Background
Methods
Design
Study participants
SSI# | Age range in years | Sex | Country | Qualification | Type of job |
---|---|---|---|---|---|
SSI-1 | 50–60 | M | Nepal | PhD | Government |
SSI-2A | 40–50 | M | Bhutan | MPH | Government |
SSI-2B | 50–60 | M | Bhutan | PG Diploma | Government |
SSI-3 | 40–50 | M | Nepal | MD, MPH | Non-Government |
SSI-4 | 40–50 | M | Pakistan | MBBS, MPH | Government |
SSI-5 | 50–60 | M | Nepal | MD, MSc | Non-Government |
SSI-6 | 40–50 | M | India | MD | Government |
SSI-7 | 60–70 | M | Bangladesh | MD, PhD | Government |
SSI-8 | 50–60 | M | Bhutan | PhD | Non-Government |
SSI-9 | 50–60 | M | Cambodia | MD, MPH | Non-Government |
SSI-10 | 50–60 | M | Laos | MD, PhD | Government |
SSI-11 | 50–60 | M | Afghanistan | MPH | Government |
SSI-12 | 50–60 | M | Cambodia | MD, MPH | Non-Government |
SSI-13 | 50–60 | M | Cambodia | MD | Non-Government |
SSI-14 | 40–50 | F | Afghanistan | MD, MPH | Government |
SSI-15 | 50–60 | M | Salomon Island | MPH | Government |
SSI-16 | 40–50 | M | Pakistan | MSc | Government |
SSI-17 | 50–60 | M | Philippines | MD, MPH | Government |
SSI-18 | 40–50 | F | Thailand | MD, MCTM | Government |
SSI-19 | 60–70 | M | Indonesia | MD, PhD | Non-Government |
SSI-20 | 60–70 | M | India | MBBS, MD | Government |
SSI-21 | 30–40 | M | Vietnam | MD, PhD | Non-Government |
SSI-22 | 60–70 | F | Indonesia | MD | Government |
SSI-23 | 60–70 | M | Myanmar | MD, PhD | Non-Government |
SSI-24 | 60–70 | M | Philippines | MD, DTM&H | Non-Government |
SSI-25 | 40–50 | F | Vietnam | PhD | Non-Government |
SSI-26A | 50–60 | M | Malaysia | MD | Government |
SSI-26B | 50–60 | F | Malaysia | MPH | Government |
SSI-27 | 40–50 | M | Myanmar | MD, PhD, MBA | Non-Government |
SSI-28 | 40–50 | F | Vanuatu | PhD | Non-Government |
SSI-29 | 50–60 | M | PNG | MD, MPH | Non-Government |
SSI-30 | 40–50 | M | Afghanistan | MD, MPH | Non-Government |
SSI-31 | 40–50 | M | Afghanistan | MD, MPH | Non-Government |
Data collection and interview guide
Data analysis
Results
Study context
Overview
Policy priority towards vivax malaria
‘Well, there are couple of things going on here. One thing is the wrong health belief that P. vivax cannot hurt. This is the infection that cannot hurt. We now know that’s not true. But that evidence has been slow to emerge and very slow for people to accept the reality that untreated P. vivax is actually very dangerous. But the thinking that has been for decades, this is a harmless infection. The drug that we use to prevent recurrence is potentially dangerous. So, the practice in Indonesia overwhelmingly has been simply not to prescribe the treatment.’SSI-19, Indonesia.
Ah ya before, the most dominant species was Pf as we move[d] on, the proportion of falciparum steadily gone [went] down. But then before, we didn’t treat with primaquine…. just lately, primaquine was included in the treatment just because we have rise of vivax malaria.SSI-15, Solomon Island
Operational challenges and barriers to roll out current radical cure regimens
R: I think there are three challenges. First thing is complexity of regimen. Second one is adherence. that is quite difficult for people.I: Follow-up for 14 days?R: Ya, follow-up for 14 days. And the last one is need for pretesting of G6PD. Because of our supply system is not stable. That means some time we found G6PD test short of supply and Pv patients could not get radical treatment without G6PD testing.SSI-10, Laos
I: So, your vivax treatment regimen currently includes low dose primaquine for 14 days?R: Ya, but currently only for the piloting provinces, in the early next year we will have combined ACT and primaquine for 14 days.SSI-09, Cambodia
‘Primaquine is only available in public sector and that too only in few hospitals and high [malaria] prevalent districts only. [In] [t]The low [malaria] prevalent districts and private market, primaquine is not available. So, this availability is one of the main challenges and we know that most of the cases would go to the private sector; and those cases are treated on clinical grounds. So, as I have explained earlier that clinically diagnosed patients in the private sector won’t get any radical therapy. Second, with regards to routine clinical care to patients, their capacity, capacity of the health care providers, their reluctancy in some areas to prescribe primaquine according to national guidelines is due to absence of G6PD screening. That is again is, we try but there are medical doctors [who] won’t prescribe this primaquine without G6PD screening. Then of course compliance remains like anywhere in other countries in the world. Case compliance remains [a] challenge in Pakistan as well.’SSI-16, Pakistan
‘So, if G6PD tests are available and risk of patient [is known, G6PD test is done before providing radical cure treatment]. The program has supplied few kits in places where based on research there are high prevalence of G6PD deficiency but in most of [the] areas there are no G6PD tests. In those areas, we have mentioned in the guideline that a very thorough counselling should be done. Using annexes in our national guideline which recommends to follow up on 3, 4, 7 and 14 days of starting treatment and it has list of checklists on what to follow up, what kind of symptoms to follow up when they make contacts during those days.’SSI-03, Nepal.
I: Why do you not ask G6PD test before initiating radical cure regimen? Is it the budget, or any other factor?R: I think it’s not about budget availability. Because our government has money even to provide PCR-TB test…gene expert that is much more expensive. So, perhaps because we don’t see a lot of side effects of primaquine due to the G6PD deficient [deficiency] [in] [a] patient who takes [a] low dose of primaquine. But if we want to use the high dose of primaquine to eliminate vivax, I am sure they will start making plan and proposal and go to the central government to get it funded.SSI-22, Indonesia.‘….. we just give them [primaquine without G6PD test] and see how it goes.’SSI-23, Myanmar.
‘At the moment the lab technicians [do the G6PD test], but in case there [is] be point of care testing [available] there might be possibility to test through the community health workers…[which is] also possible. … It would be good if we use the biosensor at the level of community health workers.’SSI-11, Afghanistan.‘We have to train Village health workers to use biosensors.’SSI-22, Indonesia.‘… in our situation where malaria cases are in the community level, the person who does the tests should be village health workers.’SSI-21, Vietnam.‘It depends on how technically [simple these tests are] and simplicity of these tests. For example, RDTs, it is being used at [the] community level by village health workers, depends on how complex it is, [if it is simple] simpler than it can be used at [the] community level.’SSI-29, PNG
‘I don’t think it will be effective because [there is a low prevalence of vivax patients] as now patients become less and less. So, some malaria worker they won’t get any patients. …We implemented [a pilot study for radical cure with biosensor] when the health center has at least one case every month. You know to setup this system you need to train people; you need to equip health center with one fridge to keep the tests you know a lot [of] requirement. So, I don’t see it a need to start expanding to community volunteer because they don’t have a lot of cases.’SSI-12, Cambodia‘It’s quite hard as we have got only 576 [P. vivax] cases annually to now talk about introducing a more advanced technology approach for G6PD testing.’SSI-28, Vanuatu
Evidence gaps for future radical cure regimens
I: Have you heard of shorter regimens, what about high dose primaquine for 7 days?R: Yes, [but] comfortable with current regimen of 14 days. Higher dose means it will be mandatory to conduct G6PD test. 14 days means we are able to follow this regimen even without G6PD testing. Even if there is haemolysis that will be of low range.I: What about single dose Tafenoquine?R: First thing, it has to be approved by the regulatory bodies. Number 2, there has to be G6PD test, a suitable G6PD test [needs to be] available; third thing, there again is need of operation[al] research on this implementation study just to introduce it, [it is] not possible to implement without having first time experience… without operational research.SSI-06, India
‘… honestly and very frankly they will be rolled [out] by Global Fund. I don’t [think] national or provincial malaria program are in any sort of position to introduce it. … Global Fund recommends and WHO approves it … It’s basically between WHO and Global Fund.’SSI-4, Pakistan
‘WHO is the only organisation whose recommendation is mostly applicable, and country will comply to their recommendations.’SSI-14, Afghanistan‘To be in WHO guideline you probably know how it works. So, you have to go through complete process of evidence accumulation and review and this will be based on decision of expert committee or several expert committees meeting in Geneva and then you are in WHO guideline. As simple as that.’SSI-13, Cambodia‘… then WHO said they don’t recommend it so we did not go forward with that trial and stuck with the 14 days … sometimes [WHO] they might give us wrong decision as well.’SSI-15, Solomon Islands
I: If you were to adopt a new biosensor for G6PD point-of-care testing, what evidence would you need to recommend it?R: We need published articles, we need the data on safety and efficacy (Specificity and sensitivity), like RDTs are WHO pre-qualified, if applicable--these are the things we need first before considering it into the program. We will be asked to justify why we are recommending this new technology? Other than that, it has to pass the Health Technology Assessment and all regulatory requirements- FDA registration. We need to pilot test the technology to determine, whether our health workers can use and interpret the data correctly, its practicability, cost effectiveness, etc – before we can consider expanding it on more areas.SSI-17, Philippines