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Dihydroartemisinin-piperaquine versus chloroquine to treat vivax malaria in Afghanistan: an open randomized, non-inferiority, trial.

Awab, GR; Pukrittayakamee, S; Imwong, M; Dondorp, AM; Woodrow, CJ; Lee, SJ; Day, NP; Singhasivanon, P; White, NJ; Kaker, F (2010) Dihydroartemisinin-piperaquine versus chloroquine to treat vivax malaria in Afghanistan: an open randomized, non-inferiority, trial. MALARIA JOURNAL, 9 (105). ISSN 1475-2875
SGUL Authors: Woodrow, Charles Jonathan

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BACKGROUND: Afghanistan's national guidelines recommend chloroquine for the treatment of Plasmodium vivax infection, the parasite responsible for the majority of its malaria burden. Chloroquine resistance in P. vivax is emerging in Asia. Therapeutic responses across Afghanistan have not been evaluated in detail. METHODS: Between July 2007 and February 2009, an open-label, randomized controlled trial of chloroquine and dihydroartemisinin-piperaquine in patients aged three months and over with slide-confirmed P. vivax mono-infections was conducted. Consistent with current national guidelines, primaquine was not administered. Subjects were followed up daily during the acute phase of illness (days 0-3) and weekly until day 56. The primary endpoint was the overall cumulative parasitological failure rate at day 56 after the start of treatment, with the hypothesis being that dihydroartemisinin-piperaquine was non-inferior compared to chloroquine (Delta = 5% difference in proportion of failures). RESULTS: Of 2,182 individuals with positive blood films for P. vivax, 536 were enrolled in the trial. The day 28 cure rate was 100% in both treatment groups. Parasite clearance was more rapid with dihydroartemisinin-piperaquine than chloroquine. At day 56, there were more recurrent infections in the chloroquine arm (8.9%, 95% CI 6.0-13.1%) than the dihydroartemisinin-piperaquine arm (2.8%, 95% CI 1.4-5.8%), a difference in cumulative recurrence rate of 6.1% (2-sided 90%CI +2.6 to +9.7%). The log-rank test comparing the survival curves confirmed the superiority of dihydroartemisinin-piperaquine over chloroquine (p = 0.003). Multivariate analysis showed that a lower initial haemoglobin concentration was also independently associated with recurrence. Both regimens were well tolerated and no serious adverse events were reported. CONCLUSIONS: Chloroquine remains an efficacious treatment for the treatment of vivax malaria in Afghanistan. In a setting where radical therapy cannot be administered, dihydroartemisinin-piperaquine provides additional benefit in terms of post-treatment prophylaxis, reducing the incidence of recurrence from 4-8 weeks after treatment.

Item Type: Article
Additional Information: © 2010 Awab et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Keywords: Adolescent, Afghanistan, Antimalarials, Artemisinins, Child, Child, Preschool, Chloroquine, Drug Administration Schedule, Drug Therapy, Combination, Female, Follow-Up Studies, Humans, Infant, Malaria, Vivax, Male, Multivariate Analysis, Plasmodium vivax, Prospective Studies, Quinolines, Recurrence, Treatment Outcome, Science & Technology, Life Sciences & Biomedicine, Parasitology, Tropical Medicine, UNCOMPLICATED PLASMODIUM-FALCIPARUM, SULFADOXINE-PYRIMETHAMINE, THERAPEUTIC RESPONSES, NORTHERN AFGHANISTAN, PRIMAQUINE THERAPY, ANTIMALARIAL-DRUGS, PAKISTAN, RESISTANCE, INFECTION, INDONESIA
Journal or Publication Title: MALARIA JOURNAL
ISSN: 1475-2875
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21 April 2010Published
Web of Science ID: WOS:000277363200001
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