Mass primaquine treatment to eliminate vivax malaria: lessons from the past

Published 7 February 2014 by Malaria Journal

As efforts to treat Plasmodium falciparum have seen increasing success, the proportion of Plasmodium vivax (P.vivax) cases may continue to rise. A significant obstacle to malaria elimination in Asia is the large burden of Plasmodium vivax, which is more difficult to eliminate than Plasmodium falciparum. The Malaria Atlas Project (MAP) estimates that some 2.85 billion people were at risk of contracting the illness in 2009.¹ While less life-threatening than P. falciparum, P. vivax is a major cause of death, particularly amongst women and children in low-income countries. Despite this tremendous disease burden, less than 3.1% of global funding for malaria research was committed to P. vivax in the last 10 years.

A recent paper published by Malaria Journal highlights the complexity of drug treatment options for P. vivax, "Persistent P. vivax liver stages can be eliminated only by radical treatment with a > 7-day course of an 8-aminoquinoline drug." In addition there are further risks of complications such as acute haemolytic anaemia in some patients often caused by a deficiency in Glucose-6-phosphate dehydrogenase (G6PD). Primaquine is the only generally available 8-aminoquinoline, yet despite the widespread recommendation in drug treatment guidelines it is often not prescribed due to the difficulties in identifying and confirming the G6PD deficiency and resultant risks of treatment failure. 

Despite these complications, several countries in Eastern Europe and Asia have tried to eradicate P. vivax by treating large numbers of patients without testing for the anaemia susceptibility. Tajikistan (formerly USSR) and Northern Afghanistan were cited to have a G6PD deficiency prevalence of up to 38.7%, yet despite these numbers, reported levels of severe adverse affects related to primaquine treatment were very low. Patients were administered a 14-day "standard" or a 17-day "interrupted" primaquine dose in a concerted effort to control further malaria outbreaks.

The authors results suggest that, if carefully managed and monitored, mass drug administration of primaquine can be effectively used to as a preventive measure for P.vivax malaria in endemic regions. The critical success factor appears to be the routine supervision and ongoing monitoring of patients for adverse reactions or risk factors. Reassuringly, the approach used has achieved high population treatement coverage and substantially reduced P.vivax malaria transmission across several countries. 

Download the latest paper by Kondrashin et al entitled Mass primaquine treatment to eliminate vivax malaria: lessons from the past Malaria Journal 2014, 13:51; doi:10.1186/1475-2875-13-51.

¹ Guerra CA, Howes RE, Patil AP, Gething PW, Van Boeckel TP, et al. The International Limits and Population at Risk of Plasmodium vivax Transmission in 2009. PLoS Negl Trop Dis 2010; 4(8): e774. doi:10.1371/journal.pntd.0000774

² Price RN, Tjitra E, Guerra CA, Yeung S, White NJ, Anstey NM. Vivax Malaria: Neglected and Not Benign. American Journal of Tropical Medicine and Hygiene 2007; 77 (Suppl 6): 79–87.
³ Carlton JM, Sina BJ, Adams JH. Why Is Plasmodium vivax a Neglected Tropical Disease? PLoS Negl Trop Dis 2011; 5(6): e1160. 2,3