The WHO malaria treatment guidelines recommend a total dose in the range of 3.5 to 7.0 mg/kg of primaquine to eliminate Plasmodium vivax (P. vivax) hypnozoites and prevent relapses. There are however indications that for tropical P. vivax isolates, notably from Southeast Asia, the lower dose of 3.5 mg/kg is insufficient. Determining the most effective regimen to eliminate P. vivax hypnozoites is needed to achieve elimination of this malaria parasite. We conducted an open-label randomised controlled trial in Kampong Speu province, Western Cambodia. P. vivax infected patients with uncomplicated malaria, diagnosed at the community level or in health centres of the province, were offered to participate. Patients aged less than 15 years old, and pregnant or breastfeeding women were excluded. Enrolled patients were treated with a blood schizonticidal artesunate regimen of 2 mg/kg/day for 7 days. Upon enrolment, patients glucose-6-phosphate dehydrogenase (G6PD) activity was determined. G6PD normal patients were randomly assigned (2:2:1) to receive either (i) 3.5 mg/kg (low dose as 0.25 mg/kg/day) or (ii) 7.0 mg/kg (high dose as 0.5 mg/kg/day) of primaquine over 14 days or (iii) no primaquine as comparator arm. G6PD deficient patients were assigned to the no-primaquine comparator arm. Randomisation was done by blocks of 5 using sealed envelopes. Upon enrolment, patients were relocated to the study site in Aoral town where no malaria transmission occurs to ensure that they were not reinfected during their 90-day follow-up. After 90 days of relocation, G6PD normal patients in the no-primaquine arm were provided 3.5 mg/kg for 14 days of primaquine to be taken unsupervised. At day 90, all the patients returned home and they were further followed monthly for three months until day 180. The primary outcome was the treatment failure rate defined as the proportion of patients with at least one P. vivax recurrence within 90 days of relocated follow-up. All patients that completed treatment and complied with relocation without interruption before any recurrence was detected were included in the primary efficacy analysis. All patients enrolled and assigned to an intervention arm were included in the safety analysis. Between Nov 10, 2021, and Feb 10, 2024, a total of 160 patients were enrolled and 156 were allocated to one of the three study arms. Of these, 37 G6PD deficient patients were assigned to the no primaquine arm and 119 G6PD normal patients were randomised: 24 in the no primaquine arm, 49 in the primaquine 3.5 mg/kg arm, and 46 in the primaquine 7.0 mg/kg arm. The proportion of participants with at least one P. vivax recurrence within 90 days in the no primaquine arm was 81.4% (95% CI 69.6-89.2). The proportion of participants with recurrence was higher in the low dose primaquine arm (24.4%, 95% CI 14.2-38.7) compared to the high primaquine arm (4.7%, 95% CI 0.8-15.5, p=0.0141) resulting in a hazard ratio of high dose primaquine compared to low dose of 0.17 (95% CI 0.04-0.79, p=0.0229). Both primaquine arms were well tolerated. Not providing primaquine to patients led to a considerable rate of P. vivax recurrence. The risk of P. vivax recurrence was 5.9 times lower for the 7.0 mg/kg of primaquine treatment compared to 3.5 mg/kg. Tolerability and safety of both primaquine regimens in G6PD normal individuals was comparable. Policy makers in Cambodia and most likely in other Southeast Asian countries should endorse the 7.0 mg/kg of primaquine regimen to reduce the risk of P. vivax relapses.

The authors have declared no competing interest.

NCT04706130

This study was funded by the NIH/NIAID (R01AI146590).

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The National Ethics Committee for Health Research of Cambodia and the University of Maryland Institutional Review Boardgave ethical approval for this work

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