1. Session 4: G6PD deficiency in Myanmar
Point-of-care testing for G6PD deficiency to optimize
radical cure of P. vivax
Knowledge sharing
Partnership for Vivax Elimination (PAVE)
Novotel Hotel, Yangon 28 Nov 2022
5. Point-of-care testing for G6PD deficiency to optimize
radical cure of P.vivax
Malaria epidemiology
Malaria Morbidity and Mortality in Myanmar (2005-2021)
59,405
62,813
371,612
447,073
384,531
440,208
465,294
481,204
333,871
205,658
182,616
110,146
85,019
76,518
56,411
58,836
79,001
456,636
475,297
149,275
187,207
206,961
252,916
102,158
0
200
400
600
800
1000
1200
1400
1600
1800
-
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
Number
of
Malaria
Deaths
Number
of
Malaria
Cases
Confirmed Malaria Probable Malaria Malaria Death
VBDC Annual
Review Meeting,
2022
6. Point-of-care testing for G6PD deficiency to optimize
radical cure of P.vivax
Malaria epidemiology
(VBDC Annual Review Meeting, 2022)
Malaria Situation in States/Regions (2017 to 2021)
0
5
10
15
20
25
Malaria
Cases
Thousands
2017 2018 2019 2020 2021
Annual Parasite Incident by State/ Region (2021)
7. Point-of-care testing for G6PD deficiency to optimize
radical cure of P.vivax
Malaria epidemiology
VBDC Annual
Review Meeting,
2022
Monthly Malaria Cases and Proportion by species
(2019-2022 Apr)
0
10
20
30
40
50
60
70
80
90
100
0
2000
4000
6000
8000
10000
12000
14000
Jan-19
Mar-19
May-19
Jul-19
Sep-19
Nov-19
Jan-20
Mar-20
May-20
Jul-20
Sep-20
Nov-20
Jan-21
Mar-21
May-21
Jul-21
Sep-21
Nov-21
Jan-22
Mar-22
Proportion
Total
Number
Axis Title
Total Pf + Mix Total Pv PfMix% Pv%
8. Point-of-care testing for G6PD deficiency to optimize
radical cure of P.vivax
Malaria epidemiology
VBDC Annual
Review Meeting,
2022
High malaria burden townships in Myanmar
for implementing Intensification Plan & Acceleration Plan
Sr.
No.
State/
Region
Township Sr. No.
State/
Region
Township
1 Chin Paletwa 13 Mon Ye
2 Kachin Waingmaw 14 Rakhine Buthidaung
3 Kachin Momauk 15 Rakhine Kyauktaw
4 Kachin Shwegu 16 Rakhine Maungdaw
5 Kachin Injangyang 17 Rakhine Minbya
6 Kachin Mansi 18 Rakhine Mrauk U
7 Kachin Sumprabum 19 Sagaing Banmauk
8 Kachin Myitkyina 20 Sagaing Pinlebu
9 Kachin Bhamo 21 Tanintharyi Yebyu
10 Kayin Hpapun 22 Tanintharyi Tanintharyi
11 Kayin Kyainseikgyi 23 Tanintharyi Dawei
12 Kayin Myawaddy 24 Tanintharyi Palaw
9. Point-of-care testing for G6PD deficiency to optimize
radical cure of P.vivax
G6PD Brief for Myanmar
• Several studies estimated Glucose-6-phosphate dehydrogenase (G6PD)
deficiency prevalence in Myanmar, however, no nationwide survey has taken
place to determine overall G6PD deficiency prevalence
• G6PD brief –
• Provide background information on methods to measure G6PD
• Collate all available and accessible data from grey and peer-reviewed
literature on G6PD deficiency
• Inform decision-makers with a comprehensive view of the situation in
Myanmar.
• After collating available data, a draft of this document was shared with members
of the extended Technical Strategy Group for Malaria (TSG) that coordinates
malaria partners in Myanmar.
• Feedback from extended TSG members was incorporated into this document
10. Point-of-care testing for G6PD deficiency to optimize
radical cure of P.vivax
How G6PD was measured
previously in Myanmar
• We identified 17 subnational studies undertaken in nine states in Myanmar
• Nine measured G6PD prevalence with qualitative, or semi-quantitative tests
either the Brewers test, Fluorescent Spot Test (FST), Formazan test.
• Five studies measured G6PD quantitatively using either spectrophotometry or
point-of-care quantitative tests such as the Trinity Biotech® quantitative G6PD or
the G6PD CareStart biosensor.
11. Point-of-care testing for G6PD deficiency to optimize
radical cure of P.vivax
G6PD deficiency
prevalence in Myanmar
G6PD deficiency prevalence rates varied considerably both between genders and states/ethnic
groups
Overall prevalence of any G6PD deficiency defined as ‘below normal’ (i.e. either intermediate or
deficient) ranged from 0% (8) - 30.5%.
Three studies reported quantitative G6PD deficiency estimates by spectrophotometry for males.
Estimates of G6PDd in these studies were 11.7%, 9.4%, and 11.1%. It is expected that G6PD
deficiency prevalence would be half as much in females as the male G6PD deficiency
prevalence rate, and G6PD intermediate prevalence would be twice as much in females.
Work by the Malaria Atlas Project that collates G6PD data with associated location data
estimates a G6PD deficiency prevalence rate of 6.1% in Myanmar, or over 1.5 million males in
2010 and 880,000 females that year.
12. Point-of-care testing for G6PD deficiency to optimize
radical cure of P.vivax
G6PD deficiency in different
ethnic groups of Myanmar
The most commonly studied group were Burmese (8 studies), Kachin (5 studies) and
Rakhine (3 studies). Chin, Karen, Mon, and Shan were also participants in two studies
each, while Kayah and Pa-O populations were identified in one study each. Other
ethnicities such as Chinese and Indian were identified in one study.
The highest prevalence of G6PD deficiency (i.e. either deficient or intermediate) was
reported among Kachin populations with a range of 0% – 30.5% G6PD non-normal
activity.
In the one study that used quantitative measures, severe G6PD deficiency was
estimated as 2.1% in females and 9.4% in males.
The population with the next highest prevalence of G6PD non-normal activity were
Burmese with a range from 0 – 21.2 %. In studies using quantitative measures, G6PD
intermediate ranged from 0.9 – 15.8% while G6PD deficient ranged from 0.3 – 11.7%.
13. Point-of-care testing for G6PD deficiency to optimize
radical cure of P.vivax
G6PD deficiency variants in
Myanmar
The most commonly reported mutations identified in Myanmar over the last two
decades were
• Mahidol (>=86% of samples),
• Kaiping (4- 18%) and
• Viangchan (6%).
Others that were identified included
• Mediterranean (4%),
• Union (2%) and
• Canton (2%)
•
G6PD Mahidol is considered a moderately severe variant with varying G6PD
activities which classifies it as WHO class II/III.
14. Point-of-care testing for G6PD deficiency to optimize
radical cure of P.vivax
G6PD deficiency
prevalence in Myanmar
State_Region G6PD intermediate prevalence (%) G6PD deficiency prevalence (%) Total cases (2021)
Ayeyarwady Not available Not available 92
Bago Not available Not available 585
Chin 2.7 - 14.4 0.3 - 12.5
15,961
Kachin 13.2 - 23.4 2.1 - 30
22,449
Kayah 0.14 - 1.3 0 - 1.9 7
Kayin Not available 12.9 - 14.1
21,382
Magway Not available Not available 149
Mandalay 0.9 - 15.8 0.3 - 11.1 411
Mon Not available 0 - 12 2,012
Naypyitaw Not available Not available 7
Rakhine 0.8 - 14.4 0 - 12.5 6,364
Sagaing Not available Not available 1,089
Shan Not available 10.9 - 21.2 707
Tanintharyi Not available 0.3 - 11.1 7,748
Yangon 0 - 14 0.9 - 21 38
15. Point-of-care testing for G6PD deficiency to optimize
radical cure of P.vivax
Implications of evidence-based information
to inform policy makers for data-driven
policy adoption
High malaria burden townships (2021) Malaria Atlas Project
estimated G6PD deficiency
allele frequency
12%
0%
6%
G6PDd allele
frequency
Myanmar has an average G6PDd allele
frequency of 6.1%
Annual Parasite Incident by State/ Region (2021)
16. Point-of-care testing for G6PD deficiency to optimize
radical cure of P.vivax
UNOPS-PR
VBDC Annual
Review Meeting,
2022
Sr.
No
.
Sub-
recipients
No. of State/
Region
No. of
townships
covered
No. of
ICMV
Activities
1 MAM Mon, Chin,
Kachin, Kayin,
Sagaing
22 1752 Malaria case
management, Prevention
2 MCC Chin, Kachin 17 529 Malaria case
management, Prevention
3 MHAA Bago East,
Chin
3 141 Malaria case
management, Prevention
4 MMA Ayeyarwady 2 100 Malaria case
management, Prevention,
elimination surveillance
5 MRCS SSS 5 185 Malaria case
management, Prevention
6 SMRU Kayin 4 916 Malaria case
management, Prevention,
Research
17. Point-of-care testing for G6PD deficiency to optimize
radical cure of P.vivax
Save the Children Co-PR
VBDC Annual
Review Meeting,
2022
Sr.
No
.
Sub-
recipients
No. of
State/
Region
No. of
townshi
ps
covered
No.
of
ICMV
Activities
1 ARC BagoE,
Kayin,
Mon,
NSS, TYI
23 596 Malaria case management,
Prevention, elimination surveillance
2 HPA Kachin,
NSS, ESS
18 516 Malaria case management,
Prevention
3 IOM Mon,
Sagaing
11 651 Malaria case management,
Prevention, elimination surveillance
4 MI
(Country &
Regional)
Rakhine,
ESS
7 177 Malaria case management,
Prevention
5 PSI
(Country &
Regional)
11 27 759 Malaria case management,
Prevention, elimination surveillance
6 SCI
(Country &
Regional)
Magway,
NSS
7 426 Malaria case management,
Prevention
18. Point-of-care testing for G6PD deficiency to optimize
radical cure of P.vivax
PMI Eliminate Malaria
VBDC Annual
Review Meeting,
2022
Sr.
No
.
Sub-
recipie
nts
No. of
State/
Region
No. of
townshi
ps
covered
NO. of
ICMV
Activities
1 ARC Kayin,
TYI
7 394 Malaria case management,
Prevention, elimination
surveillance
2 MHAA Rakhine 3 231 Malaria case management,
Prevention
3 MNMA Rakhine 2 181 Malaria case management,
Prevention
4 URC Rakhine,
Sagaing,
TYI
24 1338 Malaria case management,
Prevention, elimination
surveillance
19. Point-of-care testing for G6PD deficiency to optimize
radical cure of P.vivax
Implication of G6PD deficiency prevalence
and variants on NMCP recommendations
Studies over time, and in several different populations in Myanmar have identified populations with
moderate to high prevalence of G6PD deficiency up to 30.5% prevalence.
These results strongly support the WHO recommendations to screen G6PD deficiency at health facility
level before the use of primaquine (or any 8-AQ) prior to radical curative regimen for Plasmodium vivax.2
Given the variability of G6PDd prevalence, patient counselling as to the potential side effects of 8-
aminoquinolines and a strong pharmacovigilance system are important in Myanmar to ensure patient
safety
Treatment strategies to treat vivax malaria in G6PD deficient patients will be important to achieve malaria
elimination in Myanmar
20. Session 4: G6PD deficiency in Myanmar
Point-of-care testing for G6PD deficiency to optimize
radical cure of P. vivax
Knowledge sharing
Thank you.
