Overall Malaria Situation and Challenges in Lao PDR 7 July 2015 Updating of Malaria NSP Stakeholder Workshop Thalat, Vientiane Province Dr. Bouasy Director, CMPE

Outline of Presentation 1. Emergence of Pv malaria burden 2. Piloting of Primaquine Radical Treatment of Vivax Malaria 3. Monitoring of patients on Primaquine 4. Progress to-date 5. Recommendations on the way forward

3 Emergence of Pv Malaria Burden Note: Species breakdown in 2014: Pf-49.9%, Pv-46.9% and Mixed-3.1% Note: Combo RDTs introduced in Q4, 2011.

Pilot Study on Primaquine for Vivax Malaria A pilot study (April-September 2015) has begun of the use of the AccessBio CareStart RDT to detect G6PD status in Plasmodium vivax patients to facilitate safe use of primaquine. The first field use started late April 2015, in three provinces at the provincial and district hospitals of Luangprabang, Savannakhet, and Champasack. The RDT identifies those who are G6PD normal. All those who are G6PD normal are administered Primaquine 0.25 mg / kg / daily dose (15 mg. for adults) for 14 days. G6PD positive cases are excluded from the pilot.

Monitoring of Patients Primaquine was given only to G6PD-normal patients. These patients were monitored on Day 0, Day 4, and Day 7 for their anemia status with either hemoglobin or hematocrit. There were zero patients that showed any change in either hemoglobin or hematocrit at any time post-treatment.

Progress till date After two months of the implementation of the pilot:  308 vivax patients enrolled (231 from Champasack, 30 from Savannakhet and 47 from Luangprabang)  294 G6PD-normal (95.5%), 14 G6PD- deficient (4.5%)

G6PD Status & Primaquine Piloting Period:April + May 2015 (piloting period: April-Sept 2015) Targeted area:All districts of 3 provinces: Champasack (Tier 1), Savannakhet (Tier 2), Luangprabang (Tier 3) Inclusion Criteria:Pv (+), G6PD normal, willingness for 14 days treatment course with Hb follow-up on D4 N=308

G6PD Status in the 3 pilot provinces

Compliance with Primaquine among G6PD Normal Pv Patients

Recommendations on the way forward On 3 July 2015, the Technical Working Group-Malaria met at CMPE, discussed the results and made following recommendations for G6PD testing and safe use of primaquine.  Primaquine should be prescribed according to patient’s bodyweight  0.25 mg / kg / daily dose for G6PD-14 days- normal patients  0.75 mg / kg / weekly dose for G6PD-deficient patients - 8wks  At present, primaquine can only be used at district level facilities (by FDD regulation)  No longer necessary to monitor hemoglobin in G6PD-normal patients  Expansion of the pilot project as soon as possible to cover all central hospitals in Vientiane, military hospitals, and provincial hospitals; however, the current stock of G6PD RDTs (4000) will limit this expansion, until new stock is procured (GF RAI and ADB)

Recommendations on the way forward  Telephone monitoring of compliance (Telephone observed treatment- TOT) until Day14 should continue for all patients.  G6PD-deficient patients should also receive primaquine, but with close medical supervision/monitoring of any hemolysis resulting from primaquine use  If laboratory confirmation (fluorescent spot test or PCR) is available, this could be used to further validate the G6PD RDT results.  Follow up of vivax cases is a priority issue; CMPE needs to develop a patient card and create physician’s role to recognize and treat vivax relapse cases.  All vivax patients diagnosed at Health Center or by community health workers should be referred to nearest District Hospital for primaquine treatment.  The National Treatment Guidelines should be revised regarding the Standard Use of G6PD RDT to guide safe use of primaquine.