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ANNEX 9. Treatment of Plasmodium vivax, P. ovale and P. malariae infections

a9.6 Question:
What is the best treatment for P. vivax malaria in areas of chloroquine resistant
P. vivax?

Background
As ACTs become widely available and chloroquine resistance becomes more widespread,
it is important to assess the effects of ACTs on P. vivax.

GraDE approach
The benefits and harms of ACTs versus the standard treatments for P. vivax were assessed
(search date: January 2009).
1. Are ACTs more effective than CQ in areas of CQ resistant P. vivax? (No evidence
available.)
2. Are ACTs with primaquine more effective at reducing relapses of P. vivax than CQ
with primaquine in areas of CQ resistant P. vivax? (No evidence available.)
3. Is one ACT (plus primaquine) more effective than another for treatment of P. vivax
in areas with CQ resistant P. vivax? (See GRADE tables 9.6.1 and 9.6.2.)

When assessing this evidence the WHO GRADE panel considered the following factors
to be important:
• ACTs do not have a substantial effect on the liver stage of P. vivax so radical cure
requires primaquine.
• In areas with chloroquine resistance the recommendation concerns ACTs as a
replacement for CQ.

Other considerations

The ability of ACTs to delay or reduce relapses due to P. vivax is likely to reflect the
pharmacokinetics of the drug. DHA+PPQ has a notably longer half-life than AL6 and
AS+AQ and a similar half-life to AS+MQ.

Decision

On the basis of this evidence, the WHO GRADE panel made a weak recommendation
that DHA+PPQ may be superior to AL6 and AS+AQ for the treatment of P. vivax. A9

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