Targeting Plasmodium falciparum transmission with primaquine: same efficacy, improved safety with a lower dose?

Malaria transmission is declining worldwide, leading to a growing interest in strategies to reach elimination and eradication. Insecticide and drug resistance threaten these efforts, driving an interest in the use of gametocytocidal drugs to curb the spread of artemisinin resistance and accelerate the path to malaria elimination. Primaquine is the only marketed drug that can kill mature Plasmodium falciparum gametocytes, which can otherwise contribute to ongoing transmission for long periods of time. While primaquine has been widely used in Asia and the Americas, African countries have little experience with this drug and are reluctant to use primaquine due to a fear of hemolytic side effects. We discuss the underlying knowledge base and motivation to use primaquine as a P. falciparum transmission blocker, revealing that while primaquine implementation can benefit from further study, there remains an overall need for improved transmission-blocking drugs.