Abstract
BackgroundThe Bangladeshi national treatment guidelines for uncomplicated malaria follow WHO recommendations but without G6PD testing prior to primaquine administration. A prospective observational study was conducted to assess the efficacy of the current antimalarial policy.MethodsPatients with uncomplicated malaria, confirmed by microscopy, attending a health care facility in the Chittagong Hill Tracts, Bangladesh, were treated with artemether-lumefantrine (days 0–2) plus single dose primaquine (0.75mg/kg on day2) for P. falciparum infections, or with chloroquine (days 0–2) plus 14 days primaquine (3.5mg/kg total over 14 days) for P. vivax infections. Hb was measured on days 0, 2 and 9 in all patients and also on days 16 and 30 in patients with P. vivax infection. Participants were followed for 30 days. The study was registered with the clinical trials website (NCT02389374).ResultsBetween September 2014 and February 2015 a total of 181 patients were enrolled (64% P. falciparum, 30% P. vivax and 6% mixed infections). Median parasite clearance times were 22.0 (Interquartile Range, IQR: 15.2–27.3) hours for P. falciparum, 20.0 (IQR: 9.5–22.7) hours for P. vivax and 16.6 (IQR: 10.0–46.0) hours for mixed infections. All participants were afebrile within 48 hours, two patients with P. falciparum infection remained parasitemic at 48 hours. No patient had recurrent parasitaemia within 30 days. Adjusted male median G6PD activity was 7.82U/gHb. One male participant (1/174) had severe G6PD deficiency (<10% activity), five participants (5/174) had mild G6PD deficiency (10–60% activity). The Hb nadir occurred on day 2 prior to primaquine treatment in P. falciparum and P. vivax infected patients; mean fractional fall in Hb was -8.8% (95%CI -6.7% to -11.0%) and -7.4% (95%CI: -4.5 to -10.4%) respectively.ConclusionThe current antimalarial policy remains effective. The prevalence of G6PD deficiency was low. Main contribution to haemolysis in G6PD normal individuals was attributable to acute malaria rather than primaquine administration.Trial RegistrationClinicalTrials.gov NCT02389374
Highlights
In Bangladesh approximately 14 million people are at risk of malaria infection, with 13 out of 64 districts reporting clinical cases in 2012 [1]
Patients with uncomplicated malaria, confirmed by microscopy, attending a health care facility in the Chittagong Hill Tracts, Bangladesh, were treated with artemether-lumefantrine plus single dose primaquine (0.75mg/kg on day2) for P. falciparum infections, or with chloroquine plus 14 days primaquine (3.5mg/kg total over 14 days) for P. vivax infections
All participants were afebrile within 48 hours, two patients with P. falciparum infection remained parasitemic at 48 hours
Summary
In Bangladesh approximately 14 million people are at risk of malaria infection, with 13 out of 64 districts reporting clinical cases in 2012 [1]. The CHT are located on the Bangladesh- Myanmar border and are a potential gateway for the spread of artemisinin resistance from the Mekong region into the Indian subcontinent and onwards into Africa. The last systematic evaluation of the national guidelines for the treatment of uncomplicated malaria was conducted in 2009 [14], with a subsequent trial of artesunate monotherapy in 2012 [15]. Both studies demonstrated the high efficacy of artemisinin against P. falciparum in this region. The Bangladeshi national treatment guidelines for uncomplicated malaria follow WHO recommendations but without G6PD testing prior to primaquine administration. A prospective observational study was conducted to assess the efficacy of the current antimalarial policy
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