The use of ultrasensitive quantitative-PCR to assess the impact of primaquine on asymptomatic relapse of Plasmodium vivax infections: a randomized, controlled trial in Lao PDR

Abstract

Background: Trials to assess the efficacy of the radical cure of Plasmodium vivax malaria with 8-aminoquinolines require that most post-treatment relapses are identified, but there is no consensus on the optimal duration of follow-up in either symptomatic or asymptomatic vivax malaria. The efficacy of a 14-day course of primaquine on the cumulative incidence of recurrent asymptomatic P. vivax infections detected by ultrasensitive quantitative PCR (uPCR) as a primary endpoint was assessed.

Methods: A randomized, placebo-controlled, single-blind trial was conducted in four villages of the Lao PDR during 2016-2018 nested in a larger project evaluating mass drug administrations (MDA) with dihydroartemisinin-piperaquine (DP) and a single low-dose primaquine to clear Plasmodium falciparum infections. In the nested sub-study, eligible participants with mono- or mixed P. vivax infections detected by uPCR were randomized to receive either 14 days of primaquine (0.5 mg/kg/day) or placebo during the last round of MDA (round 3) through directly observed therapy. Participants were checked monthly for 12 months for parasitaemia using uPCR. The primary outcome was cumulative incidence of participants with at least one recurrent episode of P. vivax infection.

Results: 20 G6PD-normal participants were randomized in each arm. 5 (29%) of 20 participants in the placebo arm experienced asymptomatic, recurrent P. vivax infections, resulting in a cumulative incidence at month 12 of 29%. None of the 20 participants in the intervention arm had recurrent infections (p = 0.047 Fisher's exact test). Participants with recurrent P. vivax infections were found to be parasitaemic for between one and five sequential monthly tests. The median time to recurrence of P. vivax parasitaemia was 178 days (range 62-243 days).

Conclusions: A 14-day course of primaquine in addition to a DP-MDA was safe, well-tolerated, and prevented recurrent asymptomatic P. vivax infections. Long follow-up for up to 12 months is required to capture all recurrences following the treatment of asymptomatic vivax infection. To eliminate all malarias in settings where P. vivax is endemic, a full-course of an 8-aminoquinolines should be added to MDA to eliminate all malarias. Trial registration This study was registered with ClinicalTrials.gov under NCT02802813 on 16th June 2016. https://ichgcp.net/clinical-trials-registry/NCT02802813.

Keywords: Malaria; P. vivax; PCR; Primaquine; Relapse.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1

Map of study site (red star indicates study site)

Fig. 2

Consort flow chart of recruitment. uPCR ultrasensitive polymerase chain reaction, G6PD glucose 6 phosphate dehydrogenase deficiency, FU follow-up

Fig. 3

Cumulative recurrent incidence of P. vivax infections by intervention

Fig. 4

The pattern of recurrent P. vivax infections in 5 study participants all in the placebo group. The x-axis shows the time of the survey in relation to the drug administration (D = Day, M = Month; Baseline of Recurrent 1, 2, and 3 = M0 of malaria elimination project; Baseline of Recurrent 4 and 5 = During cross sectional surveys of malaria elimination project either M6, M9 or M12). The y-axis shows the density (genomes/ml) on a log scale. The numbers above the columns indicate the parasite density at that point in time

Fig. 5

Changes in haemoglobin level of participants in primaquine and placebo arms over the first 28 days after drug administration