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G6PD testing and radical cure for Plasmodium vivax in Cambodia: A mixed methods implementation study

INTRODUCTION: Cambodia aims to eliminate malaria by 2025, however tackling Plasmodium vivax (P.v) presents multiple challenges. The prevalence of glucose-6-phosphate dehydrogenase (G6PD) deficiency has prevented the deployment of 8-aminoquinolones for “radical cure”, due to the risk of severe haemol...

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Autores principales: Kheang, Soy Ty, Ridley, Rosemarie, Ngeth, Eng, Ir, Por, Ngor, Pengby, Sovannaroth, Siv, Lek, Dysoley, Phon, Somaly, Kak, Neeraj, Yeung, Shunmay
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Public Library of Science 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9584508/
https://www.ncbi.nlm.nih.gov/pubmed/36264996
http://dx.doi.org/10.1371/journal.pone.0275822
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author Kheang, Soy Ty
Ridley, Rosemarie
Ngeth, Eng
Ir, Por
Ngor, Pengby
Sovannaroth, Siv
Lek, Dysoley
Phon, Somaly
Kak, Neeraj
Yeung, Shunmay
author_facet Kheang, Soy Ty
Ridley, Rosemarie
Ngeth, Eng
Ir, Por
Ngor, Pengby
Sovannaroth, Siv
Lek, Dysoley
Phon, Somaly
Kak, Neeraj
Yeung, Shunmay
author_sort Kheang, Soy Ty
collection PubMed
description INTRODUCTION: Cambodia aims to eliminate malaria by 2025, however tackling Plasmodium vivax (P.v) presents multiple challenges. The prevalence of glucose-6-phosphate dehydrogenase (G6PD) deficiency has prevented the deployment of 8-aminoquinolones for “radical cure”, due to the risk of severe haemolysis. Patients with P. vivax have therefore continued to experience recurrent relapses leading to cumulative health and socioeconomic burden. The recent advent of point of care testing for G6PD deficiency has made radical cure a possibility, however at the time of the study lack of operational experience and guidance meant that they had not been introduced. This study therefore aimed to design, implement and evaluate a new care pathway for the radical cure of P.vivax. METHODS: This implementation study took place in Pursat province, Western Cambodia. The interventions were co-developed with key stakeholders at the national, district, and local level, through a continuous process of consultations as well as formal meetings. Mixed methods were used to evaluate the feasibility of the intervention including its uptake (G6PD testing rate and the initiation of primaquine treatment according to G6PD status); adherence (self-reported); and acceptability, using quantitative analysis of primary and secondary data as well as focus group discussions and key informant interviews. RESULTS: The co-development process resulted in the design of a new care pathway with supporting interventions, and a phased approach to their implementation. Patients diagnosed with P.v infection by Village Malaria Workers (VMWs) were referred to local health centres for point-of-care G6PD testing and initiation of radical cure treatment with 14-day or 8-week primaquine regimens depending on G6PD status. VMWs carried out follow-up in the community on days 3, 7 and 14. Supporting interventions included training, community sensitisation, and the development of a smartphone and tablet application to aid referral, follow-up and surveillance. The testing rate was low initially but increased rapidly over time, reflecting the deliberately cautious phased approach to implementation. In total 626 adults received G6PD testing, for a total of 675 episodes. Of these 555 occurred in patients with normal G6PD activity and nearly all (549/555, 98.8%) were initiated on PQ14. Of the 120 with deficient/intermediate G6PD activity 61 (50.8%) were initiated on PQ8W. Self-reported adherence was high (100% and 95.1% respectively). No severe adverse events were reported. The pathway was found to be highly acceptable by both staff and patients. The supporting interventions and gradual introduction were critical to success. Challenges included travel to remote areas and mobility of P.v patients. CONCLUSION: The new care pathway with supporting interventions was highly feasible with high levels of uptake, adherence and acceptability in this setting where high prevalence of G6PD deficiency is high and there is a well-established network of VMWs. Scaling up of the P.v radical cure programme is currently underway in Cambodia and a decline in reduction in the burden of malaria is being seen, bringing Cambodia a step closer to elimination.
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spelling pubmed-95845082022-10-21 G6PD testing and radical cure for Plasmodium vivax in Cambodia: A mixed methods implementation study Kheang, Soy Ty Ridley, Rosemarie Ngeth, Eng Ir, Por Ngor, Pengby Sovannaroth, Siv Lek, Dysoley Phon, Somaly Kak, Neeraj Yeung, Shunmay PLoS One Research Article INTRODUCTION: Cambodia aims to eliminate malaria by 2025, however tackling Plasmodium vivax (P.v) presents multiple challenges. The prevalence of glucose-6-phosphate dehydrogenase (G6PD) deficiency has prevented the deployment of 8-aminoquinolones for “radical cure”, due to the risk of severe haemolysis. Patients with P. vivax have therefore continued to experience recurrent relapses leading to cumulative health and socioeconomic burden. The recent advent of point of care testing for G6PD deficiency has made radical cure a possibility, however at the time of the study lack of operational experience and guidance meant that they had not been introduced. This study therefore aimed to design, implement and evaluate a new care pathway for the radical cure of P.vivax. METHODS: This implementation study took place in Pursat province, Western Cambodia. The interventions were co-developed with key stakeholders at the national, district, and local level, through a continuous process of consultations as well as formal meetings. Mixed methods were used to evaluate the feasibility of the intervention including its uptake (G6PD testing rate and the initiation of primaquine treatment according to G6PD status); adherence (self-reported); and acceptability, using quantitative analysis of primary and secondary data as well as focus group discussions and key informant interviews. RESULTS: The co-development process resulted in the design of a new care pathway with supporting interventions, and a phased approach to their implementation. Patients diagnosed with P.v infection by Village Malaria Workers (VMWs) were referred to local health centres for point-of-care G6PD testing and initiation of radical cure treatment with 14-day or 8-week primaquine regimens depending on G6PD status. VMWs carried out follow-up in the community on days 3, 7 and 14. Supporting interventions included training, community sensitisation, and the development of a smartphone and tablet application to aid referral, follow-up and surveillance. The testing rate was low initially but increased rapidly over time, reflecting the deliberately cautious phased approach to implementation. In total 626 adults received G6PD testing, for a total of 675 episodes. Of these 555 occurred in patients with normal G6PD activity and nearly all (549/555, 98.8%) were initiated on PQ14. Of the 120 with deficient/intermediate G6PD activity 61 (50.8%) were initiated on PQ8W. Self-reported adherence was high (100% and 95.1% respectively). No severe adverse events were reported. The pathway was found to be highly acceptable by both staff and patients. The supporting interventions and gradual introduction were critical to success. Challenges included travel to remote areas and mobility of P.v patients. CONCLUSION: The new care pathway with supporting interventions was highly feasible with high levels of uptake, adherence and acceptability in this setting where high prevalence of G6PD deficiency is high and there is a well-established network of VMWs. Scaling up of the P.v radical cure programme is currently underway in Cambodia and a decline in reduction in the burden of malaria is being seen, bringing Cambodia a step closer to elimination. Public Library of Science 2022-10-20 /pmc/articles/PMC9584508/ /pubmed/36264996 http://dx.doi.org/10.1371/journal.pone.0275822 Text en © 2022 Kheang et al https://creativecommons.org/licenses/by/4.0/This is an open access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/) , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
spellingShingle Research Article
Kheang, Soy Ty
Ridley, Rosemarie
Ngeth, Eng
Ir, Por
Ngor, Pengby
Sovannaroth, Siv
Lek, Dysoley
Phon, Somaly
Kak, Neeraj
Yeung, Shunmay
G6PD testing and radical cure for Plasmodium vivax in Cambodia: A mixed methods implementation study
title G6PD testing and radical cure for Plasmodium vivax in Cambodia: A mixed methods implementation study
title_full G6PD testing and radical cure for Plasmodium vivax in Cambodia: A mixed methods implementation study
title_fullStr G6PD testing and radical cure for Plasmodium vivax in Cambodia: A mixed methods implementation study
title_full_unstemmed G6PD testing and radical cure for Plasmodium vivax in Cambodia: A mixed methods implementation study
title_short G6PD testing and radical cure for Plasmodium vivax in Cambodia: A mixed methods implementation study
title_sort g6pd testing and radical cure for plasmodium vivax in cambodia: a mixed methods implementation study
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9584508/
https://www.ncbi.nlm.nih.gov/pubmed/36264996
http://dx.doi.org/10.1371/journal.pone.0275822
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