Addressing health equity for breastfeeding women: primaquine for Plasmodium vivax radical cure
Issued Date
2024-09-27
Resource Type
eISSN
14752875
Scopus ID
2-s2.0-85205336732
Pubmed ID
39334094
Journal Title
Malaria journal
Volume
23
Issue
1
Rights Holder(s)
SCOPUS
Bibliographic Citation
Malaria journal Vol.23 No.1 (2024) , 287
Suggested Citation
Abla N., Marrast A.C., Jambert E., Richardson N., Duparc S., Almond L., Rowland Yeo K., Pan X., Tarning J., Zhao P., Culpepper J., Waitt C., Koldeweij C., Cole S., Butler A.S., Khier S., Möhrle J.J., El Gaaloul M. Addressing health equity for breastfeeding women: primaquine for Plasmodium vivax radical cure. Malaria journal Vol.23 No.1 (2024) , 287. doi:10.1186/s12936-024-05112-9 Retrieved from: https://repository.li.mahidol.ac.th/handle/20.500.14594/101521
Title
Addressing health equity for breastfeeding women: primaquine for Plasmodium vivax radical cure
Author's Affiliation
Makerere University College of Health Sciences
Mahidol Oxford Tropical Medicine Research Unit
Certara, United Kingdom
Institut Montpelliérain Alexander Grothendieck
Medicines and Healthcare products Regulatory Agency
Bill & Melinda Gates Foundation
University of Liverpool
Nuffield Department of Medicine
Radboud University Medical Center
Medicines for Malaria Venture
Magenta Communications Ltd
Mahidol Oxford Tropical Medicine Research Unit
Certara, United Kingdom
Institut Montpelliérain Alexander Grothendieck
Medicines and Healthcare products Regulatory Agency
Bill & Melinda Gates Foundation
University of Liverpool
Nuffield Department of Medicine
Radboud University Medical Center
Medicines for Malaria Venture
Magenta Communications Ltd
Corresponding Author(s)
Other Contributor(s)
Abstract
Plasmodium vivax malaria remains a global health challenge, with approximately 6.9 million estimated cases in 2022. The parasite has a dormant liver stage, the hypnozoite, which reactivates to cause repeated relapses over weeks, months, or years. These relapses erode patient health, contribute to the burden of malaria, and promote transmission. Radical cure to prevent relapses requires administration of an 8-aminoquinoline, either primaquine or tafenoquine. However, malaria treatment guidelines updated by the World Health Organization (WHO) in October 2023 restrict primaquine use for women breastfeeding children < 6 months of age, or women breastfeeding older children if their child is G6PD deficient or if the child's G6PD status is unknown. Primaquine restrictions assume that 8-aminoquinoline exposures in breast milk would be sufficient to cause haemolysis in the nursing infant should they be G6PD deficient. WHO recommendations for tafenoquine are awaited. Notably, the WHO recommends that infants are breastfed for the first 2 years of life, and exclusively until 6 months old. Repeated pregnancies, followed by extended breastfeeding leaves women in P. vivax endemic regions potentially vulnerable to relapses for many years. This puts women's health at risk, increases the malaria burden, and perpetuates transmission, hindering malaria control and elimination. The benefits of lifting restrictions on primaquine administration to breastfeeding women are significant, avoiding the adverse consequences of repeated episodes of acute malaria, such as severe anaemia. Recent data challenge the restriction of primaquine in breastfeeding women. Clinical pharmacokinetic data in breastfeeding infants ≥ 28 days old show that the exposure to primaquine is very low and less than 1% of the maternal exposure, indicating negligible risk to infants, irrespective of their G6PD status. Physiologically-based pharmacokinetic modelling complements the clinical data, predicting minimal primaquine exposure to infants and neonates via breast milk from early post-partum. This article summarizes the clinical and modelling evidence for a favourable benefit:risk evaluation of P. vivax radical cure with primaquine for breastfeeding women without the need for infant G6PD testing, supporting a change in policy. This adjustment to current treatment guidelines would support health equity in regard to effective interventions to protect women and their children, enhance malaria control strategies, and advance P. vivax elimination.