How P vivax strain threatens India’s progress towards malaria elimination by 2030

India has made great strides in its fight against malaria. We’ve been able to develop an elaborate health system as a bulwark against malaria attacks, however, due to the disease’s evolving nature – it continues to threaten millions in the country.

This is partially because of plasmodium vivax (P.vivax) which is recurrent, very difficult to treat and greatly disabling. This strain is different, as the life cycle of P.vivax has an additional stage of placing dormant forms in the liver that can cause multiple malarial attacks over two years, making it one of the most epidemiologically and clinically complex diseases to treat. Therefore, there is a constant need to study and share knowledge about the risk, timing, and frequency of various malaria attacks within the medical community so that cases are not misdiagnosed, and better preventive measures can be taken.  This article aims to analyze the need to ensure that the radical cure for P.vivax happens in real-time, at scale and sustainably.

In 2020, 241 million malaria cases were reported globally, a 6  per cent increase from 2019. Malaria-related deaths stood at a shocking 6,27,000 in 2020, a 12 per cent rise from 2019. Two-thirds of these deaths were attributed to disruptions caused by COVID-19. P.vivax contributes greatly to the high incidences of malaria and related deaths – and its incidences range in the tens of millions . Significant steps have been made into building access and knowledge surrounding the radical cure for P.vivax, however, it will still take a long time to ensure its use for malaria care delivery equally across the world.

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The maxim ‘an ounce of prevention is better than a pound of cure’, finds few better demonstrations than in malaria caused by P.vivax. Vector control is the number one prevention and elimination strategy of these difficult infections. Use of insecticide-treated nets (ITNs), long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) are other effective ways of preventing malaria caused by P.vivax.

Awareness campaigns are also central to fighting vivax malaria. There is a lack of awareness about the severity of the disease in India. Media coverage of acute vivax malaria, and malaria in general, has also been patchy. Reports of the severity of the disease and information about preventive measures do not reach people at the grassroots at sufficient frequency. Under the current policy, it is the responsibility of ASHA workers to drive awareness on matters of public health. However, malariologists should aid in knowledge-building among ASHA workers about the heavy burdens of P.vivax in India and how vivax malaria cannot be considered benign.

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As ASHA workers are also responsible for immunization, community-based screening, risk assessment, and ensuring follow-up action – they need to understand why vivax malaria must be combatted with more rigor than ever before. Therefore, the success of public health campaigns to eradicate malaria rests largely upon training ASHA workers on awareness and communication strategies to slow the spread of P.vivax.

Speaking about treatment for P.vivax, there are rapid elimination therapies that have been developed, like the drugs of blood schizonticides and hypnozoitocides.  Together, these two drug classes are referred to as a ‘radical cure’ in malariology. The partnership of chloroquine and primaquine has been the only pair of drugs with no drug-drug interactions and remains the most effective radical cure of vivax-caused malaria. However, P.vivax is becoming resistant to chloroquine, which has led to the development of new blood schizonticide-primaquine partnerships. The difficulty of consistently finding new blood schizonticides as the disease evolves will limit the therapeutical options for the radical cure of vivax malaria.

Secondly, the only drug that’s resistant to relapses of P.vivax is primaquine, a drug that causes mild, severe and fatal cases of acute hemolytic anemia in patients having an inborn deficiency of glucose-6-phosphate dehydrogenase (G6PD). This complex disorder affects 400 million persons globally, with an average prevalence in malaria-endemic nations of 8%. [3] There is technology to diagnose the G6PD deficiency where most of the patients live, but point-of-care testing needs to be strengthened.

Usually, once the chloroquine treatment commences, post 3-4 days, patients start feeling better. In fear of causing more harm than good, most providers either do not prescribe the primaquine treatment at all or fail to request their patients to take the medication as directed – patients too don’t seem keen on continuing with the required medication as they’re seeing results with the chloroquine.

The 14 days of daily dosing with primaquine has been designed with G6PD deficiency safety in mind, i.e. patients taking the drug under recommended clinical supervision could cease the regimen with the onset of signs of hemolytic reaction. Not providing regular supervision of the primaquine treatment invites the danger of the patient ignoring the signs of hemolysis or not recognizing them while following the doctor’s orders.

Therefore, we must ensure that vulnerable and infected patients can get the supervision that they deserve. In India, since most of the population’s healthcare needs are catered to by both the formal and informal private sector, it ultimately becomes even more important to ensure that the radical cure for P.vivax is properly administered.

The author is Director-Health, Research Triangle Institute International. Views are personal.

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