Cambodia 2017
Genetic epidemiology of P. falciparum
malaria and associated antimalarial drug
resistance
LOCAL CONTACTS:
Long Dianna
Technical Service Director
Population Services Khmer,
# 29, Street 334, Boeung Keng Kang I,
Chamkar Mon,Phnom Penh, Cambodia.
Phone: +855-23-210-814
Fax: +855-23-218-735
Email: dianna@psk.org.kh
Phok Sochea
Research Manager (Malaria and Child Survival)
Population Services Khmer,
# 29, Street 334, Boeung Keng Kang I,
Chamkar Mon,Phnom Penh, Cambodia.
Phone: +855-23-210-814
Fax: +855-23-218-735
Email: psochea@psk.org.kh
 1. DESCRIPTION OF STUDY GENESIS AND ORGANISATION
The Genetic epidemiology of P. falciparum malaria and associated antimalarial drug resistance study is a
joint research study of Population Services Khmer, Cambodia (PSK) and Mahidol Oxford Tropical
Medicine Research Unit, Thailand (MORU). Funding is provided to both organizations by the Bill and
Melinda Gates Foundation: through the GEMS program for PSK and as part of the GenRe-Mekong
project for MORU. GenRe-Mekong supports a network of scientists and public health teams in the
Greater Mekong Subregion (GMS) to supply strategically important information derived from genetic
data to national malaria control programs (NMCP) in the region, to support timely actions towards
malaria elimination.

The table below summarises the key roles of each organisation and the responsibilities of PSI/PSK
research staff involved in the study.

Position on study Name Affiliation Role

Chief investigator Dr Olivo Miotto MORU Leads study design
Investigator Dr Richard J Maude MORU Leads training of trainers for PSK staff
Investigator Dr Mehul Dhorda MORU Leads data entry
Investigator Dr Xin Hui Chan MORU Leads molecular analysis
Leads production of molecular reports
Responsible for data storage
Co-leads additional analysis
Investigator/ Dr Leang Rithea CNM Supports local compliance to study design
Co-leads study design

Investigator / Mr Sochea Phok PSK

Co-PI for PSI Supports training of trainers and cascade
training
Ensures local compliance to study design
including ethics provisions
Co-leads additional analysis
Investigator / Mr Stephen Poyer PSI Leads institutional collaboration with MORU
Co-PI for PSI Supports local compliance to study design
Co-leads additional analysis

2. GOAL OF THE STUDY

Genetic surveillance of Plasmodium falciparum can provide key information to the NMCP and partners
involved in elimination efforts. By routinely monitoring known drug-resistance mutations, it is possible
to evaluate the efficacy of program interventions, and switch treatment regimens as required. In
addition, genomic-level surveillance can provide key data on the diversity and evolution of parasite
populations, which can be analysed to inform interventions, such as:

 Monitoring the spread of resistant genetic backgrounds to identify areas of future emergence. 1
 Identification of gene flow patterns between populations, and of transmission hotspots where
strains tend to admix, to help identify high-priority elimination targets.
 Assessment of genetic similarity to assess geographical provenance of imported strains, and the
contribution of cross-border travel.

2 Cambodia, 2017
  Identification of locally expanding highly inbred populations of resistant parasites 11 to help
monitor the emergence and spread of new resistant strains.

The goal of this study is to contribute knowledge to National Malaria Control Programmes and other
groups in the GMS through the genetic surveillance of P. falciparum, in order to inform the inventions
above.

3. RESEARCH OBJECTIVES
The study aims to determine the prevalence and geographical distribution of antimalarial drug
resistance-linked genetic mutations, the genetic structure of the parasite population, likely routes of
gene flow between populations, and geographic origins of parasites in the GMS.

Objectives Outcome Measures Time points of

evaluation of this
outcome measure

Primary Objective
To determine the prevalence and
geographical distribution of antimalarial
drug resistance-linked genetic mutations in
clinical P. falciparum and mixed infections in
the GMS, and in particular in Cambodia
Annual maps and reports on the Annually, starting
prevalence of drug resistance-linked 12 months after the
genetic mutations in P. falciparum and project start
mixed parasites in the GMS, and in
particular in Cambodia

Secondary Objectives
1. To determine the genetic population
structure and degree of differentiation
of P. falciparum parasites within and
between different regions in the GMS,
and in particular in Cambodia
2. To estimate gene flow patterns and
likely geographic origin of P. falciparum
malaria parasites in the GMS, and in
particular in Cambodia
Annual analysis reports on Annually, starting
 Genetic population structure and 12 months after the
degree of differentiation of P. project start
falciparum parasites within and
between different regions in the
GMS, and in particular in Cambodia
 Gene flow patterns and likely
geographic origin of P. falciparum
malaria parasites in the GMS, and in
particular in Cambodia

4. COUNTRY/HEALTH CONTEXT

Although considerable progress has been made in malaria control in the GMS during the past 10 years,
malaria remains a major concern for the international community and ministries of health in the region.
This is due primarily to the development and possible spread of resistance to artemisinin drugs, the
principal component of the combination therapies for malaria that now are the first-line treatment for
malaria throughout the GMS and the world. Plasmodium falciparum resistance to artemisinin drugs was
first confirmed in western Cambodia; treatment failures to artemisinin-based combination therapy (ACT)
have been reported from multiple sites on the Thai-Cambodian border; and an early warning sign of

3 Cambodia, 2017
 artemisinin resistance – prolongation of parasite clearance times – has been reported throughout the
region.

Over the last decade, many of Cambodia’s key health indicators have improved as the country’s
economy has developed. Significant progress has also been achieved in malaria prevention and control;
since 2009, malaria incidence, malaria cases, and malaria deaths have all decreased. Despite the
successes, artemisinin resistance and mobile at-risk populations remain challenges to reaching national
elimination goals. Malaria predominantly affects adult males, many of whom are workers who move
from low to high transmission areas and lack access to malaria services and education, which makes
them more vulnerable to infection. In 2014, Cambodia developed a Malaria Elimination Action
Framework, the goal of which is to eliminate P. falciparum by 2020. This framework lays out a phased
approach whereby districts progressively transition from implementing burden control activities to
malaria elimination activities.

While the Thai/Cambodian border has historically been the epi-centre of drug resistance, today, there is
evidence that artemisinin resistance is appearing de novo across the GMS. In light of the significant
number of patients who seek care for suspected malaria from the private sector, outlets in PSK’s Public
Private Mix program (~700 outlets) and its Worksite program (~130 sites) provide an opportunity to
provide samples to the GenRe-Mekong program in addition to those already being supplied through
Cambodia’s NMCP public sector facilities as part of the same program.

5. SUMMARY OF PROGRAM
The study is a genetic reconnaissance activity to be conducted in Cambodia in partnership with the
GenRe-Mekong project, described above. It is proposed that dried blood spot (DBS) samples will be
collected along with short surveys on patient demographics and population movement from every
confirmed case of P. falciparum and mixed malaria presenting to – initially – 100 PSK/PSI Cambodia
health outlets across 8 12 selected provinces in Cambodia: (1) Banteay Meanchey, (2) Kampong
Chhnang, (3) Kampong SpeuCham, (4) Kampong Thom, (5) Koh Kong, (6) Kratie, (7) Mondul Kiri, and
(8) Steung Treng, (9) Rattanak Kiri, (10) Tboung Khmom, (11) Preah Sihanouk and (12) Preah Vihear . The
study objective is to determine, for P. falciparum and mixed infections, the prevalence and geographic
distribution of antimalarial drug resistance-linked genetic mutations, as well as the genetic structure of
the parasite population, likely routes of gene flow between populations, and geographic origins of
parasites.

6. RESEARCH CONTEXT AND SIGNIFICANCE

Artemisinin-based combination therapy (ACT), the frontline treatment for P. falciparum infection, has
played a vital role in reducing the number of deaths due to malaria over the past decade globally. In the
GMS, ACTs which incorporate mefloquine, lumefantrine or piperaquine alongside an artemisinin
derivative are used as the frontline treatment. However, artemisinin resistance has now emerged in
multiple countries across the GMS, causing parasite clearance rates to decrease substantially. 2-5 This has
presented opportunities for parasites to develop resistance to currently deployed ACT partner drugs,
causing ACT cure rates to drop in several geographical regions. 6-9 The rise in of antimalarial-resistant
parasites threatens global treatment strategies, with the potential for dramatic consequences if these

4 Cambodia, 2017
 strains were to spread to other endemic regions, particularly to Africa. Historical evidence supports
these concerns: P. falciparum drug resistance originated and spread from the GMS on multiple
occasions, causing high global levels of resistance to important antimalarials such as chloroquine,
sulfadoxine-pyrimethamine and mefloquine. Countries in the GMS region have been repeatedly at the
epicentre of drug resistance emergence, and there is mounting evidence that some parasite populations
from this region carry a genetic background, which facilitates the development of multidrug resistance. 1
Because of the recurring emergence of antimalarial resistance, the WHO and major funders have
identified as a the elimination of P. falciparum malaria in the GMS as a public health emergency, and
have planned intensified and accelerated elimination efforts. 10 However, the resistant nature of strains
circulating in the GMS makes it increasingly difficult to select effective frontline treatments that can be
relied on for such elimination efforts. 6 In addition, drug resistance is causing parasite populations to
evolve and expand in complex patterns, such as independently-emerging founder populations which
carry distinct resistant mutations, making it harder to implement simple monitoring of genetic markers
to support the planning of intervention strategies. 1,11,12

7. RESEARCH DESIGN
This is a prospective observational study of patients with confirmed P. falciparum and mixed infection
using parasite DNA obtained from point-of-care finger prick dried blood spot samples and a short survey
on patient demographics, employment, and travel, and mobile phone use to study P. falciparum
parasite genotypes, population characteristics, and gene flow patterns.

The total duration of the study is expected to be 36 months following ethical approval. Training will
precede sample collection by up to 1 month. DBS sample and survey data processing, analysis, and
reporting are planned to take place on a rolling basis throughout the study.

SUBJECTS AND SAMPLING

Description of subjects
Study subjects are patients aged 5 years and above who present to one of initially 100 purposefully
selected PSK-supported sites in the 8 12 target provinces with P. falciparum or a Pf mixed infection. PSK-
supported sites are Public Private Mixed health providers (PPM) and Mobile Malaria Workers in
plantations (MMW).
Existing Standard Operating Procedures (SOPs) for PPM and MMW sites stipulate that patients
presenting with symptoms of suspected malaria and/or patients who have visited a forested area in the
past 2 weeks are tested for malaria by trained providers. These SOPs are in line with the most recent
National Malaria Treatment Guidelines for Cambodia. These SOPs further require that children under
age five, pregnant women and severe cases are referred to the nearest public facility; these categories
of patients will be excluded from this study. Patients who test positive for Pf or mixed infection by RDT
(or microscopy where available) will be eligible for this study. Full informed consent will be obtained
before any study-specific procedures are conducted.
All study participants must satisfy the applicable inclusion and exclusion criteria, as follows:

5 Cambodia, 2017
 Inclusion criteria Exclusion criteria
 Male or female age 5 years and above.  Children age <5 years of age.
 P. falciparum or mixed malaria as confirmed by  Pregnant women.
positive RDT or asexual forms of P. falciparum  Patients with severe symptoms who require
on blood smear microscopy, where performed immediate referral.
(may be mixed with non-falciparum  Patients with RDT negative results.
Plasmodium species).  Patients with microscopy negative results.
 Written informed consent to participate by
patient, or oral assent combined with written
consent from parent, guardian or legally
authorised representative for patients aged 14
to 17 years inclusive.

Sampling and sample size determination

Study participants will be drawn from initially 100 PPM and MMW sites distributed across 128 provinces
as shown in the table below. PPMs and MMWs have been purposefully selected based on patient
caseload data recorded through routine monitoring in 2016.

This is a surveillance study in an elimination setting. As such, there is no formal sample size calculation;
rather the study will seek to capture samples from all consenting eligible cases during the study period.
It is estimated that approximately 3,000 dried blood spots per annum will be collected from 100 sites,
based on PPM and MMW monitoring data from 2016.

No. of
Total Total 2016 Positive Estimated Estimated
Providers for
Number Number Cases case load case load
N DBS
Provinces PPMs in MMW in From From
°
province province selected selected
PPM MMWs PPM MMWs
(2016) (2016) PPM sites MMW sites

1 Banteay Meanchey 110 0 4 0 8 n/a 50 0

2 Preah Vihear 0 0 0 0 0 4 0 30
3 Steung Treng 68 20 1,281 23 8 4 600 30
4 Ratanakiri 148 94 286 54 7 6 180 30
5 Mondulkiri 90 28 4,493 59 8 4 1120 40
6 Kratie 0 132 n/a 196 0 6 0 100
7 Tbong Khmom 108 36 308 21 8 2 150 19
8 Kampong Cham 82 20 93 6 5 2 70 6
9 Kampong Thom 0 44 n/a 69 0 6 0 60
10 Kampong Chhnang 52 0 980 n/a 8 n/a 750 0
11 Koh Kong 44 0 173 n/a 7 n/a 100 0
12 Preah Sihanouk 46 0 34 n/a 7 n/a 20 0
TOTAL     12837 428 66 34 3040 315

Sites Estimated cases,2015

Province Total PPMs Total Number of Number of MMWs From From

6 Cambodia, 2017
 in province MMW in PPMs selected selected selected
(Dec 2015) province selected PPM sites MMW
(Dec 2015) sites
Kampong Speu 0 NP 0 TBD 0 NP
Stueng Treng 34 13 13 3 1633 21
Kratie 0 64 0 4 0 34
Mondul Kiri 46 16 18 3 750 34
Kampong
27 NP 10 TBD 473 NP
Chhnang
Kampong Thom 0 20 0 3 0 54
Koh Kong 26 NP 7 TBD 157 NP
Banteay
NP 0 TBD 0 NP 0
Meanchey
Total 133 113 48+ 13+ 3013 143
NP: This type of network was not present / not established as of Dec 2015

8. STUDY PROCEDURES

Informed consent
The age of legal consent in Cambodia is 18 years. On confirmation of P. falciparum or mixed infection
malaria by RDT or microscopy, the patient - or their parent, guardian or legal representative when the
patient is under age 18 - will be informed about the study. Eligible patients - or their parent, guardian or
legal representative when the patient is under age 18 - must provide written consent before study-
specific procedures are performed. In addition, oral assent will be required from patients aged 14 to 17
years inclusive who have the cognitive capability to make decisions.

A printed Participant Information Sheet (PIS) and Informed Consent Form (ICF) will be presented in
Khmer to the participants, parent/guardian, or legally authorised representative detailing: the exact
nature of the study; what it will involve for the participant; the implications and constraints of the
protocol; and any perceived benefits or risks involved in taking part. It will be clearly stated that the
participant is free to not join the study for any reason without prejudice to future care, without affecting
their legal rights, and with no obligation to give the reason for declining to join the study. The PSI and
ICF will be read by the health provider in cases where the patient or their adult representative is not
able to read the printed version.

The participant, parent/guardian, or legally authorised representative will be allowed as much time as
they wish for to consider the information, and the opportunity to question the provider directly or
contact the local Co-Principal Investigator (Co-PI) before deciding whether they will participate in the
study.

Written informed consent will then be obtained, as appropriate, from the patient, their parent, guardian
or legally authorised representative. The provider will countersign the consent form. Illiterate patients
will be asked for their thumbprint in lieu of a signature and a witness will be asked to sign the ICF to
confirm that the participant has been administered informed consent verbally and has agreed to

7 Cambodia, 2017
 participate. Oral assent will be sought from all patients aged 14 to 17 years inclusive after sharing the PIS
and after seeking consent from their parent, guardian or legally authorised representative.

The person obtaining consent will be suitably qualified and experienced, and have been authorised to do
so by the Chief Investigator (CI). PSK, represented by the local Co-PI, will ensure these criteria are met
through support to MORU for the training of PPM providers and PSK-led on-the-job training at the time
of recruiting PPM and MMWs into the study.

Sample and participant identification

Participants will be identified on survey forms by a unique study code and a unique barcode, and
samples will be identified by a unique barcode (matching the code on the corresponding survey form).
Barcode stickers will be provided in triplicate for use on samples, on the survey form and on an
anonymous sample manifest used for shipping the samples to MORU. The use of barcodes allows linking
of samples to questionnaire responses so the information therein can be matched with the relevant
blood spot and its related genetic data, while retaining sample anonymity.

Sample collections and survey administration

On inclusion into the study and before standard malaria treatment is administered by the provider,
dried blood spots will be obtained through finger prick blood sampling from patients, with three blood
spots on one piece of filter paper being obtained from each patient. Each blood spot will contain ~20µl
of blood, for a total of ~60µl of blood being collected from each patient for the study. A unique barcode
will be stuck onto the filter paper. Date and place of collection of DBS will be recorded on the survey
form and on the sample manifest and linked to the DBS sample paper using copies of the unique
barcode.

In order to have a greater understanding of the possible sites of malaria transmission and to relate
genetic diversity to geographic location, patients or their parents/guardians will also be asked a short set
of questions on demographics, their places of residence and work, recent mobile phone use, and their
history of travel. Location questions will capture information at the village-level and above: no uniquely
identifying addresses will be recorded in this study. The basic questions on phone utilisation will provide
information on the use of mobile phones in the study population, including which mobile phone
companies are used, and how many SIM cards and handsets each person carries. No identifying phone
data (such as personal numbers) will be collected through this study, rather the data collected will be
employed to derive information on population movement from anonymised, aggregated data on mobile
phone telephone use, i.e. call detail records (CDR), obtained from mobile phone companies in each
country. This will be used for the modelling of population movement, its impact on the distribution of
malaria and antimalarial drug resistance, and subsequent prediction of potential routes of spread of
malaria and antimalarial drug resistance.

As some of this information can be sensitive, during the consent process the patient will be given the
option of not providing some or all of this information without needing to provide a reason. For those
who do not wish to provide information, this will be documented in the survey form.

All patients in the study will receive standard care for P. falciparum or mixed infection including drug
therapy according to the National Treatment Guidelines.

8 Cambodia, 2017
 Following data collection, the DBS filter paper will be air-dried overnight at room temperature before
being stored in a zip-lock plastic bag packed with a desiccant sachet. All bagged samples and associated
forms will be stored in a secured area (either an existing lockable site or in a lock box provided by the
project) until they are collected by a PSK-employed medical rep once a month. At this time, groups of 10
plastic bags with one DBS paper each will be placed in an aluminium foil bag for transport. The foil bags,
together with all associated consent forms, survey forms and a complete sample manifest, will be
packed into one large-size zip-lock bag for transport to Phnom Penh and handover to a MORU
representative.

Sample processing and analysis

Sample processing, including DNA extraction from DBS, will be conducted at the MORU Specimen
Management Laboratory in Bangkok, Thailand, and coordinated by the WWARN Asia Regional Centre.

Samples will be sent to the Wellcome Trust Sanger Institute (WTSI) in Hinxton, Cambridgeshire, UK for
genotyping and whole genome sequencing.

9. TRAINING

The MORU Chief Investigator and/or one or more MORU Investigators will travel from Thailand to
Phnom Penh to conduct a two-day training of trainers for selected PSK staff and PSK-employed medical
representatives. Training logistics will be supported and coordinated locally by PSK staff. The training of
trainers agenda will cover:

 The basics of research ethics;

 How to introduce the study and administer informed consent and assent procedures;
 How to collect DBS samples from patients using filter paper;
 How to label and store DBS samples;
 How to complete the survey form (called the Case Recording Form – CRF);
 How to package all study materials for a given patient and store them safely in a secure lock box;
 How to complete the Sample Manifest Form (SMF), used when handing samples over to MORU;
 How to perform quality control checks on the CRF, patient study packages, and SMF;
 How to respond in the event of an unanticipated problem (who to contact, how to record the
details, etc);
 How to maintain a log of samples collected from the field and passed to MORU staff in Phnom Penh
for transport to Bangkok.

PSK medical representatives will cascade the training to PPM and MMW staff in their assigned provinces
during routine site visits.

10. PILOT TESTING

Prior to undertaking the study at scale a pilot test will be conducted with support from MORU. In this
context, the pilot test will allow the study team to assess the level of commitment from providers in
explaining the study and administering the consent form, collecting the dried blood spot, and
completing the Case Reporting Forms. The pilot testing will last one week and will be conducted with 3

9 Cambodia, 2017
 PPM providers and 3 mobile malaria workers, in separate provinces to the actual study. Insights from
the pilot test will be used to make any necessary adjustments to the study SOPs and data collection
tools (to improve the reliability of recorded data).

11. DATA ANALYSIS

A broad variety of statistical and informatics analyses will be used at different stages in this study. The
analyses of genetic material will be presented descriptively drawing on covariates calculated from the
patient Case Reporting Forms. Examples of the analyses that will be used in this study include:

 Whole-genome sequencing data alignment and genotype calling from Illumina sequencing data,
using bespoke computing pipelines for quality control. 14
 Clustering analyses to derive genotypes from Sequenom (mass-spectrometry) data, using both
manufacturer-provided and bespoke software.
 Allele frequency estimations for drug resistance mutations and other genome-wide variations,
and analyses of differentiation between populations and geographies (e.g. F ST).14
 Analyses of heterozygosity, both within the population and within individual samples (e.g. F WS
and complexity of infection).15
 Genetic distance estimation (measuring the degree of genetic divergence between individuals)
and analyses of population structure (identification of genetic subpopulations), including but not
limited to Principal Component Analysis, Neighbour–joining and hierarchical trees, STRUCTURE
and chromosome painting.10,12
 Genomic analyses of haplotype length, similarity and diversity, to locate regions under selective
pressure, assess haplotype origin,10,16 or identify genetic introgression and recombination
events.
 Future extended analyses may include genotyping of human variations (restricted only to those
relevant to malaria epidemiology, disease severity and response to antimalarial treatments) and
analyses of their epidemiology and correlations with parasite genetic variants.
 Geographical analyses and mapping; analyses and correlation of genetic data with geographic,
demographic, employment, travel, and mobile phone use information, as well as information on
population movement from aggregated, anonymised CDR to model population movement, its
impact on the distribution of malaria and antimalarial drug resistance and subsequent
prediction of potential routes of the spread of malaria and antimalarial drug resistance.

12. DATA MANAGEMENT

Data flow
Data collection in the field is described above. On every monthly visit to a participating study site, the
PSK-employed medical representative will collect the DBS package and transport it back to Phnom Penh
for quality assurance checks and storage at the PSK office. Per MORU’s QA procedures, samples will not

10 Cambodia, 2017
 be shared if they are missing information on location or date of sampling. PSK will attempt to rectify any
such cases prior to sharing material with MORU.

Once a month the local MORU representative will collect the available packages from PSK’s Phnom Penh
office and transport them to MORU Bangkok for data entry and processing.

The Case Reporting Form will be used as the source document for demographic, employment, travel,
and mobile phone use data. The local Co-PI is responsible for ensuring the accuracy, completeness, and
legibility of the data reported. All source documents will be completed in a neat, legible manner to
ensure accurate interpretation of data. When making changes or corrections, the original entry will be
marked through with a single line, initialled, and dated. There will be no erasing, overwriting, or using
correction fluid or tape on original documents.

Data handling and record keeping

No primary data will be kept by PSK; all DBS, consent forms and Case Reporting Forms will be passed to
MORU for storage.

All study documents will be stored securely at all stages and will be accessible only to study staff and
other authorised personnel. Paper records and DBS will be temporarily stored in locked cabinets in the
local study office at PSK, and periodically transported MORU Bangkok, Thailand for storage for a period
of up to 10 years before being destroyed by shredding. On arrival at MORU, investigators will check that
each survey tool and DBS sample is accompanied by a completed consent form. MORU investigators will
then separate the consent form from the study tools and store then separately. These paper records will
be accessible only to the Chief Investigator in Bangkok and authorised study personnel responsible for
the entry of data into electronic databases, as well as study personnel performing quality assurance.
Study electronic databases will be located at MORU, password-protected and accessible only to the
Chief Investigator and authorised study personnel, including the Co-PIs from PSK and PSI.

Genetic data will be generated only in electronic form, and stored in bespoke database systems
implemented at the WTSI and University of Oxford. These systems will provide access to the genetic
data, and to its accompanying data on location and date of sampling, and will guarantee patient
anonymity (as no personal identifiers are captured as part of this study). Access to the genetic data will
be through anonymous sample barcode identifiers, which do not carry any information about the
patient. Access to the genetic data will be restricted to the Chief Investigator and authorised study
personnel, until the time when the data is made available for open access as stipulated by the data
sharing policy. Access restrictions will be implemented through password-protected access to the
systems.

Data may be used alone or in combination with data from related studies in secondary analyses
(following the necessary ethical approval for such secondary analysis).

Data sharing policy

Anonymised genetic data will be shared with Investigators at MORU and PSK/PSI in the form of Genetic
Report Cards. Genetic Report Cards will contain information about presence of antimalarial drug
resistance-linked genetic mutations and whether there is co-infection with P. vivax and/or P. knowlesi.

11 Cambodia, 2017
 After Genetic Report Cards are shared with Investigators, genetic data from the submitted samples,
together with geographical location and date of sampling, will be deposited in the SpotMalaria Parasite
Evolution Observatory, an open access database of worldwide genetic variation. These data are initially
password-protected until inclusion in the next available data release. Periodic data releases will make
the data open access following a period of analysis by analysis working groups. All data made public via
the SpotMalaria Observatory will be anonymous as no personal identifiers are captured through this
study.

Anonymised data recorded in the Case Reporting Forms will be shared by PSK via DataVerse generally,
and specifically referenced there for open access as per the requirements of any journal in which the
results of the study are published.

A partnership agreement covering data sharing, standard protocols for describing and acknowledging
the study partner roles and SOPs for publishing joint publications will be agreed between MORU and
PSK/PSI in writing.

Sample sharing and storage

Samples collected will be used for the purpose of this study as stated in the protocol and any residual
sample materials stored for up to 10 years for future reanalysis as it is anticipated that the technological
platform will continue to evolve and improve. Consent will be obtained from participants for sample
storage and/or shipment of specific samples to collaborating institutions for investigations that cannot
be performed locally.

Any proposed plans to use samples other than for those investigations detailed in this protocol will be
submitted to the relevant ethics committees prior to any testing.

13. LIMITATIONS
The study success depends primarily on provider commitment to and performance aligned with the
study SOPs. To that end the Co-PIs will closely monitor levels of client recruitment by comparing
monitoring data available through an existing routine electronic system with the number of participants
recruited to this study. Dependent on the outcome of this analysis, the local study team will investigate
the possible role of non-financial incentives for participation.

12 Cambodia, 2017
 14. REGULATORY REQUIREMENTS/ HUMAN SUBJECTS PROTECTION
Risks and Mitigating Risks
Potential Risks
Risks to subjects are Psychological Discomfort/Stress and Breach of Confidentiality.

Psychological Discomfort/Stress: A finger prick is required for this study. This will be a second finger
prick following the one administered outside of the study as part of standard malaria case management.
Conducting a second finger prick could induce stress, discomfort or fear in a subject. However, the
process for the finger prick is identical to the one that will have been used to test the patient in the first
instance, and this will be clearly explained to the subject.

Breach of Confidentiality: In this study, a breach of confidentiality could occur if private information
from the study could be linked to an individual participant and this information was obtained by
person(s) outside of the study. However, the risks to participants of a breach of confidence are very
small. No full names will be recorded on survey tools; location information (home and place of work or
school) will only be recorded at the village level and above (village, commune, district and province); and
survey tools will be linked to dried blood spot samples only by use of an anonymous barcode. On arrival
at MORU, investigators will check that each survey tool and DBS sample is accompanied by a completed
consent form. MORU investigators will then separate the consent form from the study tools and store
then separately.

Strategies to Address Risks

Steps will be taken to protect participants against potential risks, even if it minimal, posed by their
participation in this research. Participants will be encouraged to contact the local PSK Co-PI or any other
named researcher at any time to discuss any concerns they might have. All data and other information
will be maintained confidentially and anonymous to the greatest extent possible. The following steps
will be taken to protect against risks.

Breaches of Confidentiality
1. Identification on data sources.

a. There will be no personal identification of the respondent on questionnaire;

b. Unique, anonymous barcode values will be used to link survey tools to dried blood spot
samples.

2. Staff ethical training. All PPM providers and Mobile Malaria Workers will be recruited from the
existing PSK network. They will be trained in human subject’s protection by PSK-employed medial
represenatives who have participated in a training of trainers; this training will underline the
importance of protecting privacy and confidentiality.

3. Participants’ rights. Research participants will be informed of risks and protections in the consent
form. Participants will also be informed of their right to withdraw from the study and to not answer
any questions they do not feel comfortable answering. Respondents will be provided contact
information for a local PSK employee who will be available to answer any questions about the study.

13 Cambodia, 2017
 4. Data collection procedures will maintain subject confidentiality. PPM providers and Mobile Malaria
Workers will be trained to conduct subject interviews in privacy and to keep all information
obtained confidential. Study materials will be kept in locked storage boxes at PPM and MMW sites
while awaiting collection by PSK medical reprentatives.

5. Data reporting. All results of this research will be reported in aggregate form. Where individual case
data is made available per existing data sharing agreements, no identifying data will be included in
the open access databases.

Psychological Discomfort/Stress
If the respondent expresses discomfort or stress during the study-required finger prick or subsequent
interview, the PPM/MMW provider will pause and remind the respondent they can end their
participation at any time without consequence, or refuse to answer any question they wish; the provider
will give the respondent time to recover before proceeding with data collection (if the respondent
wishes to continue).

The PSK Co-PI will lead a local spot check team that will present at an outlet during the data collection
timeline to ensure that appropriate data collection methodologies are being applied. The spot check
team will silently observe and will stop any data/sample collection they observe in which the study
process is not being followed and/or there is evident discomfort on the part of the respondent. In all
instances the team will offer feedback to the provider based on how they performed during the
observed encounter.

Benefits
There are no direct benefits to the participants for their participation in the study. There are indirect
benefits in that information collected will help the National Malaria Control Program in Cambodia,
MORU, PSK/PSI and partners strengthen their decision-making and implementation activities in light of
rapidly evolving artemisinin drug resistance within the country and the wider GMS.

Consent/Assent procedures
A written consent process will be used. The patient - or the parent, guardian or legal representative of a
legal minor patient - will be given copies of the information sheet and consent form to read. If unable to
read, the entire information sheet and consent form will be read to him/her by the PPM provider or
MMW. Once the consent is read, the participant will be given time to ask questions. The patient, or the
parent, guardian or legal representative of a legal minor patient, will be asked to either sign or
thumbprint on the consent form to proof the agreement to join the study. A copy of the consent form
will be given to the respondent to keep.

There is risk that those under 18 years may be forced to participate in studies by others who have
authority over them. In addition to parental/ guardian consent, assent will be obtained from the legal
minor patients aged 14 to 17 after obtaining adult consent and before study procedures begin.

No participants will be included without their informed consent (and assent where appropriate). The
information sheet will include the following points:

 Explains that they are being asked to participate in research;

14 Cambodia, 2017
  Explains the purpose of this research and the expected number of subjects involved;
 Clarifies the expected duration of the subject’s participation and the procedure followed;
 Explains how the research will benefit the target groups and/or the participant, or society;
 Describes potential risks if any are anticipated or explains that there are no known risks;
 Clarifies that the subject’s participation is anonymous and that individual responses will be
not be linked to identifying information;
 States that the subject’s participation is voluntary and that refusal to participate will have
no consequences;
 States that some questions may cause discomfort and that subjects may refuse to answer
individual questions or desist from the interview at any time;
 Provides the name and telephone number of a local PSK/PSI staff member who the subject
may contact with any pertinent questions about the research, about the health topics
discussed, or to whom the subject may issue a complaint; explains how subjects provide
verbal consent

The information sheet and informed consent forms will be written at a readability level adapted to the
selected audience.

Confidentiality and Privacy

Every effort will be made to protect the confidentiality and the identity of participants. The importance
of confidentiality and the protection of the identity of respondents will be emphasized during training of
PPM providers and MMWs selected as study sites. They will be trained not to share any information
collected during fieldwork.

Subject Compensation
Respondents will receive a towel for their participation in the study. This compensation will be given to
the respondent after completion of the Case Reporting Form. As the value of the towel is small, it will
not result in coercion to participate in the study. The compensation will also be paid even if the
respondent decides that they do not want to complete the discussion.

15. UNANTICIPATED PROBLEMS

PPM providers and MMWs will be trained to report unanticipated problems to the local PSK Co-PI and
programmers as soon as possible. A record of the problem will be kept and shared with the Chief
Investigator based at MORU. If the local team cannot resolve the problem, it will be quickly shared with
the wider research team for assistance.

The local PSK Co-PI will monitor study packages as they return from the field on a monthly basis and
perform quality spot checks on 10% on the case record forms and sample manifests.

16. REFERENCES
X1.Miotto O, Amato R, Ashley Ea, et al. Genetic architecture of artemisinin-resistant Plasmodium
falciparum. Nature Genetics. 2015.

15 Cambodia, 2017
 2. Dondorp AM, Nosten F, Yi P, et al. Artemisinin resistance in Plasmodium falciparum malaria. N
Engl J Med. 2009;361(5):455-467.
3. Amaratunga C, Sreng S, Suon S, et al. Artemisinin-resistant Plasmodium falciparum in Pursat
province, western Cambodia: a parasite clearance rate study. The Lancet infectious diseases.
2012;12(11):851-858.
4. Phyo AP, Nkhoma S, Stepniewska K, et al. Emergence of artemisinin-resistant malaria on the
western border of Thailand: a longitudinal study. Lancet. 2012;379(9830):1960-1966.
5. Ashley EA, Dhorda M, Fairhurst RM, et al. Spread of artemisinin resistance in Plasmodium
falciparum malaria. The New England Journal of Medicine. 2014;371(5):411-423.
6. Amaratunga C, Lim P, Suon S, et al. Dihydroartemisinin-piperaquine resistance in Plasmodium
falciparum malaria in Cambodia: a multisite prospective cohort study. The Lancet. Infectious
diseases. 2016;16(3):357-365.
7. Leang R, Taylor WR, Bouth DM, et al. Evidence of Plasmodium falciparum Malaria Multidrug
Resistance to Artemisinin and Piperaquine in Western Cambodia: Dihydroartemisinin-Piperaquine
Open-Label Multicenter Clinical Assessment. Antimicrobial agents and chemotherapy.
2015;59(8):4719-4726.
8. Saunders DL, Vanachayangkul P, Lon C. Dihydroartemisinin-piperaquine failure in Cambodia. The
New England Journal of Medicine. 2014;371(5):484-485.
9. Carrara VI, Lwin KM, Phyo AP, et al. Malaria burden and artemisinin resistance in the mobile and
migrant population on the Thai-Myanmar border, 1999-2011: an observational study. PLoS
medicine. 2013;10(3):e1001398.
10. World Health Organization. Strategy for Malaria Elimination in the Greater Mekong Subregion
Geneva: World Health Organization;2015.
11. Miotto O, Almagro-Garcia J, Manske M, et al. Multiple populations of artemisinin-resistant
Plasmodium falciparum in Cambodia. Nature Genetics. 2013;45(6):648-655.
12. Takala-Harrison S, Jacob CG, Arze C, et al. Independent emergence of artemisinin resistance
mutations among Plasmodium falciparum in Southeast Asia. The Journal of Infectious Diseases.
2015;211(5):670-679.

16 Cambodia, 2017
Appendix 1: Participant information sheet and consent form

Participant information sheet

Study title: Genetic epidemiology of P. falciparum malaria and associated antimalarial drug
resistance

(To be read to—or read by—patient)

1. Introduction & Study Summary

You/your child have/has been diagnosed with P. falciparum malaria. Falciparum malaria is a type of
malaria which is quite common in this area. It is caused by the falciparum parasite which infects the
blood and is transmitted by mosquitoes.
We would like to invite you/your child to participate in a study to help us better understand the
falciparum parasite as well as to work out where you/your child might have caught the falciparum
infection.
In this information sheet, we will give you/your child information about this study to help you/your child
decide whether or not you/your child would like to take part. If you/your child have any questions or
concerns, you/your child will have a chance to discuss them with the study staff.
In total, about 3,000 patients who have been diagnosed with falciparum malaria in Cambodia are
expected to be recruited into this study every year.

2. Purpose of Study
There is a group of drugs called artemisinins which are recommended by the World Health Organization
(WHO) and used all around the world in combination with a partner drug to treat people with malaria.
These artemisinin-combination therapies have always been considered to work very quickly, and are
very safe and effective at curing the disease.
However, in many places this treatment now takes longer to kill the parasites and in some cases the
treatment has not worked. This means that the artemisinins and their partner drugs may be becoming
less effective and the falciparum parasites are becoming resistant to treatment. There is a concern that
this resistance may be becoming more common in this region and may even spread to other parts of the
world. This has happened before with other antimalarial drugs.
It is important that we study the falciparum parasite and its genes to look for signs of resistance to
artemisinins and other antimalarial drugs, where these parasites with signs of resistance are, whether
these signs of resistance are spreading, as well as collect information to work out where you/your child
might have caught the falciparum infection. This would help with planning how best to treat and stop
the spread of falciparum malaria.

17 Cambodia, 2017
 3. What Does Participation in the Study Involve?
You/your child will have a tiny blood sample taken from your/their finger which will be blotted onto a
small piece of paper. In total, we will collect approximately 1 large drop of your/their blood. It will be
the same as when I took your/your child’s blood for the blood test we just did to test for malaria.
We will also ask you about where you/your child live, where you/your child work, where you/your child
have travelled to recently, and how you/your child use your mobile phone to find out where you/your
child might have been infected by malaria. If you feel you do not want to answer some or all of the
questions asked for any reason, you do not have to do so and you do not need to provide a reason.

4. What Will Happen to My Blood and Data?

The blood will be used to study the falciparum parasite to look for signs of resistance to antimalarial
drugs, to look for infection with other malaria parasites, as well as to get an understanding of where
parasites may have come from and how they are spreading. Samples will be stored at first in Cambodia.
As tests on the samples cannot be done locally in Cambodia, the samples will then be sent to Thailand
for processing and the United Kingdom for analysis. Results from the parasites in your/your child’s
samples will be combined with those from other participants. If you agree to participate in this study,
some of your/your child’s leftover blood samples will be stored for up to 10 years and may be analysed
again for parasite genes as our knowledge and technology improves. In some cases, the blood samples
may also be analysed for human genes, but only for a small number which are related to malaria, such
as genes which are known to make you more or less sick when you are infected with malaria.
Survey data will be used to work out where you/your child may have been infected by malaria. These
data will also be combined with those from other participants for analysis.
Confidentiality
It will not be possible to identify you/your child from the information collected from this study. Any
information collected about you/your child will have a number on it instead of your/their name. All
study documents will be stored securely and will only be seen by authorised study staff.
Sharing Results
We will share the knowledge that we get from this study with your community before it is made
available to the public. There will be small meetings in the community, when these results will be
announced, but no confidential information will be shared. Afterwards, we will publish the results and
make them available so that other interested people may learn from our study.

5. What Are the Benefits of Taking Part?

You/your child will not benefit directly from taking part in this study. However, the results of this study
are likely to be very valuable for future generations, by improving our understanding of malaria and its
ability to become resistant to treatment, as well as where people might be catching the disease. This
would help the planning of treatment and control of malaria in your area.

6. Are There Any Risks in Taking Part?

18 Cambodia, 2017
 The risks are of blood being obtained with a finger prick which include discomfort, occasionally bleeding
or bruising of the skin at the site where the needle goes in, and rarely infection. If any of these occur,
they usually go away in a short period of time.

7. Do I Have to Take Part?

Your/your child’s participation in this study is entirely voluntary. We want to give you enough
information to help you make an informed decision. Once you have this information, it will be your
decision whether to take part or not. You do not have to take part in this study if you do not want to and
you do not need to give a reason. You may ask questions at any time. You may also want to talk to your
family and friends about your decision.
If you do not agree to take part in the study, you will still receive standard care for your malaria, and this
will not affect your medical treatment or legal rights now or in the future.

8. Ethics Committee Review

This study has been reviewed and approved by the Oxford Tropical Research Ethics Committee
(OxTREC), University of Oxford, United Kingdom, the Research Ethics Board of Populations Services
International, and the National Ethical Committee for Health Research of Cambodia.

9. Study Contact Information

If you have any questions or feel you have been harmed in any way by participating in this study, please
contact Mr. Phok Sochea, PSK researcher, tel. 017 562 568.

Participation to this study is voluntary and refusal to participate will have no consequence.

Would you like to take part in this study?

19 Cambodia, 2017
 Informed Consent Form

Study title: Genetic epidemiology of P. falciparum malaria and associated antimalarial drug
resistance

I have/my child has been invited to participate in the study mentioned above.

I confirm that I have read the patient information sheet for the above study or someone else has read
this information to me. I have had the opportunity to consider the information and ask questions, and
have had these answered satisfactorily. I agree to/for my child _______________________________ to
take part in the above study. (print name of child)

In addition,

 I give consent for my/my child’s data and samples to be shipped and stored overseas

 I give consent for my/my child’s data and samples to be retained and used in future research
studies, including genetic studies, if approved by an ethics committee.

o Yes No (tick applicable box)

Signature of participant or parent/guardian _______________________________

Print name of participant or parent/guardian _______________________________

Date _______________________________

Signature of person conducting consent _______________________________

Print name of person conducting consent _______________________________

Date _______________________________

20 Cambodia, 2017
 For patients who cannot read or sign the consent form, they can include their thumbprint in the
following box to indicate their consent.

I cannot read but the investigator/study staff have read the information in this informed consent form to
me and I have fully understood their explanation. Therefore, I provide my thumbprint to indicate my
voluntary consent to/for my child _______________________________ to take part in the above study.
(print name of child)

Signature of person conducting consent _______________________________

Print name of person conducting consent_______________________________

Date _______________________________

Right thumbprint of
patient

Signature of witness _______________________________

Print name of witness _______________________________

Date _______________________________

LEAVE A COPY OF THE STUDY INFORMATION SHEET WITH THE PARTICIPANT

21 Cambodia, 2017
 Appendix 2: Study gantt chart

Description 2017 2018

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Study Design and Questionnaire Development x

PSI REB Preparation and Submission x
PSI REB Approval x
Local REB Preparation and Submission x
Local REB Approval x
Training to provider and MMW for pilot testing x
Pilot Testing x
Adjust tools x
Training to provider and MMW for sample x
collection
Data/Sample Collection x x x x x x x x x x x x
Data/Sample deliver to Moru x x x x x x x x x x x
Data Analysis x x x x x x x x x x
Top line presentation x
Appendix 3: Budget outline for PSK’s contribution to overall study
 Appendix 4: Case Record Form

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 Long Case Record Form: Cambodia PSK

Study Code |___I___| |___I___I___I___|

 Consent obtained Study site: ………………………………..…… Date |___I___|/|___I___|/|___I___|

History obtained from  Patient  Attendant (Relationship to patient………….............
Have you been enrolled in this study before?  YES  NO  don’t know

Age: |___I___| years |___I___| months Initials: |___I___|

Sex: Male Female
Diagnostic test:  RDT  Slide MUST BE POSITIVE
Species:  P. falciparum  P. vivax  Mixed (Pf + Pv)  Unknown
Residence: Village / Phum ……………………….. Commune / Sangkat ………..……………….
District / Srok / Khan ………..………………. Province / Khaet ………..……………….
Occupation:…………………….…. …….…..
Place of work / school: Village / Phum ……………………….. Commune / Sangkat ………..……………….
District / Srok / Khan ………..………………. Province / Khaet ………..……………….
On average, how many days a week do you travel to work / school and back? |___I___| days

TRAVEL IN PREVIOUS 2 MONTHS

Have you visited the forest in the previous 2 months?  YES  NO  I live in the forest

If yes: Why did you go there? …………………………………………………………..

How many times did you go in the previous 2 months? |___I___| per month
How long did you stay in total? |___I___| nights
Where did you go? Village / Phum ……………………….. Commune / Sangkat ………..……………….
District / Srok / Khan ………..………………. Province / Khaet ………..……………….

Have you been to another country in the previous 2 months?  YES  NO

If yes: How many times did you go to another country in the previous 2 months? |___I___|
When did you go?  1-7 days ago  8-14 days ago  15-30 days ago  31-60 days ago
How long did you stay? |___I___| nights
Where did you go? Village / Town / City: ………………………... District / County: ……………………….
Province: ………..……………………. Country: ………..…………………….

Did you frequently travel to another village/town/city for a purpose other than work / school?  YES  NO
If yes: Why did you travel? ………..………………………………………………..

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 How many times did you go in the last 2 months? |___I___| total times How long did you stay in total? |___I___|
nights
Where did you go? Village / Phum ……………………….. Commune / Sangkat ………..……………….
District / Srok / Khan ………..………………. Province / Khaet ………..……………….

Other than this regular travel, have you been to another village/town/city in this country in the past 2
months?
 YES  NO
If yes, please provide more information below and on the next page:
Trip 1: When did you go?  1-7 days ago  8-14 days ago  15-30 days ago  31-60 days ago
How long did you stay? |___I___| nights
Where did you go? Village / Phum ……………………….. Commune / Sangkat ………..……………….
District / Srok / Khan ………..………………. Province / Khaet ………..……………….
Trip 2: When did you go?  1-7 days ago  8-14 days ago  15-30 days ago  31-60 days ago
How long did you stay? |___I___| nights
Where did you go? Village / Phum ……………………….. Commune / Sangkat ………..……………….
District / Srok / Khan ………..………………. Province / Khaet ………..……………….
Trip 3: When did you go?  1-7 days ago  8-14 days ago  15-30 days ago  31-60 days ago
How long did you stay? |___I___| nights
Where did you go? Village / Phum ……………………….. Commune / Sangkat ………..……………….
District / Srok / Khan ………..………………. Province / Khaet ………..……………….

TRAVEL: 2 MONTHS - 4 YEARS AGO

Have you been to another country between 2 months and 4 years ago?  YES  NO
If yes, how many times did you go to another country in this period? |___I___|
Which countries have you been to?  Thailand  Lao PDR  Other – please specify:…………………………..
For the two longest trips:
Trip 1:
When did you go?  2-6 months ago  6-12 months ago  1-2 years ago  2-3 years ago  3-4 years ago
How long did you stay? |___I___I___| nights
Where did you go? Village / Town / City: ………………………... District / County: ……………………….
Province: ………..……………………. Country: ………..…………………….
Trip 2:
When did you go?  2-6 months ago  6-12 months ago  1-2 years ago  2-3 years ago  3-4 years ago
How long did you stay? |___I___I___| nights
Where did you go? Village / Town / City: ………………………... District / County: ……………………….
Province: ………..……………………. Country: ………..…………………….

TRAVEL: ADDITIONAL COMMENTS

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 If you have any additional comments on your travel, please add them here: ……………………………………….
……………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………….

MOBILE PHONE USE

Do you use a mobile phone?  YES  NO Do you own a mobile phone?  YES  NO
If yes to either of these:
Is it a smartphone?  YES  NO  Don’t know
Do you have internet on the phone?  YES  NO  Don’t know
Who is your mobile phone provider? ……………………………….
How many people do you regularly share the mobile phone with? |___I___|
How many days per week do you carry a mobile phone with you? |___| days
How many mobile phone SIM cards do you own? |___I___|
How often do you use the mobile phone?  Several times per day  Daily  Weekly  Less
Do you change SIM cards if you travel to another country?  YES  NO

PARASITE GENOTYPING

Sample collected for parasite genotyping

Fingerprick:  Yes  No  Unable to say

Venepuncture:  Yes  No  Unable to say

Sample barcode number:

|___I___|___I___|___I___|

Place

sticker

here:

CRF Completed by…………….…………………….. Signature………………..….. Date……/……./...........

CRF Checked by...…………….…………………….. Signature………………..….. Date……/……./...........

- 27 - Cambodia, 2012
- 28 - Cambodia, 2012
 Short Case Record Form: Cambodia PSK
Study Code |___I___| |___I___I___I___|

 Consent obtained Study site: ………………………………..…… Date |___I___|/|___I___|/|___I___|

History obtained from  Patient  Attendant (Relationship to patient………….............
Have you been enrolled in this study before?  YES  NO  don’t know
Age: |___I___| years |___I___| months Initials: |___I___|
Sex: Male Female
Diagnostic test:  RDT  Slide MUST BE POSITIVE
Species:  P. falciparum  P. vivax  Mixed (Pf + Pv)  Unknown
Residence: Village / Phum ……………………………….... Commune / Sangkat ………………………………….
District / Srok / Khan ………..…………………. Province / Khaet ……………..…..……….………….

TRAVEL ABROAD:
Have you been to another country in the past 4 years?  YES  NO
If yes, how many times did you go to another country in this period? |___I___|
Which countries have you been to?  Thailand  Lao PDR  Other – please specify:…………………………..
For the two most recent trips:
Trip 1:
When did you go?  <2 months ago  2-6 months ago  6-12 months ago
 1-2 years ago  2-3 years ago  3-4 years ago
How long did you stay? |___I___I___| nights
Where did you go? Village / Town / City: ………………………... District / County: ……………………….
Province: ………..……………………. Country: ………..…………………….
Trip 2:
When did you go?  <2 months ago  2-6 months ago  6-12 months ago
 1-2 years ago  2-3 years ago  3-4 years ago
How long did you stay? |___I___I___| nights
Where did you go? Village / Town / City: ………………………... District / County: ……………………….
Province: ………..……………………. Country: ………..…………………….
PARASITE GENOTYPING
Sample collected for parasite genotyping Sample barcode number: Place
Fingerprick:  Yes  No  Unable to say sticker
Venepuncture:  Yes  No  Unable to say |___I___|___I___|___I___| here:

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