Ethics, economics, and the use of primaquine to reduce falciparum malaria transmission in asymptomatic populations

Abstract

© 2014 Lubell et al. Rapidly achieving falciparum malaria elimination could require mass antimalarial treatment of asymptomatic individuals to eliminate the parasite reservoir that sustains malaria transmission. Primaquine is the only licenced antimalarial that kills mature Plasmodium falciparum gametocytes, but it is associated with a dose-dependent risk of haemolysis in G6PD-deficient individuals. We discuss ethical and economic considerations pertaining to mass primaquine administration in malaria elimination programmes, which go beyond those encountered in other public health interventions. These include the lower direct benefit for individuals at higher risk, the increasingly available diagnostic tests for G6PD deficiency, and the economic implications of testing. We propose a research agenda to assist informed and rational policy decision making in the rollout of primaquine mass drug administration that is pragmatically and economically viable and within acceptable ethical standards.