-Wallaceab CJ, Elliottc SJ. Mosquitoes &amp; vulnerable spaces: Mapping local knowledge of sites for dengue control in Seremban and Putrajaya Malaysia. Applied Geography. 2014. 46: 71-79. DOI: 10.1016/j.apgeog.2013.11.003</citation>
  </reference>
  <reference>
    <citation>Escamilla V, Emch M, Dandalo L, Miller WC, Martinson F, Hoffman I. Sampling at community level by using satellite imagery and geographical analysis. Bull World Health Organ. 2014 Sep 1;92(9):690-4. doi: 10.2471/BLT.14.140756. Epub 2014 Jun 17.</citation>
    <PMID>25378761</PMID>
  </reference>
  <reference>
    <citation>Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods. 2009 Nov;41(4):1149-60. doi: 10.3758/BRM.41.4.1149.</citation>
    <PMID>19897823</PMID>
  </reference>
  <reference>
    <citation>Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007 May;39(2):175-91. doi: 10.3758/bf03193146.</citation>
    <PMID>17695343</PMID>
  </reference>
  <reference>
    <citation>Marie A, Boissiere A, Tsapi MT, Poinsignon A, Awono-Ambene PH, Morlais I, Remoue F, Cornelie S. Evaluation of a real-time quantitative PCR to measure the wild Plasmodium falciparum infectivity rate in salivary glands of Anopheles gambiae. Malar J. 2013 Jul 2;12:224. doi: 10.1186/1475-2875-12-224.</citation>
    <PMID>23819831</PMID>
  </reference>
  <reference>
    <citation>Morrison AC, Astete H, Chapilliquen F, Ramirez-Prada C, Diaz G, Getis A, Gray K, Scott TW. Evaluation of a sampling methodology for rapid assessment of Aedes aegypti infestation levels in Iquitos, Peru. J Med Entomol. 2004 May;41(3):502-10. doi: 10.1603/0022-2585-41.3.502.</citation>
    <PMID>15185957</PMID>
  </reference>
  <reference>
    <citation>Ocholla H, Preston MD, Mipando M, Jensen AT, Campino S, MacInnis B, Alcock D, Terlouw A, Zongo I, Oudraogo JB, Djimde AA, Assefa S, Doumbo OK, Borrmann S, Nzila A, Marsh K, Fairhurst RM, Nosten F, Anderson TJ, Kwiatkowski DP, Craig A, Clark TG, Montgomery J. Whole-genome scans provide evidence of adaptive evolution in Malawian Plasmodium falciparum isolates. J Infect Dis. 2014 Dec 15;210(12):1991-2000. doi: 10.1093/infdis/jiu349. Epub 2014 Jun 19.</citation>
    <PMID>24948693</PMID>
  </reference>
  <reference>
    <citation>Wampler PJ, Rediske RR, Molla AR. Using ArcMap, Google Earth, and Global Positioning Systems to select and locate random households in rural Haiti. Int J Health Geogr. 2013 Jan 18;12:3. doi: 10.1186/1476-072X-12-3.</citation>
    <PMID>23331997</PMID>
  </reference>
  <verification_date>November 2022</verification_date>
  <study_first_submitted>May 12, 2020</study_first_submitted>
  <study_first_submitted_qc>June 3, 2020</study_first_submitted_qc>
  <study_first_posted type="Actual">June 5, 2020</study_first_posted>
  <last_update_submitted>November 7, 2022</last_update_submitted>
  <last_update_submitted_qc>November 7, 2022</last_update_submitted_qc>
  <last_update_posted type="Actual">November 9, 2022</last_update_posted>
  <responsible_party>
    <responsible_party_type>Principal Investigator</responsible_party_type>
    <investigator_affiliation>Universidade Nova de Lisboa</investigator_affiliation>
    <investigator_full_name>Henrique Silveira</investigator_full_name>
    <investigator_title>Professor</investigator_title>
  </responsible_party>
  <keyword>Malaria control</keyword>
  <keyword>Spatial Repellent</keyword>
  <keyword>vector control</keyword>
  <keyword>KAP</keyword>
  <condition_browse>
    <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
    <mesh_term>Malaria</mesh_term>
  </condition_browse>
  <patient_data>
    <sharing_ipd>Yes</sharing_ipd>
    <ipd_description>The data collected from this study will be disseminated to different audiences at different times.&#xD;
A final report will be presented to the Sofala Provincial Health Directorate, Nhamatanda District Health Directorate and the Ministry of Health trough the National Institute of Health.&#xD;
In order to return the results to the communities, a meeting with the local structures of the communities will be held. The session will open to the general population using a language that will be accessible to the participants in this study, with emphasis on implementing and maintaining practices that protect them from malaria over time.&#xD;
The results will also be disseminated to the scientific community through publications and presentations at national and international scientific conferences.&#xD;
Data and specimens will be available for related studies to MSc and PhD theses at CIOB, Mozambique.</ipd_description>
    <ipd_info_type>Study Protocol</ipd_info_type>
    <ipd_info_type>Statistical Analysis Plan (SAP)</ipd_info_type>
    <ipd_info_type>Informed Consent Form (ICF)</ipd_info_type>
    <ipd_info_type>Clinical Study Report (CSR)</ipd_info_type>
    <ipd_time_frame>The information will be realised at the end of the project</ipd_time_frame>
    <ipd_access_criteria>public</ipd_access_criteria>
  </patient_data>
  <!-- Results have not yet been posted for this study                                          -->
</clinical_study>


download date: ClinicalTrials.gov processed this data on September 20, 2023
link text: Link to the current ClinicalTrials.gov record.
url: https://clinicaltrials.gov/ct2/show/NCT04419766
org study id: REPELMALARIA
nct id: NCT04419766
lead sponsor: 
collaborator: 
collaborator: 
has dmc: No
is fda regulated drug: No
is fda regulated device: No
is us export: No
Mozambique contributes with 5% of global malaria cases, and despite control efforts the
      Sofala province continues to experience a high burden of malaria. The resistance to
      insecticides and changes in vector habits can compromise the use of common vector control
      tools. The use of spatial repellents is thus an interesting alternative, as it does not exert
      selective pressure on resistance genes or eliminate other insects with impact on
      biodiversity. IR3535 is a non-toxic repellent and if used at community level can extend
      protection to outdoor biting.

      Hypothesis: Using the IR3535 repellent for indoor and outdoor spraying will reduce the
      prevalence of malaria and reduce vector density and infection.

      An experimental Before-After-Control-Intervention will be carried out with two groups: a)
      Intervention (Tambai Q2 and Q6): with intra and extra-household spraying with IR3535 and b)
      Control (Tambai Q3 and Q4): without spraying. Tambai is acommunity of Bebedo, Nhamatanda,
      Sofala, Mozambique. The mosquito distribution, diversity, density and sporozoite rate will be
      monitored indoors and outdoors in both communities for 2 years. The prevalence of malaria
      will be determined in under five years old children at the beginning, the end of the 1st year
      and at the end of the study. Additionally, cross-sectional studies with a mixed approach
      assessing the community knowledge, attitudes and practices (KAP) will be carried out to
      detect gaps that persist at the community level. Heads of households and health professionals
      will be interviewed at the beginning of the study, the end of 1st year and at the end of the
      study. The data will be analyzed using SPSS and R software packages. For matching situations
      (before and after), the McNemar test will be used to ascertain statistical significance.
      Generalized Linear Models (GLM) will be used to jointly analyze several explanatory
      variables. Linear Mixed Models (LMM) and Generalized Estimation Equation (GEE) models will be
      used to compare longitudinal data. The prevalence of malaria and entomological indices
      relevant for transmission are expected to decrease with the intervention while community
      knowledge on malaria and its control are expected to increase.
Study area and population

      The study will be carried out in the communities of Tambai, locality of Bebedo, district of
      Nhamatanda, Sofala province, Mozambique. The community is covered by the Mutondo Health
      Center.

      Study design

      A prospective experimental Before-After-Control-Intervention test will be carried out with
      two groups: a) Intervention (community of Tambai quarters 2 (Q2) and 6 (Q6)): with indoors
      and outdoors spraying with IR3535 (3-(N-acetyl-N-butyl) aminopropionic acid ethyl ester) and
      b) Control (community of Tambai quarters 3 (Q3) and 4 (Q4)): without spraying. This
      longitudinal study will last for 2 years. Mosquitoes will be captured indoors and outdoors to
      determine entomological indicators relevant to transmission. Mosquito breeding sites in the
      communities will be mapped using "Participatory Mapping". The prevalence of malaria in
      children under five will be determined in the control and in the intervention communities, at
      the beginning, middle and end of study. A KAP survey on malaria to Tambai householders (Q2,
      Q3, Q4; Q6) and health professionals and key community actors.

      Population interventions and procedures

      Initially, the Beira Operational Research Center (CIOB) and the Institute of Hygiene and
      Tropical Medicine of the Nova University Lisbon (IHMT-NOVA), in collaboration with the
      Mutondo health center, Provincial Directorate of Health of Sofala and the Directorate
      district health district of Nhamatanda and the Gorongosa National Park, will present the
      intervention in a participatory manner and explain the approach directed to the community in
      order to guarantee its appropriation by the community from the beginning of the study. Before
      conducting the study, communities will be informed, and the local structures will be briefed
      in order for the community to understand the objectives of the study.

      Surveys on community knowledge, attitudes and practices (KAP).

      Three KAP surveys will be carried out, at the start (baseline), at the end of the first year
      and at the end of the second year. The study population will comprise all households from Q2,
      Q3, Q4 and Q6 of Tambai. Household data will be collected using a questionnaire designed for
      tablets, with Android system, through the ODK application. Interviews to the head of
      household will take place at their homes or at a location proposed by them. The KAP about
      malaria and the different aspects related to the acceptability of the use of repellents will
      be complemented by focus groups and interviews to local key actors. The collection of the
      data will be carried out based on two techniques: a) semi-structured interviews (Flick, 2006)
      to health professionals at the Vinho Health Center (a Maternal and Child Health Nurse and a
      preventive medicine professional), two activists and local leaders; b) focus groups (Flick,
      2006) with matrons and practitioners of traditional medicine from the two communities under
      study. All participants in this component of the study will be selected intentionally
      (Hancock, Ockleford and Windridge, 2009). Participation will be made by signing the informed
      consent.

      Malaria prevalence

      The malaria prevalence will be determined in children under 5 years of age in both locations
      Tambai Q2 and Q6 (intervention) and Tambai Q3 and Q4 (control) at the beginning of the study,
      at the beginning of the second year and at the end of the second year (end of the project).
      Consent will be requested to the legal guardian. Capillary blood will be collected using a
      sterile pipette and individual lancet from all children in the study aged 6-59 months of age
      for: a) Rapid Diagnostic Test (RDT) for Plasmodium falciparum; b) blood drop smears and c)
      filter paper for nucleic acids extraction (FTA Cards ThermoFisher). The samples will be
      coded, and information about the coordinates of the associated household will be recorded.
      The initial sample processing will be carried out at the laboratory of the Health Center of
      Ponta Gea - Beira, and the molecular analyzes at IHMT-NOVA - Lisbon, as defined in the MTA.
      Identification of Plasmodium will be done by PCR and genotyping by whole genome sequencing
      (Ocholla et al. 2014). Children who are diagnosed with malaria by RDT during the study will
      be referred to the Mutondo Health Center for treatment.

      House Spraying with repellent

      The spraying with IR3535 will start at the beginning of the study and will be performed
      monthly during the first 3 months, bimonthly during the next 6 months and then quarterly
      thereafter. The spraying will be carried out inside and outside the houses during the
      morning. Spraying will only be carried out in intervention quarters, while there will be no
      spraying in control quarters.

      Entomology

      For entomological study households will be randomly selected. In case of failure of satellite
      imagery and geographical analysis (Wampler et al. 2013, Escamilla et al. 2014), a classic
      approach based on household inventories in each community will be used manually. Using local
      mapping and numbering, two lists of numbered households will be created. After a random
      number generator (e.g., Random.org) will be used to randomly select the households from each
      list (Wampler et al. 2013). Mosquitoes will be collected twice a month inside and outside the
      houses at the selected households for 2 years in the intervention and the control quarters.
      Inside each household, resting mosquitoes that fed the previous night will be collected using
      a Prokopak aspirator. Outside the residences, CDC- light traps will be placed in the early
      evening and collected at the following morning. The traps will be placed outdoors, in places
      equidistant from the buildings (houses) that compose the household. The physiological state
      of the mosquitoes will be determined, and the females classified as unfed, partially fed,
      fed, semi-gravid or gravid (Detinova, 1962). Mosquito females will be identified
      morphologically and confirmed by the PCR (Abilio et al. 2015). The density of mosquitoes
      caught in the control and intervention communities will be estimated using Williams'
      geometric mean. GEE and LMM will be explored to compare the two groups along time. The rate
      of infection will be determined by detecting and quantifying sporozoites in mosquitoes. The
      mosquitoes' heads and thorax will be removed and prepared to isolate DNA (Abilio et al.
      2011). Sporozoites will be detected and quantified by quantitative PCR (qPCR) as described in
      (Marie et al. 2013).

      Breeding sites mapping

      The mosquito breeding sites will be mapped using the "participatory mapping" approach (Dickin
      et al. 2014). The method will be used to identify the spatial perceptions of malaria risk in
      the community, based on the spatial identification of existing breeding sites. Interview
      participants and focus groups will be invited to draw a map of the areas they associate with
      breeding in communities and describe the important features of the map. These maps can then
      be digitized on a geographic information system (GIS) to create a georeferenced map of
      community knowledge.

      Malaria cases in the community

      During the study, cases of malaria in Tambai will be monitored through patients who visit the
      Mutondo Health Center. Patients of all ages from the communities with suspected malaria will
      be recruited. A questionnaire will be administered. A RDT, a thick drop and blood smear will
      be performed, and a drop of blood collected for subsequent molecular diagnosis by PCR (as
      described above). Enrolment and consent will be asked after the patients have received all
      the care they need in the health unit. Written informed consent will be obtained from the
      participants or their legal representatives for patients under 18 years old.

      Study variables

      The study variables can be divided into variables from the survey (questionnaire) and
      semi-structured interviews. Variables can be grouped into the following categories:

        -  Socio-demographic variables: Age; Sex; Marital status; Profession; Education level;
           Degree of kinship to the householder; Household size (nº of houses, area); Number of
           rooms in the house; nº of people per division; Type of construction.

        -  Ownership and use of mosquito nets: Ownership of mosquito nets; Use of mosquito nets;
           Mobility and activities of household members.

        -  Malaria knowledge, attitudes and practices: Malaria knowledge level; Malaria attitudes;
           Mosquito control and bites; Ownership, conservation and use of mosquito nets; Knowledge
           about repellents; After analyzing the questionnaire data, the variables are deduced;
           Level of knowledge, attitude and practices about malaria (score categorized as: bad (>
           50%), medium (50% -74%) and high (≥75%)).

      Variables of the study will also be those resulting from the collection of biological
      material (peripheral blood and mosquitoes):

        -  Malaria cases in children under five (RDT, optical microscopy and PCR);

        -  Malaria cases attending the Vinho Health Center;

        -  Mosquito density inside and outside homes; Percentage of infected mosquitoes;
           Distribution of mosquito species inside and outside homes;

        -  Breeding site (participatory mapping)

      Sample size for KAP

      Approximately 126 householders will be surveyed (according to the National Institute of
      Statistics of Moçambique (INE) report, 2017) corresponding to the total number of households
      in the communities under study. The chosen locations are comprised of only 126 households,
      therefore everyone contacted will be included to participate in order to guarantee a maximum
      power for the study.

      Prevalence of malaria in the intervention and control community

      According to the INE report, 2017, the total number of the population in the two study areas
      is 630 inhabitants. To calculate the number of children under 5 years of age, the total
      population was multiplied by 17.5%, so the sample will consist of about 110 children. The
      attempt to include all children aims to try to obtain a sample size that guarantees us the
      highest possible power.

      Sample size and statistical power for entomological indicators

      Different scenarios and programs were explored to calculate the sample size. Initially, a
      scenario corresponding to a sample size of 40 households (20 in each community) followed for
      48 moments was considered as being feasible. The statistical power was calculated using the G
      * Power v.3.2 program (Faul et al. 2007, 2009), with a correlation between measurements made
      at different times 0.2; with effect of size f = 0.25; a type I error probability equal to
      0.05. A statistical power of 91.1% was estimated. Conversely, for the same parameter values,
      fixing the power at 95%, in the perspective of using ANOVA for repeated measurements, 24
      aggregates were obtained in each community. However, if the assumptions of ANOVA for repeated
      measurements fail, LMM or GEE models will be used, so it is important to have an idea of the
      statistical power for these models. Using the Longpower package
      (https://www.rdocumentation.org/packages/longpower/versions/1.0-19/topics/longpower-package)
      of the R software, the power associated with the GEE and LMM models, for the previous
      scenario (24 households), would not be satisfactory. Considering the possibility of missing
      values (up to 20% in the last visit), a more realistic autoregressive correlation matrix for
      measurements in each visit, several scenarios were explored in Longpower to guarantee at
      least powers of 80%, for the various types of models. Thus, also keeping the budget and human
      resources available, we have 40 households in each location (80 households in total), with a
      single monthly visit to each household.

      Data analysis

      The data will be analyzed using SPSS version 25.0 and R package. Initially, descriptive
      statistics and exploratory analysis will be performed. Parametric and non-parametric tests
      will be used, either for independent samples (for example, comparing the two communities at a
      given time), or for paired samples (comparing each community at the beginning, middle and end
      of the study). The Chi-square or Fisher's test will be used to test the association between
      qualitative variables or to compare proportions between independent groups. For paired
      qualitative data, the McNemar test and Cochran's Q test (for binary data) will be applied.
      For quantitative variables, the comparison of two independent groups will be performed using
      the T-Student test, in case of compliance with the assumptions of normality and homogeneity
      of variances, or alternatively the Mann-Whitney-Wilcoxon test. ANOVA or Kruskal-Wallis test
      will be used for more than two groups. Signs, Wilcoxon and Friedman tests will be used to
      compare two or more paired samples. If the sample sizes allow, generalized linear models can
      be used to jointly analyze several explanatory variables for some events of interest (for
      example, use of repellent). For the longitudinal comparison between the intervention and
      control groups, as for entomological indices, Mixed Linear Models and Generalized Estimation
      Equation Model or a Nonparametric Analysis of Longitudinal Data in Factorial Experiments
      (nparLD) approach will be applied, using several packages of the R. software. The
      (CONsolidated Standards of Reporting Trials) CONSORT2010 standards, an intention-to-treat
      (IT) analysis will be used, and there may be a need to proceed previously with a treatment
      for missing values. Differences and associations will be considered statistically significant
      when p <0.05. In order to estimate the prevalence or other proportions of interest, 95%
      confidence intervals will be obtained by Wald method or alternatively the Wilson or Jeffreys
      methods.

      The sporozoite rate (% of mosquitoes with sporozoites in the salivary glands) will be
      compared between the control and intervention community and the percentage of reduction
      determined. The temporal and spatial distribution of the different mosquito species and their
      densities will be explored using ArcGIS 10 with Spatial Analysis and Statistical Tools) and
      compared between the 2 locations (control x intervention).

      In the qualitative component, after recording the interviews, their full transcription will
      be carried out. Data processing and analysis will be manual, using the content analysis
      technique.

      Data management - Questionnaires

      The Open Data Kit (ODK) will be used for data collection and its quality control. The
      supervisor will review the interviews on a daily basis, before sending them to the secure
      server located at the CIOB for storing. The server will be accessible only to the data
      manager and the team of researchers. The transferred data does not include the names of
      participants, only their codes. The data manager will clean and validate the data daily and
      provide feedback to the field staff. All physical documents such as informed consents, data
      collection forms and electronic devices (GPS and tablets) will be stored and only accessible
      to the CIOB Principal Investigator. The paper documents will be kept for 5 years after the
      study is completed and then destroyed.

      Data Management - Prevalence and entomology

      The data will be collected through a paper data collection form. Every day, each data
      collector must enter all data in a database available on a computer and send it to the data
      manager, after a careful revision by responsible of the team. After the data manager receives
      the data, she/he can create a password protected folder to archive the data on a daily basis.

      Quality control and monitoring - Training of staff

      Study personnel will be properly trained by the study's research team. The field team will be
      subdivided into three (3) groups:

        -  Collecting blood samples and administering the survey to householders and conducting
           interviews with health professionals. The team will consist of 3 health technicians with
           experience in research.

        -  Mosquitoes collection and breeding sites mapping. The team will consist of 2 entomology
           technicians.

        -  Sprayers that will be spraying houses with repellent. The team will consist of 4 people.

      The training will be focused on ethical aspects, selection of households, children aged 6-59
      months, conducting interviews, blood sampling procedures, good clinical and laboratory
      practices, mosquito collection, manipulation, identification, processing and storing,
      breeding mapping and spraying techniques and safety.

      Quality control and monitoring - Supervision of field work

      The teams will have a field coordinator who will be responsible for monitoring the field work
      and ensuring data quality. During the study, a team of supervisors will periodically visit
      the field teams to ensure proper practices. The quality control (QC) of the data will start
      in the pilot phase, with the identification and replacement of unclear terms and study
      questions. The field coordinator will also continuously assess compliance with standard
      operating procedures (SOP) and ethical principles.

      Data quality and quality assurance

      The baseline study will include a pilot that will be conducted during training in a community
      that is not part of the study. The pilot will have the following objectives (i) to evaluate
      and validate the contents of the data collection instruments, (ii) to ensure compliance with
      the ethical aspects related to the study. The pilot will help to identify the difficulties
      and omissions during the questionnaire. The pilot will analyze the fieldwork strategy, team
      composition, staff responsibilities and time required to complete all activities.

      The field coordinator will do the quality control of the inquiries made before they are sent
      to the CIOB and in addition to the quality control done by the field coordinator, the main
      investigators will also do the supervision to guarantee the quality of the data.

      Storage of Data

      The data will be stored at the CIOB. Study documents and data collection instruments,
      including informed consent in physical format, that will be placed in file folders and kept
      locked, with restricted access to researchers. All documents related to the research will be
      filed according to the rules of the legislation and will be kept at CIOB for a period of 5
      years.

      Storage of Biological samples

      Part of the blood and mosquito sample will be processed in the laboratory of IHMT-NOVA,
      Portugal, for that purpose a material transfer agreement (MTA) has been signed between CIOB
      and IHMT-NOVA, Portugal. Part of the blood sample will be kept in the CIOB for future
      analysis in the scope of PhDs and/or Master programs, explicitly referring to the present
      project. The samples will be kept in a freezer at CIOB at -80 ° C, for 5 years after the end
      of the study. Biological samples that will not be used for further analysis will be destroyed
      at the end of the analysis within the study.

      Ethical review

      This study protocol has been submitted for ethical approval to the Institutional Committee on
      Bioethics for Health of the National Institute of Health (CIBS-INS) and to the National
      Committee on Bioethics for Health (CNBS) - Clearance Ref. 63/CNBS/20 and Addendum Ref.
      11/CNBS/21. The study will be carried out in accordance with the rules of "good clinical
      practice (GCP)", "good clinical and laboratory practice (GCLP)" and all applicable regulatory
      requirements, such as the Declaration of Helsinki 2013, at its 64th General Assembly.

      Informed consent

      The consent from the heads of households, parents or legal representatives of the children
      and health professionals selected for the study will be obtained by trained interviewers.
      They will be fluent in the local languages (Sena and Ndau) or accompanied by an interpreter
      during the request for informed consent and interviews. All participants will be informed
      about the objectives of the study, procedures to be performed during the study and potential
      associated inconveniences, as well as the possibility of leaving the study even after signing
      the informed consent without any implications for them.

      The participant will have the right to privacy during the moment of the interview, it will be
      held in a place where the participant feels comfortable, explaining that all the information
      provided by him will be confidential, authorization for audio recording of the interview will
      be specifically requested. Permission from the householder will be ask, for the collection of
      a finger prick blood sample from the children in the household aged 6-59 months. If the
      child's legal representative is different from the head of household, informed consent will
      also be administered to her/him. If the child's parent/legal guardian is under 18, informed
      consent will be administered to authorize the child to participate.

      Authorizations for periodic visits throughout the study will be requested while explaining
      the importance of the procedures for:

        -  spraying of their homes (indoor and outdoor) with mosquito repellent (monthly). Only in
           Tambai Q2 and Q6;

        -  collection of mosquitoes from the interior and exterior of their houses (twice a month)
           in two localities.

      The inquirers and each participant will sign 2 copies of the informed consent form, in which
      one copy will remain with the participant and the other will remain with the inquirer for
      later filing in the study folder. The contact of the principal investigator of the study is
      an integral part of the document. The informed consent form will serve as proof that the
      participant accepted to be part of the study by their own free will. In order to guarantee
      confidentiality, each participant will be assigned an identification code for the
      questionnaire. Each questionnaire made will have a code corresponding to consent.

      Participation risks

      The risks of participation are minimal, but in the event that a participant feels
      uncomfortable during the interview with any question, they can ask to pass the question on.
      During the blood sample collection, there may be same risk of bleeding or inflammation from
      the collection site. To minimize that adequate material will be provided to collect capillary
      blood (sterilized lancets and disposable gloves) through health professionals trained for
      that specific activity. Regarding the spraying of houses with repellent, participants will be
      informed about potential rare adverse effects. If someone in the residence, where the
      spraying was carried out, has any reaction, which is suspected to be associated with the
      product, the spraying will be interrupted in that residence and the individual referred to
      the health service.

      Benefits of participation

      Frequently, after carrying out interviews, an increase of knowledge in the communities is
      noted. This is due to the fact that often those who apply the questionnaire can alert to best
      practices, which can contribute to improvements in the health of the community. One of the
      benefits will be knowing whether or not you have malaria, plus children diagnosed with
      malaria will be able to benefit from treatment.
allocation: Randomized
intervention model: Parallel Assignment
intervention model description: A prospective experimental Before-After-Control-Intervention test will be carried out with two groups: a) Intervention (community of Tambai): with indoors and outdoors spraying with IR3535 (3-(N-acetyl-N-butyl) aminopropionic acid ethyl ester) and b) Control (community of Micheu 1): without spraying.
primary purpose: Prevention
masking: None (Open Label)
measure: Changes from baseline in malaria prevalence in children under 5 years at 1st year
time frame: Month 1, Month 12
description: Malaria cases in children aged 6 to 59 months
measure: Changes from baseline in malaria prevalence in children under 5 years at 2nd year
time frame: Month 1, Month 24
description: Malaria cases in children aged 6 to 59 months
measure: Monthly changes of indoor Anopheles mosquito density from baseline to month 24
time frame: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 19, 20, 21, 22, 23, 24 Months
description: Mosquitoes resting inside the houses will be collected by aspiration
measure: Monthly changes of outdoor Anopheles mosquito density from baseline to month 24
time frame: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 19, 20, 21, 22, 23, 24 Months
description: Outside mosquitoes collected overnight using CDC-light traps
measure: Monthly changes of Anopheles mosquito sporozoite rate
time frame: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 19, 20, 21, 22, 23, 24 Months
description: Number of infected mosquitoes determined by PCR
measure: Change from Baseline in Knowledge, attitudes and practices - KAP score at 1st year
time frame: Month 1, Month 12
description: An evaluation scale will be defined with the attribution of points for correct answers, and whoever has <50% will be considered a participant with a bad level of knowledge, attitudes and practices and whoever has 50% -74% and ≥75% will be considered medium and high level of knowledge, attitudes or practices respectively
measure: Change from Baseline in Knowledge, attitudes and practices - KAP score at 2nd
time frame: Month 1, Month 24
description: An evaluation scale will be defined with the attribution of points for correct answers, and whoever has <50% will be considered a participant with a bad level of knowledge, attitudes and practices and whoever has 50% -74% and ≥75% will be considered medium and high level of knowledge, attitudes or practices respectively
measure: Mosquito breeding sites mapping
time frame: continuous for the 2 years
description: The mosquito breeding sites will be mapped using the "participatory mapping" approach (Dickin et al. 2014). Community generated maps will be digitized on a GIS to create a georeferenced map of community knowledge.
measure: Prevalence of symptomatic malaria cases in the area covered by the Vinho health center
time frame: continuous for the 2 years
description: Malaria cases in the locality of Bebedo will be monitored through patients of all ages with suspected malaria, attending the Vinho Health Center. Blood will be collected, for blood-smears and PCR.
arm group label: intervention
arm group type: Experimental
description: Community of Tambai: Indoors and outdoors spraying with IR3535 (3-(N-acetyl-N-butyl) aminopropionic acid ethyl ester)
arm group label: Control
arm group type: No Intervention
description: Community of Micheu 1: Without spraying.
intervention type: Other
intervention name: IR3535 (3-(N-acetyl-N-butyl) aminopropionic acid ethyl ester) house spraying
description: The spraying will be performed monthly during the first 3 months, bimonthly during the next 6 months and then quarterly thereafter. The spraying will be carried out inside and outside the houses during the morning.
arm group label: intervention
criteria: 
gender: All
minimum age: 6 Months
maximum age: N/A
healthy volunteers: Accepts Healthy Volunteers
last name: Henrique Silveira, PhD
role: Principal Investigator
affiliation: Universidade Nova de Lisboa, Portugal
last name: Joaquim Lequechane, Lic
role: Principal Investigator
affiliation: Centro de Investigação Operacional da Beira, INS, MISAU, Mozambique
facility: 
country: Mozambique
citation: Abilio AP, Kleinschmidt I, Rehman AM, Cuamba N, Ramdeen V, Mthembu DS, Coetzer S, Maharaj R, Wilding CS, Steven A, Coleman M, Hemingway J, Coleman M. The emergence of insecticide resistance in central Mozambique and potential threat to the successful indoor residual spraying malaria control programme. Malar J. 2011 May 2;10:110. doi: 10.1186/1475-2875-10-110.
PMID: 21535872
citation: Abilio AP, Marrune P, de Deus N, Mbofana F, Muianga P, Kampango A. Bio-efficacy of new long-lasting insecticide-treated bed nets against Anopheles funestus and Anopheles gambiae from central and northern Mozambique. Malar J. 2015 Sep 17;14:352. doi: 10.1186/s12936-015-0885-y.
PMID: 26377825
citation: DETINOVA TS. Age-grouping methods in Diptera of medical importance with special reference to some vectors of malaria. Monogr Ser World Health Organ. 1962;47:13-191. No abstract available.
PMID: 13885800
citation: Dickin SK, Schuster-Wallaceab CJ, Elliottc SJ. Mosquitoes & vulnerable spaces: Mapping local knowledge of sites for dengue control in Seremban and Putrajaya Malaysia. Applied Geography. 2014. 46: 71-79. DOI: 10.1016/j.apgeog.2013.11.003
citation: Escamilla V, Emch M, Dandalo L, Miller WC, Martinson F, Hoffman I. Sampling at community level by using satellite imagery and geographical analysis. Bull World Health Organ. 2014 Sep 1;92(9):690-4. doi: 10.2471/BLT.14.140756. Epub 2014 Jun 17.
PMID: 25378761
citation: Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behav Res Methods. 2009 Nov;41(4):1149-60. doi: 10.3758/BRM.41.4.1149.
PMID: 19897823
citation: Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007 May;39(2):175-91. doi: 10.3758/bf03193146.
PMID: 17695343
citation: Marie A, Boissiere A, Tsapi MT, Poinsignon A, Awono-Ambene PH, Morlais I, Remoue F, Cornelie S. Evaluation of a real-time quantitative PCR to measure the wild Plasmodium falciparum infectivity rate in salivary glands of Anopheles gambiae. Malar J. 2013 Jul 2;12:224. doi: 10.1186/1475-2875-12-224.
PMID: 23819831
citation: Morrison AC, Astete H, Chapilliquen F, Ramirez-Prada C, Diaz G, Getis A, Gray K, Scott TW. Evaluation of a sampling methodology for rapid assessment of Aedes aegypti infestation levels in Iquitos, Peru. J Med Entomol. 2004 May;41(3):502-10. doi: 10.1603/0022-2585-41.3.502.
PMID: 15185957
citation: Ocholla H, Preston MD, Mipando M, Jensen AT, Campino S, MacInnis B, Alcock D, Terlouw A, Zongo I, Oudraogo JB, Djimde AA, Assefa S, Doumbo OK, Borrmann S, Nzila A, Marsh K, Fairhurst RM, Nosten F, Anderson TJ, Kwiatkowski DP, Craig A, Clark TG, Montgomery J. Whole-genome scans provide evidence of adaptive evolution in Malawian Plasmodium falciparum isolates. J Infect Dis. 2014 Dec 15;210(12):1991-2000. doi: 10.1093/infdis/jiu349. Epub 2014 Jun 19.
PMID: 24948693
citation: Wampler PJ, Rediske RR, Molla AR. Using ArcMap, Google Earth, and Global Positioning Systems to select and locate random households in rural Haiti. Int J Health Geogr. 2013 Jan 18;12:3. doi: 10.1186/1476-072X-12-3.
PMID: 23331997
responsible party type: Principal Investigator
investigator affiliation: Universidade Nova de Lisboa
investigator full name: Henrique Silveira
investigator title: Professor
mesh term: Malaria
sharing ipd: Yes
ipd description: The data collected from this study will be disseminated to different audiences at different times.
A final report will be presented to the Sofala Provincial Health Directorate, Nhamatanda District Health Directorate and the Ministry of Health trough the National Institute of Health.
In order to return the results to the communities, a meeting with the local structures of the communities will be held. The session will open to the general population using a language that will be accessible to the participants in this study, with emphasis on implementing and maintaining practices that protect them from malaria over time.
The results will also be disseminated to the scientific community through publications and presentations at national and international scientific conferences.
Data and specimens will be available for related studies to MSc and PhD theses at CIOB, Mozambique.
ipd info type: Study Protocol
ipd info type: Statistical Analysis Plan (SAP)
ipd info type: Informed Consent Form (ICF)
ipd info type: Clinical Study Report (CSR)
ipd time frame: The information will be realised at the end of the project
ipd access criteria: public