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We conducted a review of the effects of adding a single dose (or short course) of primaquine to
malaria treatment with the aim of reducing the transmission of malaria. We included 17
randomized controlled trials and one quasi-randomized controlled trial.
Primaquine is an antimalarial drug which does not cure malaria illness, but is known to kill the
gametocyte stage of the malaria parasite which infects mosquitoes when they bite humans.
Primaquine is also known to have potentially serious side effects in people with an enzyme
deficiency common in many malaria endemic settings (glucose-6-phosphate dehydrogenase
(G6PD) deficiency). In these people, high doses of primaquine given over several days
sometimes destroys red blood cells, causing anaemia and, in some cases, possibly life-
threatening effects.
The World Health Organization (WHO) recommends adding a single dose of primaquine to
malaria treatment with the intention of reducing malaria transmission and to contribute to
malaria elimination. This recommendation was made in 2010, but in 2013 the WHO amended its
recommendation from a dose of 0.75 mg/kg to 0.25 mg/kg due to concerns about safety, and
indirect evidence suggesting this was as effective as the higher dose.This review examines the
evidence of benefits and harms of using primaquine in this way, and looks for evidence that
primaquine will reduce malaria transmission in communities.
We did not find any studies that tested whether primaquine added to malaria treatment reduces
the community transmission of malaria.
When added to current treatments for malaria (artemisinin-based combination therapy), we found
no studies evaluating the effects of primaquine on the number of mosquitoes infected. However,
primaquine does reduce the duration of infectiousness (the period that gametocytes are detected
circulating in the blood) when given at doses of 0.4 mg/kg or above (high quality evidence). We
only found one study using 0.1 mg/kg but this study did not conclusively show that primaquine
was still effective at this dose (low quality evidence).
When added to older treatments for malaria, two studies showed that primaquine at doses of 0.75
mg/kg reduced the number of mosquitoes infected after biting humans (low quality evidence).
Doses above 0.4 mg/kg reduced the duration of detectable gametocytes (high quality evidence),
but in a single study of the currently recommended 0.25 mg/kg no effect was demonstrated (very
low quality evidence).
Some studies excluded patients with G6PD deficiency, some included them, and some did not
comment. Overall the safety of PQ given as a single dose was poorly evaluated across all studies,
so these data do not demonstrate whether the drug is safe or potentially harmful at this dosing
level.
Mosquitoes become infected with Plasmodium when they ingest gametocyte-stage parasites from
an infected person's blood. Plasmodium falciparum gametocytes are sensitive to the drug
primaquine (PQ) and other 8-aminoquinolines (8AQ); these drugs could prevent parasite
transmission from infected people to mosquitoes, and consequently reduce the incidence of
malaria. However, PQ will not directly benefit the individual, and could be harmful to those with
glucose-6-phosphate dehydrogenase (G6PD) deficiency.
In 2010, The World Health Organization (WHO) recommended a single dose of PQ at 0.75
mg/kg, alongside treatment for P. falciparum malaria to reduce transmission in areas
approaching malaria elimination. In 2013 the WHO revised this to 0.25 mg/kg due to concerns
about safety.
Objectives:
Search strategy:
We searched the following databases up to 10 Feb 2014 for trials: the Cochrane Infectious
Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials
(CENTRAL), published in The Cochrane Library; MEDLINE; EMBASE; LILACS;
metaRegister of Controlled Trials (mRCT); and the WHO trials search portal using 'malaria*',
'falciparum', and 'primaquine' as search terms. In addition, we searched conference proceedings
and reference lists of included studies, and contacted researchers and organizations.
Selection criteria:
Randomized controlled trials (RCTs) or quasi-RCTs comparing PQ (or alternative 8AQ) given as
a single dose or short course alongside treatment for P. falciparum malaria with malaria
treatment given without PQ/8AQ in adults or children.
Main results:
We included 17 RCTs and one quasi-RCT. Eight studies tested for G6PD status: six then
excluded participants with G6PD deficiency, one included only those with G6PD deficiency, and
one included all irrespective of status. The remaining ten trials either did not report on whether
they tested (8), or reported that they did not test (2). Nine trials included study arms with
artemisinin-based malaria treatment regimens, and eleven included study arms with non-
artemisinin-based treatments.
Only two trials evaluated PQ given at low doses (0.25 mg/kg in one and 0.1 mg/kg in the other).
Authors' conclusions:
For the currently recommended low dose regimen, there is little direct evidence to be confident
that the effect of reduction in gametocyte prevalence is preserved.
Most trials excluded people with G6PD deficiency, and thus there is little reliable evidence from
controlled trials of the safety of PQ in single dose or short course.