CONFRONTING

PLASMODIUM VIVAX MALARIA

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 World Health Organization 2015

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WHY IS
ACTION
AGAINST
P. VIVAX
MALARIA
NEEDED?
1
Plasmodium vivax is one of five species of
Plasmodium that can cause malaria in human
beings. Although P. falciparum is responsible for the
majority of cases and deaths from malaria, P. vivax
has a wider geographical range and is responsible
for almost half the cases of malaria outside Africa.
In May 2015, the World Health Assembly endorsed the
most ambitious targets for malaria control since the
eradication era namely to eliminate malaria from
35 countries and reduce case incidence and mortality
rates by 90% globally.1 P. vivax presents a major challenge
to achieving these targets; in 2013, it was responsible
for 16 million cases globally. It predominates in
countries that are prime candidates for elimination,
accounting for more than 70% of cases in countries with
fewer than 5000 cases of malaria each year.
Not only does P. vivax present a barrier to
elimination, it can also cause severe disease;
severe cases and deaths due to P. vivax malaria
have been reported from all endemic regions.

1. W HO, Global Technical Strategy for Malaria 20162030. Geneva,
World Health Organization (WHO). 2015 (http://who.int/malaria/areas/
global_technical_strategy/en/, accessed 30 June 2015).

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 1/ More than a third of the worlds

3
population, mostly in Asia and Latin
America, is at risk of infection with
P. vivax malaria.

P. vivax is by far the most widespread of the five malaria parasites that infect people.
In 2013, it was estimated to be responsible for more than one million malaria cases
in four countries (Ethiopia, India, Indonesia and Pakistan).

16 m Despite tremendous progress in

reducing P. vivax malaria since 2000,
there were 16 million cases globally
in 2013.

Even though the number of P. vivax malaria cases fell by 35% compared to 2000,
P. vivax is still responsible for almost half the number of malaria cases outside Africa.

70 % P. vivax malaria predominates in countries

that are prime candidates for elimination.

The parasite accounts for more than 70% of malaria cases in countries with fewer than
5000 cases each year.

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 ESTIMATED NUMBER OF PLASMODIUM VIVAX CASES BY COUNTRY, 2013

>1 000 000

100 0011 000 000
10 001100 000
100110 000
11000
No estimated P.v. cases
Not applicable 0 10 000 20 000 Kilometres

Source: WHO estimates

DOWNWARD TREND IN PLASMODIUM VIVAX MALARIA CASES IN AND OUTSIDE SUB-SAHARAN AFRICA, 20002013
30
Outside sub-Saharan Africa Sub-Saharan Africa
25

20
(million)

15

10

0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Source: WHO estimates

PERCENTAGE OF MALARIA CASES DUE TO PLASMODIUM VIVAX, BY AVERAGE NUMBER OF CASES, 20002013
100

80

60

40

20

0
5 000 000+ 500 0015 000 000 50 001500 000 500150 000 5015000 0500
Average number of cases 20002013
Source: WHO estimates

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 P. VIVAX
MALARIA
POSES
MULTIPLE
CHALLENGES

2
P. vivax malaria can be more difficult to control
than P. falciparum for several reasons related to
its biology or the behaviour of mosquitoes that
carry it.
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 It can survive in cooler climates.
Whereas P. falciparum is confined to tropical zones,
P. vivax can develop and survive in the relatively cooler
climates of more temperate countries and therefore
has a wider geographical range.

I t is less responsive to conventional methods

of vector control.
In many of the areas where P. vivax is common,
mosquitoes bite early in the evening, obtain blood
meals outdoors and rest outdoors. Thus, tools such
as insecticide-treated mosquito nets (ITNs), which
work well against night-biting and indoor-feeding
mosquitoes, can be less effective in reducing
P. vivax malaria.

I t is more difficult to detect using current

diagnostic techniques.
Compared to P. falciparum, the number of parasites
circulating in the blood of a person infected with
P. vivax malaria is typically low. Therefore, P. vivax
infections may be missed, even if a patient presents for
treatment. The parasite also has a dormant liver stage
that cannot be detected by current diagnostic tools.
Hence, there may be a large reservoir of people who
are infected with P. vivax but are unaware of
their condition.

A single infection can give rise to multiple episodes

of malaria.
Even in the absence of another mosquito bite, in those
infected with P. vivax, the dormant liver stage can
awaken and can trigger multiple episodes of malaria.
These relapses not only cause further illness to the
individual, they also provide an opportunity for the
parasite to be picked up by mosquitoes and transmitted
to others.

Treatment of liver-stage parasites requires a 14-day

course of primaquine.
Only one drug, primaquine, is effective against dormant
liver parasites. The treatment for this stage of the disease
involves the patient taking tablets every day for 14 days,
even though the person may no longer be experiencing
symptoms of disease. In resource-poor areas where
P. vivax prevails, many patients have difficulty complying
with such a lengthy treatment regimen.

Primaquine treatment can produce serious side-effects.

Patients who have a severe deficiency of the enzyme
glucose-6-phosphate dehydrogenase (G6PD) are susceptible
to potentially life-threatening destruction of blood cells
while taking primaquine. However, current tests for G6PD
deficiency are complex and relatively expensive; thus, many
clinicians are reluctant to prescribe primaquine to patients
whose G6PD status is unknown. In addition, primaquine
cannot be used in pregnant women and infants because of
the risk of G6PD deficiency. In the absence of treatment,
these populations are prone to multiple relapses.

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 WHAT
SHOULD
BE DONE
AGAINST
P. VIVAX ?

3
Successful control and elimination of P. vivax
requires action on three fronts: strengthening
malaria programmes, developing new tools,
and enhancing financing and political commitment.
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STRENGTHENED
A MORE EFFECTIVE RESPONSE TO P. VIVAX WILL
MALARIA PROGRAMMES REQUIRE NEW TOOLS THAT WILL HELP TO REDUCE
Many of the strategies to control P. vivax malaria are the P. VIVAX TRANSMISSION AND INCREASE THE ABILITY
same as those used with P. falciparum malaria;
for example, using vector control to reduce
TO DETECT AND TREAT INFECTIONS.
transmission by the mosquito vector (from humans
to mosquitoes, and from mosquitoes to humans);
using chemoprevention to prevent establishment of
infections in humans; and providing accessible health
services that can rapidly detect, diagnose and treat
malaria infections. However, successful control of P. vivax
malaria calls for additional interventions; in particular:

t argeting outdoor-biting and outdoor-resting

mosquitoes, where such mosquitoes represent the
main source of transmission;

e
 nsuring that microscopy services are able to detect
low-density P. vivax infections, or that bivalent
rapid diagnostic tests are used in areas where both
P. falciparum and P. vivax are found;

treating liver stages as well as blood stages; and

testing all patients for G6PD deficiency before

administering primaquine (where possible).

Consideration of P. vivax needs to be reflected in global,

regional and national plans for malaria control.
These plans should be monitored at regular intervals
ENHANCED FINANCING AND
through P. vivax-specific indicators on programme POLITICAL COMMITMENT
coverage and disease incidence.
There is a need for international donors and domestic
governments to invest in the additional measures

DEVELOPMENT OF NEW TOOLS

required for control of P. vivax, and to continue
investment even when malaria is reduced to low levels
or eliminated. Also, those funding research will need
A more effective response to P. vivax will require new
to prioritize investments in P. vivax malaria research,
tools that will help to reduce P. vivax transmission,
to reduce the obstacles to P. vivax malaria elimination.
and increase the ability of malaria programmes to
detect and treat infections. There is a particular need
for tools against the dormant liver (hypnozoite) stage,
such as:

a
 test that is both sensitive enough to confirm the
presence of hypnozoites in a patients liver and
specific enough to confirm their absence; such a
test could inform decisions about the management
of a vivax malaria, and be used for epidemiological
assessment of the prevalence of P. vivax infection in
a given area;

a test for G6PD deficiency that can be used where

patients seek treatment, to break down a significant
barrier to treatment with primaquine; and

a drug against the liver stage that is effective,

does not have significant side-effects and is suitable
for use in all population groups.

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 WHAT CAN
BE GAINED
BY TAKING
ACTION
AGAINST
P. VIVAX ?

4
A comprehensive response to P. vivax malaria will
relieve some of the most vulnerable populations
of a significant illness that disrupts schooling
and work, and can be fatal. Such a response
will strengthen health systems, boosting their
capacity to improve the treatment of other febrile
illnesses and their ability to respond to future
public health threats.
Malaria interventions are highly cost effective,
and provide one of the highest returns on
investment in public health. They help to alleviate
poverty, improve equity and contribute to overall
development. If P. vivax malaria is conquered,
not only will international targets to eliminate
malaria from 35 countries by 2030 be achieved,
but a pathway will be set for the eventual
eradication of this ancient disease.
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/9/


For further information, please refer to Control and elimination

of Plasmodium vivax malaria A technical brief published by the
WHO Global Malaria Programme in July 2015 and available at
http://www.who.int/malaria/publications/atoz/9789241509244/en/.

Global Malaria Programme

World Health Organization
20, Avenue Appia
CH-1211 Geneva 27
Web: www.who.int/malaria
Email: infogmp@who.int