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SUMMARY OF FINDINGS FOR THE MAIN COMPARISON [Explanation] PQ for reducing P. falciparum transmission with artemisinin-based treatments Patient or population: People with symptomatic malaria Settings: Malaria-endemic areas Intervention: Single dose or short course PQ plus malaria treatment including an artemisinin derivative Control: Malaria treatment including an artemisinin derivative, without PQ Outcomes Illustrative comparative risks* (95% CI) Relative effect(95% CI) Number of participants(trials) Quality of the evidence(GRADE) Assumed risk Corresponding risk Control PQ Malaria incidence, prevalence or EIR - - - 0 trials - People infectious to mosquitoes - - - 0 trials - Participants with gametocytes on microscopy or PCR 1 (day 8) Dose < 0.4 mg/kg RR 0.67 (0.44 to 1.02) 223 (1 trial) ⊕⊕○○ 2,3,4 low 34 per 100 23 per 100 (15 to 35) Dose 0.4 to 0.6 mg/kg RR 0.30 (0.16 to 0.56) 219 (1 trial) ⊕⊕⊕○ 2,4,5,6 moderate 35 per 100 11 per 100 (6 to 20) Dose = 0.6 mg/kg RR 0.29 (0.22 to 0.37) 1380(7 trials) ⊕⊕⊕○ high 7,8,9 30 per 100 9 per 100 (7 to 11) Mean percent change in haemoglobin 10 The mean percent drop in Hb from baseline in the control group was15% The mean percent drop in Hb from baseline in the intervention groups was 3% lower(from 10% lower to 4% higher) - 101(1 trial) ⊕○○○ very low 10,11

Dose = 0.6 mg/kg RR 0.29 (0.22 to 0.37) 1380(7 trials) ⊕⊕⊕○ high 7,8,9 30 per 100 9 per 100 (7 to 11) Mean percent change in haemoglobin 10 The mean percent drop in Hb from baseline in the control group was15% The mean percent drop in Hb from baseline in the intervention groups was 3% lower(from 10% lower to 4% higher) - 101(1 trial) ⊕○○○ very low 10,11 *The basis for the assumed risk (for example, the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). PQ: Primaquine; CI: Confidence interval; RR: Risk ratio; AUC: area under curve; G6PD: glucose-6-phosphate dehydrogenase; AS: artesunate; AQ: amodiaquine;DHAP: dihydroxyartemisinin-piperaquine; MQ: mefloquine; AL: artemether-lumefantrine. GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate. 1AUC estimates (log(10)AUC for day 1 to 43) are included as footnotes for each dosing strata. 2No serious risk of bias: includes one trial with no risk of bias detected.

GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate. 1AUC estimates (log(10)AUC for day 1 to 43) are included as footnotes for each dosing strata. 2No serious risk of bias: includes one trial with no risk of bias detected. 3Downgraded by 2 for very serious imprecision: one small trial with CIs that include 50% reduction and no effect. 4There was no log(10)AUC day 1 to 43 % reduction data for this dose. 5Downgraded by 1 for serious imprecision. A single trial with few events. 6Not downgraded for serious indirectness: however this is a single trial from a single setting. 7Includes seven trials, with 11 comparisons: one trial included five separate comparisons with AS-AQ, DHAP, AS-MQ, and AL (Smithuis 2010). 8No serious inconsistency: whilst there is marked quantitative heterogeneity, the studies with no demonstrable effect had few events. Not downgraded. 9Log(10)AUC day 1 to 43 % reduction: range from 21.1% to 87.5%. We included four trials with 12 comparisons. We excluded one trial as high risk of bias (Vasquez 2009) due to small sample size and large difference in baseline gametocyte count in the two groups.

8No serious inconsistency: whilst there is marked quantitative heterogeneity, the studies with no demonstrable effect had few events. Not downgraded. 9Log(10)AUC day 1 to 43 % reduction: range from 21.1% to 87.5%. We included four trials with 12 comparisons. We excluded one trial as high risk of bias (Vasquez 2009) due to small sample size and large difference in baseline gametocyte count in the two groups. 10Shekalaghe 2007 reported relative decrease in haemoglobin against baseline in both groups at day 8, 15, 29 and 43 in all participants irrespective of G6PD status. The comparison between those receiving PQ and those not did not demonstrate a difference at any time point. We presented day 43 in this table. 11Downgraded by 2 for very serious indirectness: the percentage of people with large drops in haemoglobin, not the mean change in the population, is the important safety outcome; and the estimates are averages in a small population (N = 99) that includes people with normal G6PD function so unlikely to detect effects in a small subgroup with a relatively uncommon adverse event.

PQ should reduce the dose to 0.25 mg/kg in G6PD deficient patients; and 3) Countries not currently implementing single dose PQ but which are targeting malaria elimination, or are threatened by artemisinin resistance, should add 0.25 mg/kg PQ to treatment for uncomplicated P. falciparum malaria (White 2012; WHO 2012b). How the intervention might work A single dose of PQ could contribute to reducing malaria transmission through its effects on mature gametocytes, and it is reasonable to assume that reducing the density and duration of gametocytes in the blood of infected patients will reduce the duration of potential infectiousness to mosquitoes at the level of the individual (see Figure 1). However, any subsequent effects on the number of mosquitoes infected (infectiousness), or the number of new malaria infections in the community (transmission) are impossible to predict without measuring these effects using reliable methods. Figure 1 Review logic framework: The potential points in the Plasmodium parasite life cycle that could be impacted by PQ and the outcomes used to measure impact. Infectiousness to mosquitoes can be measured directly by allowing mosquitoes to feed on infected individuals who have been treated with and without PQ (Killeen 2006; Bousema 2012), or estimated indirectly by measuring the infection rates of wild-caught mosquitoes (Graves 1990; Lines 1991).

Figure 1 Review logic framework: The potential points in the Plasmodium parasite life cycle that could be impacted by PQ and the outcomes used to measure impact. Infectiousness to mosquitoes can be measured directly by allowing mosquitoes to feed on infected individuals who have been treated with and without PQ (Killeen 2006; Bousema 2012), or estimated indirectly by measuring the infection rates of wild-caught mosquitoes (Graves 1990; Lines 1991). Community level transmission can be measured through large cluster-randomized trials, or less reliably through controlled before and after studies. Within any community there are people who are carriers of P. falciparum gametocytes but who do not seek treatment (Bousema 2011). This is most apparent in areas of high endemicity, where much of the adult population has acquired immunity, and low level parasitemias do not produce symptoms. This reservoir of gametocytes in untreated adults will continue to facilitate community level transmission and may dilute any possible effect of PQ. Indeed, these dilutional effects may even be important in low transmission settings.

tion of P. falciparum and other Plasmodium species. For individual RCTs, eligible studies must have diagnosed patients by blood slide, rapid diagnostic test, or other valid molecular method; for cluster-RCTs, diagnosis could have been by clinical judgment if that was standard in the trial area at the time of the trial. Types of interventions Intervention A single dose or short course (up to seven days) of PQ or other 8-aminoquinoline (8AQ) added to malaria treatment(s). Control Identical treatment for malaria not including PQ/8AQ (or substituting placebo for PQ/8AQ); or using a different 8AQ with same malaria treatment, or using different dose of PQ/8AQ with same malaria treatment(s). Types of outcome measures Primary outcomes Figure 1 provides an outline of transmission of malaria that helps clarify these terms. a) Transmission Entomological inoculation rate Malaria incidence Malaria prevalence b) Infectiousness People who infect mosquitoes Mosquitoes infected by direct feeding c) Potential infectiousness AUC of gametocyte density (y-axis) over time (x-axis) Gametocyte prevalence (estimated by microscopy or PCR) Gametocyte density (estimated by microscopy or PCR) Gametocyte clearance time (duration of gametocyte carriage) Adverse events Serious adverse events leading to hospital admission or death Haematologic effects Haemolysis (higher prevalence) Haemoglobin concentration (decline) Packed cell volume (decline) Secondary outcomes Presence of asexual stage parasites (may be reported as treatment failure rate) Asexual parasite clearance time (duration of asexual carriage)

Serious adverse events leading to hospital admission or death Haematologic effects Haemolysis (higher prevalence) Haemoglobin concentration (decline) Packed cell volume (decline) Secondary outcomes Presence of asexual stage parasites (may be reported as treatment failure rate) Asexual parasite clearance time (duration of asexual carriage) Search methods for identification of studies We attempted to identify all relevant trials, regardless of language or publication status (published, unpublished, in press, and in progress). The search strategy is in Appendix 1. Electronic searches Databases We searched the following databases up to 10 February 2014 using the search terms and strategy described in Appendix 1: the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in The Cochrane Library (Issue 2 2014); MEDLINE (1966 to 10 Feb 2014); EMBASE (1980 to 10 Feb 2014) ; and LILACS (1982 to 10 Feb 2014). Also, we checked the metaRegister of Controlled Trials (mRCT) and the WHO trials search portal (both accessed 10 Feb 2014) using 'malaria*', 'falciparum', and 'Primaquine' as search terms. Conference proceedings We searched the following conference proceedings for relevant abstracts: the MIM Pan-African Malaria Conferences and the American Society of Tropical Medicine and Hygiene (ASTMH) to December 2009.

Electronic searches Databases We searched the following databases up to 10 February 2014 using the search terms and strategy described in Appendix 1: the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in The Cochrane Library (Issue 2 2014); MEDLINE (1966 to 10 Feb 2014); EMBASE (1980 to 10 Feb 2014) ; and LILACS (1982 to 10 Feb 2014). Also, we checked the metaRegister of Controlled Trials (mRCT) and the WHO trials search portal (both accessed 10 Feb 2014) using 'malaria*', 'falciparum', and 'Primaquine' as search terms. Conference proceedings We searched the following conference proceedings for relevant abstracts: the MIM Pan-African Malaria Conferences and the American Society of Tropical Medicine and Hygiene (ASTMH) to December 2009. Searching other resources Researchers and organizations We contacted researchers at the London School of Hygiene and Tropical Medicine who were authors of some of the included and in-progress trials, and other experts in the field of malaria chemotherapy, including those based at WHO. Reference lists We checked the reference lists of all studies identified by the above methods.

iggins 2011). For each included trial, we assigned a score of low, unclear or high risk of bias for the following components: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessors, incomplete outcome data, selective outcome reporting, and other biases. For sequence generation and allocation concealment, we described the methods used, if given. For blinding, we described who was blinded and the blinding method. For incomplete outcome data, we reported the percentage and proportion of loss to follow-up (the number of patients for whom outcomes are not measured of the number randomized), if given. For selective outcome reporting, we stated any discrepancies between the methods and the results in terms of the outcomes measured and the outcomes reported; we also stated if we knew that an outcome was measured but was not reported in the publication. For other biases we described any other trial features that could have affected the trial's results (for example, whether a trial was stopped early or if no sample size calculation was included). We resolved any disagreements through discussion. We reported the results of the risk of bias assessment in a 'Risk of bias' table and displayed them in a 'Risk of bias' summary and 'Risk of bias' graph (Figure 2; Figure 3). Figure 2 Risk of bias summary: review authors' judgements about each risk of bias item for each included trial. Figure 3 Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included trials.

We reported the results of the risk of bias assessment in a 'Risk of bias' table and displayed them in a 'Risk of bias' summary and 'Risk of bias' graph (Figure 2; Figure 3). Figure 2 Risk of bias summary: review authors' judgements about each risk of bias item for each included trial. Figure 3 Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included trials. Measures of treatment effect We analysed the data using Review Manager (RevMan). For dichotomous data, we estimated the Risk Ratio (RR) and used the Mantel-Haenszel method with fixed-effect, or with random-effects if there was heterogeneity. For continuous data, we estimated the mean difference (MD). All results are presented with 95% confidence intervals (CIs). We reported results only for days after the first day of PQ treatment, which, in some trials, was later than the beginning of primary treatment.

(Graves 2012), we identified 45 potentially relevant publications from literature searches. Two publications (in different languages) described the same trial (Chen 1994), leaving 44 distinct trials. We excluded 13 at abstract stage, excluded 20 after reading the full text article, and included 11 trials in the review. For this update, we repeated the searches since we had expanded the scope of the review to include other 8AQ and comparisons of different doses of PQ and other 8AQ. We identified 65 more potential studies in addition to the 45 previously identified, which we rescreened due to revised inclusion criteria. We identified an additional 41 papers from reference lists, personal knowledge of new papers, or people consulted. Of the 151 abstracts we screened, we selected 73 for full text review. Five papers were duplicates, we could not locate three articles, and we included 18 trials (Figure 4). These 18 trials included a total of 30 distinct comparisons of different malaria treatment drugs, doses or schedules. Figure 4 Study flow diagram. Included studies All 18 included trials were RCTs or quasi-RCTs. Two trials compared PQ and bulaquine, while 16 trials compared PQ versus no PQ. One trial of PQ (Khoo 1981) did not distinguish between short or long course of PQ and therefore no outcomes are included in this review. One trial did not include any gametocyte outcomes (Wang 2006).

2012 (3 to 70 years); and Sutanto 2013 (≥ 5 years). The remaining five studies included teenagers and adults only: Gogtay 2004 (= 18 years); Kamtekar 2004 (= 16 years); Pukrittayakamee 2004 (15 to 62 years); Gogtay 2006 (= 16 years); and Ledermann 2006 (≥ 15 years). See the Characteristics of included studies section. For G6PD deficiency, two studies did not screen participants (Kamtekar 2004; Smithuis 2010), one trial screened and included all participants (Shekalaghe 2007), one trial included only G6PD-deficient participants (Khoo 1981), six studies included only non-deficient participants (Gogtay 2004; Pukrittayakamee 2004; Gogtay 2006; Ledermann 2006; Eziefula 2013; Sutanto 2013), and the remaining eight studies made no comment (Chen 1993a; Chen 1994; Singhasivanon 1994; Wang 2006; El-Sayed 2007; Vasquez 2009; Arango 2012; Kolaczinski 2012); see Table 1. Additional Tables Table 1 G6PD status, partner drugs, gametocyte status at onset, and PQ dose and treatment schedule Comparator Trial Comparison Place G6PD status Parasite species Partner or alternative drug Proportion with gametocytes at onset (by microscopy unless noted) PQ day(s)* Target PQ dose per day Non-artemisinin partner CQ or (CQ+SP) Kamtekar 2004 a India (Mumbai) Not screened Pf only CQ days 1 to 3 or CQ days 1 to 3 + SP day 1 100% (within 3 days) (N = 46) day 4 45 mg (˜0.75 mg/kg) Khoo 1981 Malaysia (Sabah) Only deficient (method: Brewer's methaemoglobin reduction test) Pf, Pv or mixed CQ days 1 to 3 Not reported days 1 to 3 25 mg (˜0.42 mg/kg)

Smithuis 2010 d Myanmar (3 states) Not screened Pf or mixed AS days 1 to 3 + MQ day 1 loose 29% (N = 161) day 1 0.75 mg/kg Smithuis 2010 e Myanmar (3 states) Not screened Pf or mixed DHAP days 1 to 3 38% (N = 161) day 1 0.75 mg/kg Sutanto 2013 Indonesia (south Sumatra) Screened and only normals included (method: qualitative test) Pf only DHAP days 1 to 3 20.6% (on day 3) (N = 349) day 3 0.75 mg/kg Vasquez 2009 Colombia (Antioquia) Not reported Pf only AS+MQ days 1 to 3 (MQ only on day 2 for children < 6) 20.0% (N = 50) day 3 45 mg (˜0.75 mg/kg) Wang 2006 Gabon Not reported Pf AS i.m. days 1 to 5 Not reported (N = 204) days 1 to 5 22.5 mg (˜0.38 mg/kg) Comparison of different 8AQ PQ versus Bulaquine Gogtay 2004 India (Mumbai) Only non-deficient (method: not stated) Pf QN + doxycycline days 1 to 7 + BQ day 4 100% (N = 22) day 4 45 mg (˜0.75 mg/kg) Gogtay 2006 India Only non-deficient (method: not stated) Pf QN + doxycycline days 1 to 7 + BQ day 4 100% (N = 93) day 4 45 mg (˜0.75 mg/kg) * first day of any treatment = day 1 Abbreviations: G6PD = glucose-6-phosphate dehydrogenase; PQ = primaquine; CQ = chloroquine; SP = sulfadoxine-pyrimethamine; MQ = mefloquine; QN = quinine; AS = artesunate; ACT = artemisinin-based combination therapy; 8AQ: 8-aminoquinoline; AQ = amodiaquine; AL = artemether-lumefantrine; DHAP = dihydroxyartemisinin-piperaquine; BQ = bulaquine; i.v. = intravenous injection; i.m. = intramuscular injection; Pf = P. falciparum; Pv = P. vivax.

e; MQ = mefloquine; QN = quinine; AS = artesunate; ACT = artemisinin-based combination therapy; 8AQ: 8-aminoquinoline; AQ = amodiaquine; AL = artemether-lumefantrine; DHAP = dihydroxyartemisinin-piperaquine; BQ = bulaquine; i.v. = intravenous injection; i.m. = intramuscular injection; Pf = P. falciparum; Pv = P. vivax. Interventions Non-artemisinin-based regimens Twelve studies (15 treatment arms) evaluated PQ given alongside non-artemisinin-based treatments: chloroquine alone (CQ) (two trials), CQ+sulfadoxine-pyrimethamine (SP) (one trial), CQ alone or CQ+SP (one trial), SP (one trial), mefloquine (MQ) (two trials), MQ+SP (two trials), quinine (QN) (two trials), and QN plus doxycycline (two trials). Artemisinin-based regimens Eight studies (15 treatment arms) evaluated PQ given alongside artemisinin-based treatments: artesunate (AS) (two trials), AS+SP (two trials), AS+MQ (four trials), AS+amodiaquine (AQ) (one trial), artemether-lumefantrine (AL) (four trials) and dihydroxyartemisinin-piperaquine (DHAP) (two trials). Dose Most trials used a target dose equivalent to 0.75 mg/kg PQ per day (adult dose 45 mg/day), see Table 1. The exceptions were: Khoo 1981: adult dose of 25 mg or approximately 0.42 mg/kg/day; Kolaczinski 2012: (two comparisons) 0.5 mg/kg or adult dose 30 mg/day; Pukrittayakamee 2004: the trial with QN had two arms, one with 0.25 mg/kg and the other 0.5 mg/kg per day (adult dose 15 mg or 30 mg per day respectively); the comparison with AS used 0.5 mg/kg per day (adult dose 30 mg per day). Wang 2006: adult dose of 22.5 mg or approximately 0.38 mg/kg per day.

Kolaczinski 2012: (two comparisons) 0.5 mg/kg or adult dose 30 mg/day; Pukrittayakamee 2004: the trial with QN had two arms, one with 0.25 mg/kg and the other 0.5 mg/kg per day (adult dose 15 mg or 30 mg per day respectively); the comparison with AS used 0.5 mg/kg per day (adult dose 30 mg per day). Wang 2006: adult dose of 22.5 mg or approximately 0.38 mg/kg per day. Eziefula 2013: evaluated 0.1, 0.4 and 0.75 mg/kg and placebo. Schedule Most trials used a single dose of PQ given on the following days, and we regarded the first day of any treatment as day 1: Day 1: Chen 1993a; Chen 1994; Singhasivanon 1994; Ledermann 2006 (one of two comparisons); Smithuis 2010 (five comparisons); and Kolaczinski 2012 (one of two comparisons); Day 2: Arango 2012 (two comparisons); Day 3: Ledermann 2006 (one of two comparisons); Vasquez 2009; Kolaczinski 2012 (one of two comparisons); Eziefula 2013; and Sutanto 2013; Day 4: Gogtay 2004; Kamtekar 2004 (one of two comparisons); Gogtay 2006; El-Sayed 2007; and Shekalaghe 2007; Day 8: Kamtekar 2004 (one of two comparisons). Three trials used a longer course of PQ: 3 days: Khoo 1981; 5 days: Wang 2006; 7 days: Pukrittayakamee 2004 (three comparisons). Prevalence of gametocytes at start of trial Five trials only included people with gametocytes at onset (as detected by microscopy) (Chen 1993a; Chen 1994; Gogtay 2004; Kamtekar 2004 (both comparisons); Gogtay 2006). However Kamtekar 2004 reported this variable as "within 3 days" rather than on day 1. Four trials did not report this statistic (Khoo 1981; Singhasivanon 1994; Ledermann 2006 (both comparisons); Wang 2006).

ll trials (days 1, 8, 15, 29 and 43; see Methods section). We estimated AUC up to day 15 (Table 2), day 29 (Table 3) and day 43 (Table 4). Results are presented separately by non-artemisinin-based and artemisinin-based malaria treatments below and given for log(10)AUC in the summary of findings tables for days 1 to 43. Table 2 AUC of gametocyte density over time, days 1 to 15 after treatment Other malaria treatment type Trial Malaria treatment Dose PQ mg/kg AUC with PQ days 1 to 15 AUC without PQ days 1 to 15 % reduction AUC days 1 to 15 log(10)AUC with PQ days 1 to 15 log(10)AUC without PQ days1 to 15 % reduction log(10)AUC days 1 to 15 Non-artemisinin- based Kolaczinski 2012 a: CQ 0.5 485.26 4266.61 88.6 2.69 3.63 26.0 Kolaczinski 2012 b: SP 0.5 924.87 5964.77 84.5 2.97 3.78 21.4 Artemisinin- based Shekalaghe 2007 AS+SP 0.75 40.15 65.06 38.3 1.60 1.81 11.6 Smithuis 2010 a: AS+AQ 0.75 140.35 428.51 67.3 2.15 2.63 18.4 Smithuis 2010 b: AL 0.75 196.24 242.86 19.2 2.29 2.39 3.9 Smithuis 2010 c: AS+MQ fixed 0.75 237.78 510.03 53.4 2.38 2.71 12.2 Smithuis 2010 d: AS+MQ loose 0.75 183.51 293.28 37.4 2.26 2.47 8.3 Smithuis 2010 e: DHAP 0.75 295.24 709.60 58.4 2.47 2.85 13.4 Sutanto 2013 DHAP 0.75 1252.48 2355.84 46.8 3.10 3.37 8.1 Vasquez 2009 AS+MQ 0.75 500.40 305.67 -63.7 2.70 2.49 -8.6 Abbreviations: AUC = area under curve; PQ = primaquine; CQ = chloroquine; SP = sulfadoxine-pyrimethamine; AS = artesunate; AQ = amodiaquine; AL = artemether-lumefantrine; MQ = mefloquine; DHAP = dihydroxyartemisinin-piperaquine. Table 3 AUC of gametocyte density over time, days 1 to 29 after treatment

Vasquez 2009 AS+MQ 0.75 500.40 305.67 -63.7 2.70 2.49 -8.6 Abbreviations: AUC = area under curve; PQ = primaquine; CQ = chloroquine; SP = sulfadoxine-pyrimethamine; AS = artesunate; AQ = amodiaquine; AL = artemether-lumefantrine; MQ = mefloquine; DHAP = dihydroxyartemisinin-piperaquine. Table 3 AUC of gametocyte density over time, days 1 to 29 after treatment Other malaria treatment type Trial Malaria treatment Dose PQ mg/kg AUC with PQ days 1 to 29 AUC without PQ days 1 to 29 % reduction AUC days 1 to 29 log(10)AUC with PQ days 1 to 29 log(10)AUC without PQ days 1 to 29 % reduction log(10)AUC days 1 to 29 Non-artemisinin- based Kolaczinski 2012 a: CQ 0.5 732.98 8777.24 91.7 2.87 3.94 27.3 Kolaczinski 2012 b: SP 0.5 2111.55 12847.37 83.6 3.32 4.11 19.1 Artemisinin- based Shekalaghe 2007 AS+SP 0.75 40.30 87.69 54.0 1.61 1.94 17.4 Smithuis 2010 a: AS+AQ 0.75 141.08 649.46 78.3 2.15 2.81 23.6 Smithuis 2010 b: AL 0.75 197.57 318.23 37.9 2.3 2.5 8.3 Smithuis 2010 c: AS+MQ fixed 0.75 240.79 535.40 55.0 2.38 2.73 12.7 Smithuis 2010 d: AS+MQ loose 0.75 183.51 321.96 43.0 2.26 2.51 9.7 Smithuis 2010 e: DHAP 0.75 307.14 952.93 67.8 2.49 2.98 16.5 Sutanto 2013 DHAP 0.75 1363.10 3108.05 56.1 3.13 3.49 10.3 Vasquez 2009 AS+MQ 0.75 526.40 349.04 -50.8 2.72 2.54 -7.0 Abbreviations: AUC = area under curve; PQ = primaquine; CQ = chloroquine; SP = sulfadoxine-pyrimethamine; AS = artesunate; AQ = amodiaquine; AL = artemether-lumefantrine; MQ = mefloquine; DHAP = dihydroxyartemisinin-piperaquine. Table 4 AUC of gametocyte density over time, days 1 to 43 after treatment

Vasquez 2009 AS+MQ 0.75 526.40 349.04 -50.8 2.72 2.54 -7.0 Abbreviations: AUC = area under curve; PQ = primaquine; CQ = chloroquine; SP = sulfadoxine-pyrimethamine; AS = artesunate; AQ = amodiaquine; AL = artemether-lumefantrine; MQ = mefloquine; DHAP = dihydroxyartemisinin-piperaquine. Table 4 AUC of gametocyte density over time, days 1 to 43 after treatment Other malaria treatment type Trial Malaria treatment Dose PQ AUC with PQ days 1 to 43 AUC without PQ days 1 to 43 % reduction AUC days 1 to 43 log(10)AUC with PQ days 1 to 43 log(10)AUC without PQ days 1 to 43 % reduction log(10)AUC days 1 to 43 Non-artemisinin- based Kolaczinski 2012 CQ 0.5 71.02 279.13 74.6 1.85 2.45 24.3 SP 0.5 85.47 445.65 80.8 1.93 2.65 27.1 Artemisinin- based Shekalaghe 2007 AS+SP 0.75 1.16 3.22 64.1 0.06 0.51 87.5 Smithuis 2010 AS+AQ 0.75 3.36 19.29 82.6 0.53 1.29 59.1 AL 0.75 4.70 8.12 42.1 0.67 0.91 26.1 AS+MQ fixed 0.75 5.73 12.75 55.0 0.76 1.11 31.4 AS+MQ loose 0.75 4.37 7.74 43.5 0.64 0.89 27.9 DHAP 0.75 7.38 25.49 71.1 0.87 1.41 38.3 Sutanto 2013 DHAP 0.75 32.73 83.15 60.6 1.51 1.92 21.1 Vasquez 2009 AS+MQ 0.75 12.53 8.87 -41.3 1.10 0.95 -15.8 Abbreviations: AUC = area under curve; PQ = primaquine; CQ = chloroquine; SP = sulfadoxine-pyrimethamine; AS = artesunate; AQ = amodiaquine; AL = artemether-lumefantrine; MQ = mefloquine; DHAP = dihydroxyartemisinin-piperaquine.

Sutanto 2013 DHAP 0.75 32.73 83.15 60.6 1.51 1.92 21.1 Vasquez 2009 AS+MQ 0.75 12.53 8.87 -41.3 1.10 0.95 -15.8 Abbreviations: AUC = area under curve; PQ = primaquine; CQ = chloroquine; SP = sulfadoxine-pyrimethamine; AS = artesunate; AQ = amodiaquine; AL = artemether-lumefantrine; MQ = mefloquine; DHAP = dihydroxyartemisinin-piperaquine. Primaquine plus non-artemisinin-based treatment regimens (Comparison 1) Eleven trials contributed comparisons to this analysis, of which one trial tested a low dose PQ regimen (Pukrittayakamee 2004). One trial (Khoo 1981) did not report results in a usable manner. Gametocyte prevalence There were fewer people with gametocytes (detected by microscopy) in the PQ group at days 8, 15, 22, 29 and 36 (Analysis 1.1). The largest number of trials and comparisons was included at day 8 (RR 0.60, 95% CI 0.50 to 0.73, six trials, 498 participants, nine comparisons) and the effect appeared larger at day 15 (RR 0.31, 95% CI 0.22 to 0.43, four trials, 366 participants, seven comparisons). The trials included three with CQ or CQ combination partner treatment (Kamtekar 2004; Ledermann 2006 (two comparisons); Kolaczinski 2012); one with SP (Kolaczinski 2012); one with AQ+SP (Arango 2012 (one comparison)); one with MQ (Chen 1993a) and two with quinine (Kamtekar 2004 (one comparison); Pukrittayakamee 2004 (two comparisons)).

ls nearly all trended in the direction of a reduction, but an indirect comparison suggested a smaller effect for non-artemisinin-based (RR 0.63, 95% CI 0.44 to 0.88, six trials, 499 participants) than for artemisinin-based malaria treatments (RR 0.33, 95% CI 0.21 to 0.52, eight trials, 1642 participants, Analysis 3.1). Comparison of different 8AQ (Comparison 4) Two small trials compared the effect of bulaquine and PQ on gametocyte prevalence at day 8 (Gogtay 2004; Gogtay 2006). Both trials suggested a greater reduction of gametocytes by bulaquine (OR 0.41 95% CI 0.26 to 0.66, two trials, 112 participants, Analysis 4.1). Neither trial concealed allocation. ADDITIONAL SUMMARY OF FINDINGS [Explanation] PQ for reducing P. falciparum transmission with non-artemisinin-based treatments Patient or population: People with symptomatic malaria Settings: Malaria-endemic areas Intervention: Single dose or short course PQ plus malaria treatment which does not include an artemisinin derivative Control: Malaria treatment not including an artemisinin derivative, without PQ Outcomes Illustrative comparative risks* (95% CI) Relative effect(95% CI) Number of participants(trials) Quality of the evidence(GRADE) Assumed risk Corresponding risk Control PQ Malaria incidence, prevalence or EIR - - - - (0 trials) - People infectious to mosquitoes (day 8) 93 per 100 7 per 100 (1 to 39) RR 0.07 1 (0.01 to 0.45) 30(2 trials) ⊕⊕○○ low2,3 Participants with gametocytes on microscopy (day 8) Dose < 0.4 mg/kg - - (0 trials) - Dose 0.4 to 0.6 mg/kg RR 0.60 (0.49 to 0.75) 216 (1 trial) ⊕⊕⊕⊕ high 4,5 70 per 100 43 per 100 (35 to 53)

Malaria incidence, prevalence or EIR - - - - (0 trials) - People infectious to mosquitoes (day 8) 93 per 100 7 per 100 (1 to 39) RR 0.07 1 (0.01 to 0.45) 30(2 trials) ⊕⊕○○ low2,3 Participants with gametocytes on microscopy (day 8) Dose < 0.4 mg/kg - - (0 trials) - Dose 0.4 to 0.6 mg/kg RR 0.60 (0.49 to 0.75) 216 (1 trial) ⊕⊕⊕⊕ high 4,5 70 per 100 43 per 100 (35 to 53) Dose = 0.6 mg/kg RR 0.39 (0.25 to 0.62) 186 (4 trials) ⊕⊕⊕⊕ high 6,7 35 per 100 14 per 100 (9 to 22) Evidence of haemolysis - - - 0 trials6,7 - *The basis for the assumed risk (for example, the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). PQ: Primaquine; CI: Confidence interval; RR: Risk ratio; EIR: entomological inoculation rate; G6PD: glucose-6-phosphate dehydrogenase. GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate. 1High category dose PQ used in both studies = 0.6 mg/kg.

estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate. 1High category dose PQ used in both studies = 0.6 mg/kg. 2Downgraded by 1 for serious risk of bias: allocation was not concealed; both experiments were performed by the same author team and the methods were unclear. 3Downgraded by 1 for serious imprecision: the sample size is small (N = 30; downgraded by 2) but the effect is large (upgraded by 1). In the control group, infectivity wanes by day 15. 4No serious imprecision: although the sample size is limited, the effect is large. 5Log(10)AUC day 1 to 43 % reduction relative decrease: 2 estimates from one trial of 24.3% to 27.1% (N = 219), assessed as moderate quality evidence. 6We could not use data from Khoo 1981 because it did not distinguish between patients with P. falciparum and P. vivax and their respective treatments. There was a much higher risk of adverse haemolytic events in those who received PQ (OR of 22.27 for both haemolysis and need for blood transfusion), but the participants included those receiving a short course (three days) of PQ with those receiving a 14-day regimen.

iparum and P. vivax and their respective treatments. There was a much higher risk of adverse haemolytic events in those who received PQ (OR of 22.27 for both haemolysis and need for blood transfusion), but the participants included those receiving a short course (three days) of PQ with those receiving a 14-day regimen. 7For the 10 included trials, the G6PD status of participants varied: two trials excluded patients with G6PD deficiency trials), one trial included only those with G6PD deficiency, two trials did not screen for G6PD deficiency, and five trials did not report or comment on screening for G6PD status. No trials systematically reported on adverse effects. Discussion Summary of main results PQ with artemisinin-based regimens See Summary of findings for the main comparison. When added to artemisinin-based therapy, a single dose of PQ above 0.4 mg/kg reduces the proportion of people with detectable gametocytaemia on day eight by around two thirds (high quality evidence), and can reduce the log(10) AUC estimates for gametocytaemia by up to 87.5%. However, only a single trial evaluated lower doses (0.1 mg/kg) and did not demonstrate an effect (low quality evidence). No trials evaluated effects on infectiousness to mosquitoes, or on malaria transmission directly (incidence, prevalence, or entomological inoculation rate). PQ with non-artemisinin-based regimens See Summary of findings 2.

ual patients should be combined with modelling or community-based trials of treatment regimens with and without PQ to determine the malaria and population characteristics under which PQ is likely to be an important additional contributor to malaria elimination programmes (including mass treatment and 'test and treat'). We thank authors of Shekalaghe 2007, Vasquez 2009, Smithuis 2010, Kolaczinski 2012 and Sutanto 2013 for providing unpublished data for this review. Dr Isabela Ribeiro assisted with assessing trials in Portuguese for inclusion. Dr Adam Ye and Dr Yang Wu helped with translation of Chinese trials and Dr Nick White provided links to Chinese trials. Dr David Sinclair was the Academic Editor for this review, and assisted with the Summary of Findings tables and advised on structuring the discussion in this revision. We are grateful to our affiliated institutions and organizations, and thank the referees and editors for their comments and encouragement. The editorial base for the Cochrane Infectious Disease Group is funded by the Department for International Development (DFID), UK, for the benefit of developing countries. APPENDICES Appendix 1. Search strategy Search set CIDG SR1 CENTRAL MEDLINE2 EMBASE2 LILACS2 1 malaria MALARIA, FALCIPARUM/ DRUG THERAPY MALARIA, FALCIPARUM/ DRUG THERAPY MALARIA FALCIPARUM/DRUG THERAPY Malaria AND falciparum

We thank authors of Shekalaghe 2007, Vasquez 2009, Smithuis 2010, Kolaczinski 2012 and Sutanto 2013 for providing unpublished data for this review. Dr Isabela Ribeiro assisted with assessing trials in Portuguese for inclusion. Dr Adam Ye and Dr Yang Wu helped with translation of Chinese trials and Dr Nick White provided links to Chinese trials. Dr David Sinclair was the Academic Editor for this review, and assisted with the Summary of Findings tables and advised on structuring the discussion in this revision. We are grateful to our affiliated institutions and organizations, and thank the referees and editors for their comments and encouragement. The editorial base for the Cochrane Infectious Disease Group is funded by the Department for International Development (DFID), UK, for the benefit of developing countries. APPENDICES Appendix 1. Search strategy Search set CIDG SR1 CENTRAL MEDLINE2 EMBASE2 LILACS2 1 malaria MALARIA, FALCIPARUM/ DRUG THERAPY MALARIA, FALCIPARUM/ DRUG THERAPY MALARIA FALCIPARUM/DRUG THERAPY Malaria AND falciparum 2 primaquine OR pamaquine OR plasmoquine OR plasmochin OR plasmocide OR rhodoquine OR plasmocid OR quinocine OR pentaquine OR isopentaquine OR bulaquine OR tafenoquine OR 8-aminoquinoline* Malaria AND falciparum ti, ab Malaria AND falciparum ti, ab Malaria AND falciparum ti, ab primaquine OR pamaquine OR plasmoquine OR plasmochin OR plasmocide OR rhodoquine OR plasmocid OR quinocine OR pentaquine OR isopentaquine OR bulaquine OR tafenoquine OR 8-aminoquinoline$ 3 1 and 2 1 or 2 1 or 2 1 or 2 1 and 2

7 - 3 and 6 3 and 6 3 and 6 - 8 - - Limit 7 to Humans Limit 7 to Human - 1Cochrane Infectious Diseases Group Specialized Register. 2Search terms used in combination with the search strategy for retrieving trials developed by The Cochrane Collaboration (Lefebvre 2011); Upper case: MeSH or EMTREE heading; Lower case: free text term. WHAT'S NEW Last assessed as up-to-date: 5 January 2015. Date Event Description 4 February 2015 New citation required but conclusions have not changed Search updated and minor errors corrected. 4 February 2015 New search has been performed Search updated to 5 January 2015. We simplified the text. We corrected data extraction errors in one study and corrected the results and 'Summary of findings' table. We adjusted the wording around "evidence of no effect". We took into account comments and criticisms received. These criticisms were also published in the Malaria Journal in 2014, so this revision corrects the minor data extraction errors pointed out in this article. The conclusions are not changed. HISTORY Protocol first published: Issue 4, 2009 Review first published: Issue 9, 2012 Date Event Description 24 June 2014 New search has been performed New studies added. 24 June 2014 New citation required and conclusions have changed We stratified the analysis by dose or primaquine and added new studies. We clarified the excluded studies and adjusted the conclusions. CHARACTERISTICS OF STUDIES Characteristics of included studies [ordered by study ID] Arango 2012 Methods Quasi-RCT: alternate allocation to AQ+SP and AQ+SP+PQ, then MQ+AS and MQ+AS+PQ

24 June 2014 New citation required and conclusions have changed We stratified the analysis by dose or primaquine and added new studies. We clarified the excluded studies and adjusted the conclusions. CHARACTERISTICS OF STUDIES Characteristics of included studies [ordered by study ID] Arango 2012 Methods Quasi-RCT: alternate allocation to AQ+SP and AQ+SP+PQ, then MQ+AS and MQ+AS+PQ Participants Inclusion criteria: 1. Uncomplicated malaria 2. Pf only 3. Not pregnant 4. Voluntary consent Colombia 82 patients, aged one to 75 years (mean age ranged from 24 to 35 years in four groups) Gametocytes in 23/82 (28%) Interventions All loose combinations: 1. AQ+SP 2. AQ+SP+PQ 3. MQ+AS 4. MQ+AS+PQ AQ: 25 mg/kg total dose divided into 10 mg/kg on day 1 and 7.5 mg/kg on days 2 and 3 SP: 25 mg/kg/1.25 mg/kg single dose on day 1 MQ: 25 mg/kg total dose, divided into 8.3 mg/kg per day for 3 days AS: 4 mg/kg per day for 3 days PQ: 0.75 mg/kg, total single dose on day 2 Outcomes Day 1 (pretreatment with schizonticide), 4 and 8 Asexual and gametocyte counts in thick smears Gametocyte prevalence Gametocyte density Notes No mention of G6PD status Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) High risk Alternate allocation. Allocation concealment (selection bias) Unclear risk Not discussed. Incomplete outcome data (attrition bias) All outcomes Low risk No evidence of incomplete data. Selective reporting (reporting bias) Low risk No evidence of selective reporting. Other bias Unclear risk Nothing obvious.

Random sequence generation (selection bias) High risk Alternate allocation. Allocation concealment (selection bias) Unclear risk Not discussed. Incomplete outcome data (attrition bias) All outcomes Low risk No evidence of incomplete data. Selective reporting (reporting bias) Low risk No evidence of selective reporting. Other bias Unclear risk Nothing obvious. Blinding of participants and personnel (performance bias) All outcomes Unclear risk Not discussed. Blinding of outcome assessment (detection bias) All outcomes Unclear risk Not discussed. Chen 1993a Methods RCT Participants 18 participants with P. falciparum Interventions A: MQ 750 mg B: MQ 750 mg + SP (1500 mg/75 mg) C: MQ 750 mg + PQ 45 mg All single doses Follow-up: 28 days for gametocytes and 21 days for infectiousness Outcomes Gametocyte prevalence at days 3, 8, 14 and 21 Infectiousness to An. dirus Sporozoite infections in mosquitoes Infectivity of sporozoite-infected mosquitoes to subsequent patients Notes Only abstract available. Mosquitoes fed on the patients were allowed to develop sporozoites which were then fed on uninfected people. One of the MQ + PQ group passed the infection to a new person. Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) Unclear risk Trial authors stated it was randomized in abstract. Allocation concealment (selection bias) Unclear risk No information in abstract. Incomplete outcome data (attrition bias) All outcomes Low risk All patients were followed up. Selective reporting (reporting bias) Unclear risk No information in abstract. Other bias Unclear risk None known.

Random sequence generation (selection bias) Unclear risk Trial authors stated it was randomized in abstract. Allocation concealment (selection bias) Unclear risk No information in abstract. Incomplete outcome data (attrition bias) All outcomes Low risk All patients were followed up. Selective reporting (reporting bias) Unclear risk No information in abstract. Other bias Unclear risk None known. Blinding of participants and personnel (performance bias) All outcomes Low risk Stated to be double blind in title. Blinding of outcome assessment (detection bias) All outcomes Unclear risk No information in abstract. Chen 1994 Methods Possibly individually RCT (stated to be randomized but no information given). Dates of trial not reported. Participants 27 patients with slide positive P. falciparum including both asexual stages and gametocytes. No information given on age or sex. All dosages appear to be adult dosages. Site: malaria-endemic Hainan Island, China. Exclusion criteria: history of antimalarial treatment for present attack. Interventions 1. Artemisinin: 1200 mg per day for 5 days (not included in review) 2. MQ 750 mg single dose day 1 (reported as day 0) 3. MQ 750 mg single dose + PQ 45 mg single dose day 1 (reported as day 0) Outcomes 1. Gametocyte density: days 5, 8, 15, 22 and 29 (reported in paper as days 4, 7, 14, 21 and 28 since first day was day 0). Given as % of initial density on chart only 2. Percentage of participants infectious to An. dirus: days 5, 8, 15 and 22 (reported as days 4, 7, 14 and 21) 3. Percentage of mosquitoes infected: days 5, 8, 15 and 22 (reported as days 4, 7, 14 and 21)

ported in paper as days 4, 7, 14, 21 and 28 since first day was day 0). Given as % of initial density on chart only 2. Percentage of participants infectious to An. dirus: days 5, 8, 15 and 22 (reported as days 4, 7, 14 and 21) 3. Percentage of mosquitoes infected: days 5, 8, 15 and 22 (reported as days 4, 7, 14 and 21) Notes For gametocyte density, graph only of percentages; no raw numbers given except range of asexuals and gametocyte numbers reported for each group on day 1 (reported as day 0). Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) Unclear risk No information on sequence generation. Trial authors described process as participants "divided into groups A, B, and C". Equal number in each group and lack of detail suggests randomization not done adequately. Allocation concealment (selection bias) High risk No data to suggest any measures to conceal allocation. Incomplete outcome data (attrition bias) All outcomes Low risk No missing participants in intervention groups 2 and 3. Selective reporting (reporting bias) Low risk No obvious selective reporting. Other bias Low risk No indication of other bias. Blinding of participants and personnel (performance bias) All outcomes Unclear risk Not reported. Blinding of outcome assessment (detection bias) All outcomes Unclear risk Not reported. El-Sayed 2007 Methods Individually RCT Dates of trial: Randomization June 2004; trial done 17 August 2004 to 3 September 2004.

Other bias Low risk No indication of other bias. Blinding of participants and personnel (performance bias) All outcomes Unclear risk Not reported. Blinding of outcome assessment (detection bias) All outcomes Unclear risk Not reported. El-Sayed 2007 Methods Individually RCT Dates of trial: Randomization June 2004; trial done 17 August 2004 to 3 September 2004. Participants 104 people with asymptomatic P. falciparum positive by slide and positive for gametocytes by PCR. No information given on age and sex. Site: Two villages in East Sudan where there is seasonal malaria, mainly P. falciparum, during October to December. Exclusion criteria: Pregnancy, history of sulfa allergy, fever or other symptoms, Plasmodium spp other than P. falciparum present. Interventions 1. AS: Children < 50 kg: 4 mg/kg; All = 50 kg: 200 mg (two 100 mg tabs) days 1, 2, and 3 (reported as days 0, 1, and 2). SP: Children < 50 kg: 25 mg/kg S + 1.25 mg/kg P; All = 50 kg: 3 tablets of 500 mg S + 25 mg P. 2. As for 1. above plus PQ 0.75 mg/kg day 4 (reported as day 3). Outcomes 1. Proportion of people with P. falciparum parasites by PCR days 4, 8 and 15 (reported as days 3, 7 and 14) 2. Proportion of people with gametocytes by RT-PCR days 8 and 15 (reported as days 7 and 14) 3. Adverse events days 2, 3, 4, 8 and 15 (reported as days 1, 2, 3, 7 and 14) 4. Packed cell volume days 1, 8 and 15 (reported as days 0, 7 and 14) Notes The trial was conducted about two months after the initial screening for positives (asymptomatic carriers). Risk of bias Bias Authors' judgement Support for judgement

Outcomes 1. Proportion of people with P. falciparum parasites by PCR days 4, 8 and 15 (reported as days 3, 7 and 14) 2. Proportion of people with gametocytes by RT-PCR days 8 and 15 (reported as days 7 and 14) 3. Adverse events days 2, 3, 4, 8 and 15 (reported as days 1, 2, 3, 7 and 14) 4. Packed cell volume days 1, 8 and 15 (reported as days 0, 7 and 14) Notes The trial was conducted about two months after the initial screening for positives (asymptomatic carriers). Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) Low risk "The list of carriers was sorted according to village and age to ensure that the treatment groups were balanced with respect to these two variables. The random allocation of this ordered list into the treatment arms was then created using restricted randomization with a block size of 12 in STATA v7" Allocation concealment (selection bias) Unclear risk No information given. Incomplete outcome data (attrition bias) All outcomes Low risk Only three of 104 participants did not complete follow-up. Selective reporting (reporting bias) Low risk No obvious selective reporting. Other bias Low risk No indication of other bias. Blinding of participants and personnel (performance bias) All outcomes High risk Patients and health staff were not blinded. Blinding of outcome assessment (detection bias) All outcomes Low risk Lab staff doing PCR were blinded. Eziefula 2013 Methods Individually randomized placebo-controlled, double blind trial conducted December 2011 to March 2013

Blinding of participants and personnel (performance bias) All outcomes High risk Patients and health staff were not blinded. Blinding of outcome assessment (detection bias) All outcomes Low risk Lab staff doing PCR were blinded. Eziefula 2013 Methods Individually randomized placebo-controlled, double blind trial conducted December 2011 to March 2013 Participants 468 randomized, aged one to 10 years old, male and female Inclusion criteria: 1. P. falciparum mono infection with parasite density lower than 500,000 parasites/μL 2. Normal G6PD enzyme function 3. Fever or history of fever in past 24 hours Exclusion criteria: 1. Signs of severity 2. Haemoglobin concentration < 80 g/L 3. Known allergy to the trial drugs 4. Antimalarials taken within the past two days 5. PQ taken within the past four weeks 6. Blood transfusion within the past 90 days Interventions 1. AL standard three day (twice per day) course + placebo (given with 5th AL dose, ie, with 1st dose on 3rd day of treatment) 2. AL + 0.1 mg/kg PQ 3. AL + 0.4 mg/kg PQ 4. AL + 0.75 mg/kg PQ (reference)

Participants 468 randomized, aged one to 10 years old, male and female Inclusion criteria: 1. P. falciparum mono infection with parasite density lower than 500,000 parasites/μL 2. Normal G6PD enzyme function 3. Fever or history of fever in past 24 hours Exclusion criteria: 1. Signs of severity 2. Haemoglobin concentration < 80 g/L 3. Known allergy to the trial drugs 4. Antimalarials taken within the past two days 5. PQ taken within the past four weeks 6. Blood transfusion within the past 90 days Interventions 1. AL standard three day (twice per day) course + placebo (given with 5th AL dose, ie, with 1st dose on 3rd day of treatment) 2. AL + 0.1 mg/kg PQ 3. AL + 0.4 mg/kg PQ 4. AL + 0.75 mg/kg PQ (reference) Outcomes Primary efficacy: Mean duration of gametocyte carriage Secondary efficacy: Point prevalence of gametocytes on days 7, 10 and 14; gametocyte circulation time (days), AUC of gametocyte density Primary safety: Arithmetic mean maximum decrease in haemoglobin concentration from enrolment to day 28 Secondary safety: Day of haemoglobin nadir, maximum percentage decrease in haemoglobin, percentage of participants with haemoglobin concentration lower than 50 g/L, requirement for blood transfusion, evidence of black urine, and frequency of severe adverse events. Notes G6PD enzyme function based on a fluorescence spot test (R&D Diagnostics, Aghia Paraskevi, Greece) Risk of bias Bias Authors' judgement Support for judgement

Outcomes Primary efficacy: Mean duration of gametocyte carriage Secondary efficacy: Point prevalence of gametocytes on days 7, 10 and 14; gametocyte circulation time (days), AUC of gametocyte density Primary safety: Arithmetic mean maximum decrease in haemoglobin concentration from enrolment to day 28 Secondary safety: Day of haemoglobin nadir, maximum percentage decrease in haemoglobin, percentage of participants with haemoglobin concentration lower than 50 g/L, requirement for blood transfusion, evidence of black urine, and frequency of severe adverse events. Notes G6PD enzyme function based on a fluorescence spot test (R&D Diagnostics, Aghia Paraskevi, Greece) Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) Low risk Computer-generated four-digit treatment assignment codes and allocated these to random dose groups in block sizes of 16. Allocation concealment (selection bias) Low risk Only the pharmacist was aware of allocation. Incomplete outcome data (attrition bias) All outcomes Low risk Only 8% of patients were lost to follow-up. No group significantly different from others. Selective reporting (reporting bias) Low risk None detected or suspected. Other bias Low risk None detected or suspected. Blinding of participants and personnel (performance bias) All outcomes Low risk "Masking syrup" added to all treatments to mask taste of drug. Blinding of outcome assessment (detection bias) All outcomes Low risk Assessors were blinded. Gogtay 2004 Methods Allocated by "simple, computer-generated randomization code"

Other bias Low risk None detected or suspected. Blinding of participants and personnel (performance bias) All outcomes Low risk "Masking syrup" added to all treatments to mask taste of drug. Blinding of outcome assessment (detection bias) All outcomes Low risk Assessors were blinded. Gogtay 2004 Methods Allocated by "simple, computer-generated randomization code" Participants Twenty-two patients in Mumbai, India Inclusion criteria: 1. = 18 years 2. Normal G6PD 3. = 55 P. falciparum gametocytes/μL on admission Exclusion criteria: 1. Complicated malaria Interventions 1. Quinine days 1 to 7: 30 mg/kg/day + PQ (45 mg) 2. Quinine days 1 to 7: 30 mg/kg/day + bulaquine (approximately 75 mg base) Outcomes Asexual and gametocyte counts on days 1, 4, 8, 15, 22 and 29 Adverse events Notes Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) Low risk Computer-generated randomization. Allocation concealment (selection bias) Unclear risk Not reported. Incomplete outcome data (attrition bias) All outcomes Low risk No evidence of incomplete data. Selective reporting (reporting bias) Low risk No evidence of selective reporting. Other bias High risk Unbalanced allocation (9 versus 13) and small number of participants. Blinding of participants and personnel (performance bias) All outcomes Unclear risk Not reported. Blinding of outcome assessment (detection bias) All outcomes Low risk Laboratory technician reading blood smears was blinded. Gogtay 2006 Methods Randomized (computer-generated) to PQ or bulaquine (1:2 ratio) after primary treatment with quinine + doxycycline

Blinding of participants and personnel (performance bias) All outcomes Unclear risk Not reported. Blinding of outcome assessment (detection bias) All outcomes Low risk Laboratory technician reading blood smears was blinded. Gogtay 2006 Methods Randomized (computer-generated) to PQ or bulaquine (1:2 ratio) after primary treatment with quinine + doxycycline Participants 93 participants in India Inclusion criteria: 1. = 16 years 2. Male 3. Uncomplicated Pf only 4. = 55 P. falciparum gametocytes/μL on admission Exclusion criteria: 1. Antimalarial treatment in previous two weeks 2. Allergy to trial drug 3. G6PD deficient Interventions All patients: Quinine days 1 to 7: 30 mg/kg/day (10 mg/kg/day three times per day) + 100 mg doxycycline Randomization and treatment on day 4 1. PQ 2. Bulaquine Outcomes Gametocyte prevalence, density and viability on days 1, 4, 15, 22 and 29 Adverse events Notes Gametocyte viability assessed by Shute's technique (exflagellation) Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) Low risk Computer-generated randomization. Allocation concealment (selection bias) Unclear risk Not reported. Incomplete outcome data (attrition bias) All outcomes Low risk No evidence of incomplete data. Three participants (two bulaquine, one PQ) did not return for follow-up. Selective reporting (reporting bias) Low risk No evidence of selective reporting. Other bias Low risk None noted. Blinding of participants and personnel (performance bias) All outcomes Unclear risk Not reported.

Incomplete outcome data (attrition bias) All outcomes Low risk No evidence of incomplete data. Three participants (two bulaquine, one PQ) did not return for follow-up. Selective reporting (reporting bias) Low risk No evidence of selective reporting. Other bias Low risk None noted. Blinding of participants and personnel (performance bias) All outcomes Unclear risk Not reported. Blinding of outcome assessment (detection bias) All outcomes Low risk Slide readers were blinded. Kamtekar 2004 Methods Individually RCT, comprising two distinct comparisons a: (CQ or [CQ+SP]) with and without PQ and b: QN with and without PQ. Dates of trial: Not given. Participants 57 people aged ≥ 16 years with symptomatic uncomplicated and 46 with severe (WHO criteria) P. falciparum malaria, diagnosed by thick and thin blood slides. Gametocytaemic within first 72 hrs with = 55 P. falciparum gametocytes/μL Site: Urban areas of Mumbai, India. Exclusion criteria: Pregnant or lactating, treatment for malaria within last two weeks, co-infection with P.vivax, history of PQ allergy. Interventions Comparison a: for uncomplicated malaria All received CQ (some also got SP) Day 4: Randomized to PQ or placebo (45 mg) Comparison b: For severe malaria All received quinine Day 8: Randomized to PQ or placebo (dose 45 mg) Doses background drugs: CQ 10 mg/kg on days 1 and 2; 5 mg/kg on day 3; SP 1500 mg; quinine dose 10 mg/kg every 8 hrs for 24 to 48 hrs and orally for total of 7 days

so got SP) Day 4: Randomized to PQ or placebo (45 mg) Comparison b: For severe malaria All received quinine Day 8: Randomized to PQ or placebo (dose 45 mg) Doses background drugs: CQ 10 mg/kg on days 1 and 2; 5 mg/kg on day 3; SP 1500 mg; quinine dose 10 mg/kg every 8 hrs for 24 to 48 hrs and orally for total of 7 days Outcomes 1. Proportion of people with gametocytes, days 1, 4, 8, 15, 22 and 29 2. Proportion of people with viable gametocytes (exflagellation), days 1, 4, 8, 15, 22 and 29 3. Gametocyte density (given as range) days 1, 4, 8, 15, 22 and 29 Notes No screening for G6PD deficiency. It is not stated how many got SP in addition to CQ or why. Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) High risk "simple computer generated randomization code". Not all patients had gametocytes on day 1. Inclusion criteria were that the person had to have gametocytes in the first 72 hours (from day 1?). This suggests some post randomization inclusions or exclusions. Allocation concealment (selection bias) Unclear risk No information. Incomplete outcome data (attrition bias) All outcomes High risk Originally there were 57 people included in uncomplicated comparison (a), of whom 2 were lost to follow-up and 9 were not evaluated as they showed CQ resistance. There were 46 in severe comparison (b), of whom 3 were lost to follow-up. The final numbers evaluated in each group were (a) 22 and 24 (b) 22 and 21. Selective reporting (reporting bias) Unclear risk No obvious selective reporting.

Incomplete outcome data (attrition bias) All outcomes High risk Originally there were 57 people included in uncomplicated comparison (a), of whom 2 were lost to follow-up and 9 were not evaluated as they showed CQ resistance. There were 46 in severe comparison (b), of whom 3 were lost to follow-up. The final numbers evaluated in each group were (a) 22 and 24 (b) 22 and 21. Selective reporting (reporting bias) Unclear risk No obvious selective reporting. Other bias High risk It was not clear why some patients got SP and others did not, and the numbers in each group are not given. Blinding of participants and personnel (performance bias) All outcomes Low risk Trial used a placebo for PQ. Patients and health workers were blinded. Blinding of outcome assessment (detection bias) All outcomes Low risk Slide readers were blinded. Khoo 1981 Methods Individually RCT Dates of trial: between June 1976 and March 1978. Participants 69 people (adults and children of both sexes, no ages specified) with G6PD deficiency (full or partial by Brewer's methaemoglobin reduction test) who were slide positive for malaria (P. falciparum, P. vivax or mixed). Site: Sabah, Malaysia. Exclusion criteria: Other associated clinical conditions. Interventions 1. CQ: 1.5 g CQ over 3 days for P. falciparum, P. vivax or mixed, less for children 2. CQ + PQ: CQ as above plus 75 mg PQ over 3 days for P. falciparum; 210 mg PQ over 14 days for P. vivax and mixed infections; less for children 3. SP (not included in this review): 1.5 g S and 75 mg P, single dose

Participants 69 people (adults and children of both sexes, no ages specified) with G6PD deficiency (full or partial by Brewer's methaemoglobin reduction test) who were slide positive for malaria (P. falciparum, P. vivax or mixed). Site: Sabah, Malaysia. Exclusion criteria: Other associated clinical conditions. Interventions 1. CQ: 1.5 g CQ over 3 days for P. falciparum, P. vivax or mixed, less for children 2. CQ + PQ: CQ as above plus 75 mg PQ over 3 days for P. falciparum; 210 mg PQ over 14 days for P. vivax and mixed infections; less for children 3. SP (not included in this review): 1.5 g S and 75 mg P, single dose Outcomes 1. Haemolysis 2. Proportion cleared parasites by 72 hours 3. Need for blood transfusion 4. Renal failure Notes The participants are not divided by P. falciparum, P. vivax or mixed, so it is not possible to use the data. Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) Unclear risk "those found G6PD deficient were randomly assigned". Allocation concealment (selection bias) Unclear risk No information given. Incomplete outcome data (attrition bias) All outcomes Unclear risk No information given. Selective reporting (reporting bias) Low risk No apparent selective reporting. Other bias Low risk No indication of other bias. Blinding of participants and personnel (performance bias) All outcomes Unclear risk Not reported. Blinding of outcome assessment (detection bias) All outcomes Unclear risk Not reported. Kolaczinski 2012 Methods Individually RCT Dates of trial: between July and January, from 2000 to 2003.

Other bias Low risk No indication of other bias. Blinding of participants and personnel (performance bias) All outcomes Unclear risk Not reported. Blinding of outcome assessment (detection bias) All outcomes Unclear risk Not reported. Kolaczinski 2012 Methods Individually RCT Dates of trial: between July and January, from 2000 to 2003. Participants 237 individuals aged from 3 to 70 years, in 5 villages for Afghan refugees in Pakistan. Inclusion: = 2 years of age, P. falciparum mono-infection, confirmed by slide, will be resident during entire follow-up period. Exclusions: Pregnancy, signs of severe malaria, report of antimalarial drug in past 21 days, other serious disease Interventions 1. CQ: 3 days 25 mg/kg. 2. CQ+PQ: CQ as in 1; PQ on day 3 (0.5 mg/kg). 3. SP: 25(S)/1.25(P) mg/kg in single dose. 4. SP+PQ: SP as in 3; PQ on same day (0.5 mg/kg). Outcomes 1. Clinical treatment failure (PCR non-adjusted and adjusted). 2. Gametocytes on day 8. 3. Gametocyte density on days 1 to 8 of follow-up. 4. Genotyping of resistant strains for CQ and SP-specific mutations. Notes Also included CQ + AS and SP + AS arms, compared with CQ +/- PQ and SP +/- PQ arms, respectively. Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) Low risk Patients numbered sequentially at enrolment. Random numbers with treatment assignment from Excel-generated lists, then paired with patient numbers. Allocation concealment (selection bias) Low risk Patient number concealed until after enrolment.

Bias Authors' judgement Support for judgement Random sequence generation (selection bias) Low risk Patients numbered sequentially at enrolment. Random numbers with treatment assignment from Excel-generated lists, then paired with patient numbers. Allocation concealment (selection bias) Low risk Patient number concealed until after enrolment. Incomplete outcome data (attrition bias) All outcomes Low risk 209 of 237 randomized completed treatment and at least one follow-up test. 47 (13%) of those randomized did not contribute data. Variable numbers tested during follow-up (see analyses). Selective reporting (reporting bias) Low risk None detected. Other bias Low risk None noted. Blinding of participants and personnel (performance bias) All outcomes High risk Identified in report as 'single-blind'. Manager (gave Rx) not blinded; patients, microscopists and health workers 'partially blinded' due to different drug appearance and times of follow-up. No placebos used, but vitamin given to those in non-PQ arms. Blinding of outcome assessment (detection bias) All outcomes Low risk Implied only. Ledermann 2006 Methods Individually RCT Date of trial: July to Oct 2001.

Blinding of participants and personnel (performance bias) All outcomes High risk Identified in report as 'single-blind'. Manager (gave Rx) not blinded; patients, microscopists and health workers 'partially blinded' due to different drug appearance and times of follow-up. No placebos used, but vitamin given to those in non-PQ arms. Blinding of outcome assessment (detection bias) All outcomes Low risk Implied only. Ledermann 2006 Methods Individually RCT Date of trial: July to Oct 2001. Participants 117 malaria cases with P. falciparum ≥ 400 asexual stages/μL (thick film) recruited by mass blood survey and passive case detection. Symptoms not required. Age: ≥ 15 years Site: Central Java, Indonesia, an area with high CQ resistance and resurgent malaria approximately equal P. falciparum and P. vivax. Exclusion criteria: Pregnancy, breast feeding, body weight < 40kg, G6PD deficiency, history of antimalarial or antibiotic in last seven days, severe or complicated malaria, history or allergy or adverse reaction to trial medications, Pv or mixed infection. Interventions 1. CQ only (not included in this review) 2. CQ+SP: CQ 150 mg base, 10, 10 and 5 mg/kg on days 1, 2, 3 (reported as days 0, 1, 2). SP 500 mg S 25 mg P on day 1 (reported as day 0) 3. CQ+SP as for group 2 above plus PQ 45 mg on day 1 (reported as day 0) 4. CQ+SP as for group 2 above plus PQ 45 mg on day 3 (reported as day 2)

Q only (not included in this review) 2. CQ+SP: CQ 150 mg base, 10, 10 and 5 mg/kg on days 1, 2, 3 (reported as days 0, 1, 2). SP 500 mg S 25 mg P on day 1 (reported as day 0) 3. CQ+SP as for group 2 above plus PQ 45 mg on day 1 (reported as day 0) 4. CQ+SP as for group 2 above plus PQ 45 mg on day 3 (reported as day 2) Outcomes 1. Parasite clearance time assessed at days 1, 3, 8, 15, 22, 29 or day of recurrent parasitaemia (reported as days 0, 2, 7, 14, 21, 28) 2. Fever clearance time at days 2, 3, 4, 5, 8, 12, 15, 19, 22, 29 3. Proportion of people with gametocytes (from chart) days 1 to 29 4. Adverse events Notes Some comparisons in the results reported include the CQ only group. Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) Low risk Trial subject codes were assigned to treatment arms by a random process (not specified). Allocation concealment (selection bias) High risk Eligibles were assigned a sequential participant number by the screening physician. Pre-packaged treatment but not stated whether allocation was concealed. Incomplete outcome data (attrition bias) All outcomes Low risk 7% of participants withdrew before day 28. Selective reporting (reporting bias) Unclear risk Abstract states that drugs were well tolerated and safe but no evidence is given in report. Other bias Low risk No indication of other bias. Blinding of participants and personnel (performance bias) All outcomes Unclear risk Blinding was implied only. Blinding of outcome assessment (detection bias) All outcomes Unclear risk Blinding was implied only.

Selective reporting (reporting bias) Unclear risk Abstract states that drugs were well tolerated and safe but no evidence is given in report. Other bias Low risk No indication of other bias. Blinding of participants and personnel (performance bias) All outcomes Unclear risk Blinding was implied only. Blinding of outcome assessment (detection bias) All outcomes Unclear risk Blinding was implied only. Pukrittayakamee 2004 Methods Individually RCT Dates of trial not stated. Participants 176 patients with acute uncomplicated P. falciparum. After exclusion of QN+tetracycline group: 146. Age 14 to 62. All male. Site: Hospital for Tropical Diseases, Bangkok, Thailand. Exclusion criteria: Severe malaria, mixed malaria infection, history of drug hypersensitivity, any antimalarial within last 48 hrs, urine positive for sulfonamide or 4AQ. People with G6PD deficient phenotype were excluded from receiving PQ. Interventions 1. QN: QN sulfate (300 mg salt/tab) at 10 mg salt/kg, three times per day for 7 days 2. QN+tetracycline (excluded from this review) 3. QN+PQ low dose: QN as above in 1 plus PQ 15 mg base/tab, 0.25 mg/kg base (adult dose 15 mg base) daily for 7 days 4. QN+PQ high dose: QN as above in 1 plus PQ 0.50 mg/kg base (adult dose 30 mg base) daily for 7 days 5. AS: AS 50 mg salt/tab 3.3 mg/kg (adult dose 200 mg) on day 1 and 1.65 mg/kg (adult dose 100 mg) daily on days 2 to 7 6. AS+PQ (high dose): AS as above plus PQ 0.5 mg/kg base daily on days 1 to 7

se) daily for 7 days 4. QN+PQ high dose: QN as above in 1 plus PQ 0.50 mg/kg base (adult dose 30 mg base) daily for 7 days 5. AS: AS 50 mg salt/tab 3.3 mg/kg (adult dose 200 mg) on day 1 and 1.65 mg/kg (adult dose 100 mg) daily on days 2 to 7 6. AS+PQ (high dose): AS as above plus PQ 0.5 mg/kg base daily on days 1 to 7 Outcomes 1. Parasite clearance time: measured at 12 hrs until clearance 2. Gametocyte clearance time: median, 12 hrs until clearance 3. Fever clearance time (measured every 4 hr at first and then every 6 to 12 hrs until resolution of fever) 4. Parasite reduction ratio at 48 hrs 5. Reappearance of infection P. falciparum/P. vivax up to 28 days 6. Prevalence of gametocytes on admission/after treatment/total 7. Gametocyte carriage: total number of hours for which gametocytes were detectable Notes Patients with recrudescence of P. falciparum or relapse of P. vivax were re-treated with 7 day QN+tetracycline or 'standard doses' of CQ+PQ respectively; not clear if they were excluded from further trial. Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) High risk Method not stated. Patients with G6PD deficiency were excluded from getting PQ which suggests randomization was biased. Allocation concealment (selection bias) Unclear risk No information given.

Other bias Unclear risk Those who were unable to stay in hospital until clearance of both fever and parasites were excluded from trial of fever clearance time. Blinding of participants and personnel (performance bias) All outcomes Unclear risk Not reported. Blinding of outcome assessment (detection bias) All outcomes Unclear risk Not reported. Shekalaghe 2007 Methods Individually RCT Dates of trial: June to Sept 2006. Participants 108 children with fever = 37.5°C or history of fever in last 48 hours and P. falciparum mono-infection 500 to 100,000/μL. Age three to 15 years. Both sexes. Site: Mynuzi health centre, North-Eastern Tanzania, a hyperendemic area with rainy seasons in March to June and October to December Exclusion criteria: Hb < 8, inability to take drugs orally, known hypersensitivity to meds, reported anti-malarial treatment in last two weeks, evidence of chronic disease or acute infection other than malaria, domicile outside trial area, signs of severe malaria, eligible for other malaria studies. Interventions 1. AS+SP: AS: 4 mg/kg once daily for 3 days; SP: S 25 mg/kg and P: 1.125 mg/kg 2. AS+SP+PQ: As above for AS and SP plus PQ base 0.75 mg/kg on the third day Outcomes 1. Proportion of people with gametocytes (by microscopy) days 1, 4, 8, 15, 29 and 43 (reported as 0, 3, 7, 14, 28 and 42) 2. Proportion with gametocytes (by PCR), same time points 3. Gametocyte density by PCR 4. AUC for gametocyte presence 5. Adverse events 6. Adequate clinical and parasitological response 7. Haemoglobin Notes Hb outcome assessed with respect to G6PD variant. Risk of bias

Outcomes 1. Proportion of people with gametocytes (by microscopy) days 1, 4, 8, 15, 29 and 43 (reported as 0, 3, 7, 14, 28 and 42) 2. Proportion with gametocytes (by PCR), same time points 3. Gametocyte density by PCR 4. AUC for gametocyte presence 5. Adverse events 6. Adequate clinical and parasitological response 7. Haemoglobin Notes Hb outcome assessed with respect to G6PD variant. Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) Low risk Generated in STATA 8.0 using restricted randomization with block size of 20. Allocation concealment (selection bias) Unclear risk Pre-prepared envelopes (but person who opened envelope administered treatment). Incomplete outcome data (attrition bias) All outcomes Low risk Only 2 out of 108 failed to complete follow-up. Selective reporting (reporting bias) Low risk No information given. Other bias Low risk No indication of other bias. Blinding of participants and personnel (performance bias) All outcomes Unclear risk Trial physician evaluated patients, opened envelopes, and administered treatment. Other staff were blinded. Not clear if participants were blinded. Blinding of outcome assessment (detection bias) All outcomes Unclear risk Not stated. Singhasivanon 1994 Methods Individually RCT Dates of trial: not stated. Participants 23 people with uncomplicated P. falciparum malaria, parasitaemia between 1 to 5 per 1000 rbc. Age 5 to 12 years, sex not stated. Exclusion criteria: Antimalarial drugs, urine with quinoline and sulfonamide drugs, other diseases, hematocrit ≤ 20%, inability to take oral medication.

Methods Individually RCT Dates of trial: not stated. Participants 23 people with uncomplicated P. falciparum malaria, parasitaemia between 1 to 5 per 1000 rbc. Age 5 to 12 years, sex not stated. Exclusion criteria: Antimalarial drugs, urine with quinoline and sulfonamide drugs, other diseases, hematocrit ≤ 20%, inability to take oral medication. Interventions 1. MSP: MQ 20 mg/kg; S 40 mg base/kg; P 2 mg/kg; single dose 2. MSP + PQ: As above plus PQ 0.75 mg/kg single dose. MSP+PQ crushed and mixed with 30 mL syrup (83% dextrose) Outcomes 1. Gametocyte clearance time (days) (assessed twice daily until negative, then once daily, by blood slide) 2. Adverse drug reactions, assessed once daily in first week then once a week 3. Parasite clearance time (hrs) 4. Fever clearance time (hrs) 5. Cure rate Notes Those who vomited within three hours of Rx were excluded - this is a post randomization exclusion. Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) Unclear risk No information given. Allocation concealment (selection bias) Unclear risk No information given. Incomplete outcome data (attrition bias) All outcomes High risk Outcomes only reported for 18 of the 23 participants. Selective reporting (reporting bias) Unclear risk No information given. Other bias High risk Those who vomited within three hours of Rx were excluded- this is a post randomization exclusion. Blinding of participants and personnel (performance bias) All outcomes Unclear risk Not stated. Blinding of outcome assessment (detection bias) All outcomes Unclear risk Not stated. Smithuis 2010

Selective reporting (reporting bias) Unclear risk No information given. Other bias High risk Those who vomited within three hours of Rx were excluded- this is a post randomization exclusion. Blinding of participants and personnel (performance bias) All outcomes Unclear risk Not stated. Blinding of outcome assessment (detection bias) All outcomes Unclear risk Not stated. Smithuis 2010 Methods Individually RCT (5 comparisons - 10 arms). Follow-up: Patients were asked to return weekly for 9 weeks for assessment and at any other time they were unwell. Dates: December 2008 to March 2009. Participants Number: 808 people attending clinics in Myanmar. Inclusion criteria: Age = 6 months, weight = 5 kg, P. falciparum mono-infection 500 to 200,000 parasites/µL or co-infection with P. vivax, informed consent. Exclusion criteria: Pregnancy, signs of severe malaria, severe malnutrition, history of hypersensitivity to any of the trial drugs, severe malnutrition, concomitant febrile illness, history of psychiatric disorder, a full course of MQ in the previous nine weeks or any other antimalarial in the previous 48 hrs.

consent. Exclusion criteria: Pregnancy, signs of severe malaria, severe malnutrition, history of hypersensitivity to any of the trial drugs, severe malnutrition, concomitant febrile illness, history of psychiatric disorder, a full course of MQ in the previous nine weeks or any other antimalarial in the previous 48 hrs. Interventions Each of the five trial arms was divided into two where one half also received a one-off dose of 0.75 mg/kg PQ on day 1. Groups: 1+2. AS plus amodiaquine, fixed-dose combination: 25 mg/67.5 mg or 50 mg/135 mg or 100 mg/270 mg tablets. • AS 4 mg/kg once daily for 3 days 1. AQ 10.8 mg base/kg once daily for 3 days 3+4. AL, fixed-dose combination: 20 mg/120 mg tablets. • A 3.3 mg/kg in two divided doses each day for 3 days • L 19.8 mg/kg in two divided doses each day for 3 days • Advised to consume fatty food or breast feed before each dose 5+6. AS plus MQ, fixed-dose combination: 25 mg/55 mg or 100 mg/220 mg tablets (artesunate: Guilin, Lariam: Hoffman-La Roche) • AS 4 mg/kg once daily for 3 days • MQ 8.8 mg/kg once daily for 3 days 7+8. Artesunate plus MQ, loose combination (artesunate: Guilin, Lariam: Hoffman-La Roche) • AS 4 mg/kg once daily for 3 days • MQ 25 mg base/kg as a single dose on day 1 (reported as day 0) 9+10. DHAP, fixed-dose combination: 40 mg/320 mg or 20 mg/160 mg tablets (Artekin: Holleykin) • DHA 2.5 mg/kg once daily for 3 days • P 20 mg/kg once daily for 3 days First dose supervised, all others unsupervised.

oche) • AS 4 mg/kg once daily for 3 days • MQ 25 mg base/kg as a single dose on day 1 (reported as day 0) 9+10. DHAP, fixed-dose combination: 40 mg/320 mg or 20 mg/160 mg tablets (Artekin: Holleykin) • DHA 2.5 mg/kg once daily for 3 days • P 20 mg/kg once daily for 3 days First dose supervised, all others unsupervised. Outcomes 1. Recurrent parasitaemia at day 15, 29, 43 and 64 (reported as days 14, 28, 42 and 63) 2. Treatment failure due to P. falciparum 3. Gametocytaemia prevalence 4. Person-gametocyte weeks 5. Haemoglobin on days 1 and 64 6. Adverse events (monitoring not described) Notes Funding: Médecins sans Frontières (Holland). Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) Low risk "After patients were screened and enrolled in the study, they were stratified prospectively into three age groups (1 to 4 years, 5 to 14 years and older than 14 years). Patients were randomly assigned in equal numbers to receive one of the five different treatments. They were then randomly assigned either a single dose of PQ …or not". Allocation concealment (selection bias) Low risk "Treatment allocations were put in sealed envelopes in blocks of 50 for each age group, and random assignment was achieved by patients drawing an envelope from a box after enrolment. When the box was empty, another 50 envelopes were added". Incomplete outcome data (attrition bias) All outcomes Low risk Attrition is low in absolute numbers and unlikely to have introduced significant bias. Selective reporting (reporting bias) Low risk No evidence of selective reporting.

Allocation concealment (selection bias) Low risk "Treatment allocations were put in sealed envelopes in blocks of 50 for each age group, and random assignment was achieved by patients drawing an envelope from a box after enrolment. When the box was empty, another 50 envelopes were added". Incomplete outcome data (attrition bias) All outcomes Low risk Attrition is low in absolute numbers and unlikely to have introduced significant bias. Selective reporting (reporting bias) Low risk No evidence of selective reporting. Other bias Low risk No indication of other bias. Blinding of participants and personnel (performance bias) All outcomes High risk Open label trial for patients and medical staff. Blinding of outcome assessment (detection bias) All outcomes Low risk Microscopists were blinded. Sutanto 2013 Methods Two-arm open-label RCT Follow-up: Days 1, 2, 3, 7, 14, 21, 28, 35 and 42, and any other day in between if they felt ill. Thin and thick blood smears and dried blood spot for genotyping Dates of randomization: December 2008 to March 2010

Blinding of outcome assessment (detection bias) All outcomes Low risk Microscopists were blinded. Sutanto 2013 Methods Two-arm open-label RCT Follow-up: Days 1, 2, 3, 7, 14, 21, 28, 35 and 42, and any other day in between if they felt ill. Thin and thick blood smears and dried blood spot for genotyping Dates of randomization: December 2008 to March 2010 Participants 188 (178 left on day 3) + 186 (171 day 3). Analysis based on those still present on day 3 Setting: Hanura Primary Health Center, Padang Cermin district, Lampung province located at the southern end of Sumatra. Endemicity: Low malaria endemicity with a malaria prevalence of 1.8% across all age groups. Seasonal transmission. Inclusion criteria: 1. Parasite density ≥ 1000 parasites/μL 2. Age ≥ 5 years 3. Normal glucose-6-phosphate dehydrogenase (G6PD) enzyme levels based on a qualitative test 4. Haemoglobin level ≥ 8 g/dL 5. Negative pregnancy test (assessed by human chorionic gonadotropin urine test) or not breastfeeding 6. No signs of severe malnutrition 7. No other chronic diseases 8. No history of allergy to the trial drugs 9. Ability to return for 42 days of follow-up Interventions 1. Standard 3-day DHAP (fixed-dose tablets of 40 mg dihydroartemisinin and 320 mg piperaquine; D-ARTEPP, Guilin Pharmaceutical Co, Ltd) 2. DHAP as in intervention 1; PQ: Day 3, single dose of 0.75 mg/kg, rounded to the nearest half tablet. Mean dose was 0.74 mg/kg (range, 0.5 to 0.94 mg/kg)

Participants 188 (178 left on day 3) + 186 (171 day 3). Analysis based on those still present on day 3 Setting: Hanura Primary Health Center, Padang Cermin district, Lampung province located at the southern end of Sumatra. Endemicity: Low malaria endemicity with a malaria prevalence of 1.8% across all age groups. Seasonal transmission. Inclusion criteria: 1. Parasite density ≥ 1000 parasites/μL 2. Age ≥ 5 years 3. Normal glucose-6-phosphate dehydrogenase (G6PD) enzyme levels based on a qualitative test 4. Haemoglobin level ≥ 8 g/dL 5. Negative pregnancy test (assessed by human chorionic gonadotropin urine test) or not breastfeeding 6. No signs of severe malnutrition 7. No other chronic diseases 8. No history of allergy to the trial drugs 9. Ability to return for 42 days of follow-up Interventions 1. Standard 3-day DHAP (fixed-dose tablets of 40 mg dihydroartemisinin and 320 mg piperaquine; D-ARTEPP, Guilin Pharmaceutical Co, Ltd) 2. DHAP as in intervention 1; PQ: Day 3, single dose of 0.75 mg/kg, rounded to the nearest half tablet. Mean dose was 0.74 mg/kg (range, 0.5 to 0.94 mg/kg) Outcomes 1. Gametocyte prevalence-days 7, 14, 21, 28, 35 and 42 2. Gametocyte clearance rates by day 42 in patients with gametocytes on day 3 3. Recurrence of asexual stages of P. falciparum, PCR adjusted and unadjusted for reinfections 4. Gametocyte development by day 42 in patients who were gametocyte free on day 3 5. Gametocyte densities between days 3 and 42 inclusive 6. Asexual infection recurrence by PCR 7. Hemoglobin on days 7, 42 8. Adverse events Notes Risk of bias

Outcomes 1. Gametocyte prevalence-days 7, 14, 21, 28, 35 and 42 2. Gametocyte clearance rates by day 42 in patients with gametocytes on day 3 3. Recurrence of asexual stages of P. falciparum, PCR adjusted and unadjusted for reinfections 4. Gametocyte development by day 42 in patients who were gametocyte free on day 3 5. Gametocyte densities between days 3 and 42 inclusive 6. Asexual infection recurrence by PCR 7. Hemoglobin on days 7, 42 8. Adverse events Notes Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) Low risk Computer-generated sequences in blocks of four. Allocation concealment (selection bias) Low risk Opaque envelopes used in order at the health centre. Incomplete outcome data (attrition bias) All outcomes Low risk No evidence of differential attrition. Selective reporting (reporting bias) Low risk No evidence of selective reporting. Other bias Low risk None detected. Blinding of participants and personnel (performance bias) All outcomes High risk No blinding, no PQ placebo. Blinding of outcome assessment (detection bias) All outcomes Unclear risk No information. Vasquez 2009 Methods Individually RCT Dates of trial: April 2007 to Feb 2008. Participants 50 people with uncomplicated P. falciparum diagnosis by thick blood slide, 150 to 50,000 parasites/μL Age one year and over, both sexes. Exclusion criteria: Pregnant, mixed infection, danger signs and complications, allergy to antimalarials, serious illness at time or presentation, antimalarial treatment in last 72 hrs, MQ in last four weeks.

ated P. falciparum diagnosis by thick blood slide, 150 to 50,000 parasites/μL Age one year and over, both sexes. Exclusion criteria: Pregnant, mixed infection, danger signs and complications, allergy to antimalarials, serious illness at time or presentation, antimalarial treatment in last 72 hrs, MQ in last four weeks. Interventions 1. AS+MQ Age 1 to 6: AS 50 mg on days 1, 2, 3 (reported as 0, 1, 2); MQ 250 mg on day 2 Age 7 to 13: AS 100 mg on days 1, 2, 3; MQ 250 mg on days 1, 2, 3 Age = 13: AS 200 mg on days 1, 2, 3; MQ 500 mg on days 1, 2, 3 2. AS+MQ+PQ As above plus PQ: Age 1 to 6: 0.3 to 0.6 mg/kg day 3 (reported as day 2). Age 7 to 13: 22.5 mg/kg day 3. Age = 13: 45 mg day 3. Outcomes Assessed on days 2, 3, 4, 8, 15, 22, 29, 36, and 43. 1. Clinical recurrence 2. Parasitemia prevalence 3. Parasite density 4. Fever resolution 5. Prevalence of gametocytes 6. Density of gametocytes 7. Adverse effects Notes Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) High risk Seems to be alternate allocation following order of arrival ("segun el orden de llegada"). Allocation concealment (selection bias) Unclear risk Not clear. Incomplete outcome data (attrition bias) All outcomes Low risk No dropouts noted. Selective reporting (reporting bias) Low risk No evidence of bias. Other bias Low risk No suggestion of other bias. Blinding of participants and personnel (performance bias) All outcomes High risk Does not seem to be blinded ("con determination no ciega del efecto en grupos iguales").

Incomplete outcome data (attrition bias) All outcomes Low risk No dropouts noted. Selective reporting (reporting bias) Low risk No evidence of bias. Other bias Low risk No suggestion of other bias. Blinding of participants and personnel (performance bias) All outcomes High risk Does not seem to be blinded ("con determination no ciega del efecto en grupos iguales"). Blinding of outcome assessment (detection bias) All outcomes High risk Wang 2006 Methods Individually RCT Participants Number of participants: 214 (no dropouts mentioned) Gabon International Tropical Medicine Institute Age range: 6 to 60 All have P. falciparum malaria clinical symptoms and blood smear positive. 1. Trial group: 108, male 50, female 58, age 16.4 ± 10.5 2. Control group: 106, male 52, female 54, age 18.2 ± 9.4 Exclusion criteria: N/A Interventions 1. Artesunate IM injection, daily for 5 days, 1.2 mg/kg each dose, first dose double. PQ 3 tablets (base 7.5 mg/tablet, children use half) once a day, for 5 days 2. Only artesunate IM injection daily for 5 days, 1.2 mg/kg each dose, the first dose double total 5 days Outcomes 1. Fever clearance time: (hrs) below 37°C continuously measured four times 2. Clinical cure rate at day 7 3. Adverse events (not specified) 4. Recrudescence rate: Symptoms appeared again after clinical cure; parasite appeared in blood smear by 28 days Follow-up: 28 days Notes Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) Low risk Stated to be randomized, and the fact that numbers per group are not equal supports this contention.

Outcomes 1. Fever clearance time: (hrs) below 37°C continuously measured four times 2. Clinical cure rate at day 7 3. Adverse events (not specified) 4. Recrudescence rate: Symptoms appeared again after clinical cure; parasite appeared in blood smear by 28 days Follow-up: 28 days Notes Risk of bias Bias Authors' judgement Support for judgement Random sequence generation (selection bias) Low risk Stated to be randomized, and the fact that numbers per group are not equal supports this contention. Allocation concealment (selection bias) Unclear risk No information given. Incomplete outcome data (attrition bias) All outcomes Unclear risk Not stated. Selective reporting (reporting bias) Unclear risk Not stated. Other bias Unclear risk Unknown. Blinding of participants and personnel (performance bias) All outcomes Unclear risk Not stated to be blinded. Blinding of outcome assessment (detection bias) All outcomes Unclear risk Not stated to be blinded. AL = artemether-lumefantrine; AQ = amodiaquine; AS = artesunate; CQ = chloroquine; DHAP = dihydroartemisinin-piperaquine; G6PD = glucose-6-phosphate dehydrogenase; IM = intramuscular; MQ = mefloquine; PCR = polymerase chain reaction; Pf = Plasmodium falciparum; PQ = primaquine; QN = quinine; RCT = randomized controlled trial; SP = sulfadoxine-pyrimethamine. Characteristics of excluded studies [ordered by study ID] Study Reason for exclusion Baird 2002 Outcome is cure of asexual infection. No gametocyte outcomes. Barber 1929 Not a RCT or quasi-RCT. No controls. Barber 1932 MDA with PQ; no other drug. Brueckner 1998 Participants were not infected. Safety only trial.

Blinding of outcome assessment (detection bias) All outcomes Unclear risk Not stated to be blinded. AL = artemether-lumefantrine; AQ = amodiaquine; AS = artesunate; CQ = chloroquine; DHAP = dihydroartemisinin-piperaquine; G6PD = glucose-6-phosphate dehydrogenase; IM = intramuscular; MQ = mefloquine; PCR = polymerase chain reaction; Pf = Plasmodium falciparum; PQ = primaquine; QN = quinine; RCT = randomized controlled trial; SP = sulfadoxine-pyrimethamine. Characteristics of excluded studies [ordered by study ID] Study Reason for exclusion Baird 2002 Outcome is cure of asexual infection. No gametocyte outcomes. Barber 1929 Not a RCT or quasi-RCT. No controls. Barber 1932 MDA with PQ; no other drug. Brueckner 1998 Participants were not infected. Safety only trial. Bunnag 1980 Comparison of SP plus either five day PQ 15 mg, single dose PQ 30 mg or single dose PQ 45 mg in patients with and without gametocytes at presentation. No regimen without PQ. Not a RCT or quasi-RCT. Authors state they will do further studies, including transmission. No difference in gametocyte outcomes between regimens, and gametocytes persisted for up to 21 days. Burgess 1961 Comparison of 15 mg, 30 mg and 45 mg dose of PQ. Outcomes were gametocyte prevalence, density, percent of mosquitoes infected and mean oocysts per mosquito up to eight days. Not a RCT or quasi-RCT. No other drug. Although this trial used different doses by group (12 participants total), they were assigned to participants based on age or body size, and therefore it was not a valid comparison of different doses. Cai 1985 Not a RCT.

Burgess 1961 Comparison of 15 mg, 30 mg and 45 mg dose of PQ. Outcomes were gametocyte prevalence, density, percent of mosquitoes infected and mean oocysts per mosquito up to eight days. Not a RCT or quasi-RCT. No other drug. Although this trial used different doses by group (12 participants total), they were assigned to participants based on age or body size, and therefore it was not a valid comparison of different doses. Cai 1985 Not a RCT. Carter 2011 No 8AQ in trial. Che 1987 No mention of randomization. No valid comparison group (pyronaridine phosphate plus sulfadoxine plus PQ versus pyronaridine phosphate only). Che 1990 No appropriate control group. Chevalley 2010 In vitro studies only. Not a RCT. Clyde 1962 All patients got PQ. Clyde 1970 Individual before-and-after study, but small number of patients and not controlled. Clyde 1971 Individual before-and-after study, but small number of patients and not controlled. da Silva 1984 Trial of treatment regimens, some including PQ, for P. vivax and P. falciparum. Degowin 1966 No 8AQ in trial. Doi 1989 Community observational study. Except for a small pilot study, everyone in the intervention villages got PQ. There no 'before' data from these villages. In the control site, some children received treatment. Giao 2004 No appropriate control group (trial of CV8 (contains PQ) versus atovaquone-proguanil). Gogtay 1999 Compares QN+PQ against QN+bulaquine. Not a relevant comparison.

Doi 1989 Community observational study. Except for a small pilot study, everyone in the intervention villages got PQ. There no 'before' data from these villages. In the control site, some children received treatment. Giao 2004 No appropriate control group (trial of CV8 (contains PQ) versus atovaquone-proguanil). Gogtay 1999 Compares QN+PQ against QN+bulaquine. Not a relevant comparison. Gunders 1961 Before-and-after studies of gametocytes and mosquito feeds on people with gametocytes given pyrimethamine and PQ in doses ranging from 10 mg to 40 mg base. No group without other drug. Hii 1987 Controlled before-and-after study comparing SP+PQ+ITN versus SP+PQ only. Only one cluster per arm and no group without PQ. Huang 1993 Not a RCT. Unbalanced groups. Huang 1996 PQ given to both intervention groups in same regimen. Malaria treatment regimen was varied (low and higher dose pyronardine/SP). Huang 2001 No gametocyte outcomes. Jeffery 1956 Non-randomized comparison of gametocytes and infectivity of artificially infected patients treated with CQ or CQ+PQ. Jeffery 1963 Observational study of gametocytes and infectivity of two patients given PQ. Jerace 1933 Case series studying gametocytes and infectivity of patients given PQ. Kaneko 1989 Non-randomized community trial comparing SP+PQ in one village with SP only in another. Only one cluster per arm. The trial was predominantly mass fever test and treat but 75% of people in the intervention village were treated versus 18% in the control village. Karbwang 1991 Not randomized, no gametocyte outcomes.

Kaneko 1989 Non-randomized community trial comparing SP+PQ in one village with SP only in another. Only one cluster per arm. The trial was predominantly mass fever test and treat but 75% of people in the intervention village were treated versus 18% in the control village. Karbwang 1991 Not randomized, no gametocyte outcomes. Karbwang 1992 Pharmacokinetic study; no gametocyte outcomes or control group. Kyaw 1994 No control group. All patients got PQ. Li 2007 No gametocyte outcomes. Li 2010 No gametocyte outcomes. Lin 2004 All patients got PQ. Mackerras 1949 No other malaria treatment; one patient fed on before and after PQ. Rieckmann 1968 Two patients given 45 mg PQ only and fed on by mosquitoes before and after. No other malaria treatment or control group. Rieckmann 1969 18 patients given CQ alone (N = 2), CQ plus 45 mg PQ (N = 3), or PQ alone in doses ranging from 15 to 45 mg, at either single dose or at one to two week intervals, and fed on before and after one of the doses of PQ. Non-randomized or quasi-randomized. Santana 2007 Study of 14 day regimen of 15 mg PQ. Some P. falciparum cases were included but study did not distinguish between the patients with P. falciparum and P. vivax. Study was a comparison of association between methaemoglobinaemia after 14 day PQ in people with and without G6PD deficiency. Shah 2013 Review of 21 trials from national drug resistance monitoring system of India. Compares 9 sites where AS+SP+PQ was used with 12 sites where it was not.

Santana 2007 Study of 14 day regimen of 15 mg PQ. Some P. falciparum cases were included but study did not distinguish between the patients with P. falciparum and P. vivax. Study was a comparison of association between methaemoglobinaemia after 14 day PQ in people with and without G6PD deficiency. Shah 2013 Review of 21 trials from national drug resistance monitoring system of India. Compares 9 sites where AS+SP+PQ was used with 12 sites where it was not. Shekalaghe 2010 Randomized comparison of anaemia after SP+AS+PQ versus placebo. Children with haemoglobin < 8 g were excluded from receiving PQ. Shekalaghe 2011 Trial was a comparison of SP+AS+PQ versus placebo. No comparison of groups with and without PQ. Sun 2011 Artesunate + PQ versus Quinimax only. No appropriate control group. Suputtamongkol 2003 Comparison of MQ+AS versus MQ + PQ. No appropriate control group. Tangpukdee 2008 Comparison of Artequick (contains PQ) with MQ+AS. No appropriate control group and no gametocyte outcomes. Yang 1989 All patients got PQ, though different doses of PQ and other malaria treatments. Yeramian 2005 PQ given only to P. vivax patients for 14 days. Young 1959 No other malaria treatment; case series of PQ given either daily, twice a week or weekly to Pf patients. Characteristics of studies awaiting assessment [ordered by study ID] Chen 1993b Methods Participants Interventions Outcomes Notes Study not yet located Ishii 2009 Methods Unclear Participants Residents of trial villages in Solomon Islands (number not given)

Young 1959 No other malaria treatment; case series of PQ given either daily, twice a week or weekly to Pf patients. Characteristics of studies awaiting assessment [ordered by study ID] Chen 1993b Methods Participants Interventions Outcomes Notes Study not yet located Ishii 2009 Methods Unclear Participants Residents of trial villages in Solomon Islands (number not given) Interventions Testing of clinical malaria patients for G6PD and addition of single dose PQ to other malaria treatment if appropriate Outcomes Village prevalence of malaria Notes Li 2006 Methods Participants Interventions Outcomes Notes Study not yet located Characteristics of ongoing studies [ordered by study ID] D'Alessandro (started 2013) Trial name or title Primaquine's Gametocytocidal Efficacy in Malaria Asymptomatic Carriers Treated With Dihydroartemisinin-Piperaquine in The Gambia Methods Randomized, open label

Methods Participants Interventions Outcomes Notes Study not yet located Characteristics of ongoing studies [ordered by study ID] D'Alessandro (started 2013) Trial name or title Primaquine's Gametocytocidal Efficacy in Malaria Asymptomatic Carriers Treated With Dihydroartemisinin-Piperaquine in The Gambia Methods Randomized, open label Participants 1200 participants will be recruited Inclusion criteria: • Age ≥ 1 year • Weight = 10 kg • P. falciparum mono-infection, density of at least 20 parasites/μL • Axillary temperature < 37.5°C • Resident in the trial area and willingness to reside for the duration of the trial • Written informed consent (plus an assent in children = 12 years of age) Exclusion criteria: • G6PD deficiency haemoglobin < 8 g/dL • Known allergy to any of the trial medications • Known pregnancy or breastfeeding • Clear/documented history of anti-malarial treatment two weeks before contact with trial team • History of blood transfusion in the previous three months • Any chronic or acute conditions that might interfere with the trial as judged by the research clinician • History of sickle cell anaemia Interventions 1. Control: complete course of DHA-PPQ (Eurartesim) 2. Experimental: DHA-PPQ plus single dose PQ at 0.75 mg/kg body weight 3. Experimental: DHA-PPQ plus single dose PQ at 0.4 mg base/kg body weight 4. Experimental: DHA-PPQ plus single dose PQ at 0.2 mg base/kg body weight

Participants 1200 participants will be recruited Inclusion criteria: • Age ≥ 1 year • Weight = 10 kg • P. falciparum mono-infection, density of at least 20 parasites/μL • Axillary temperature < 37.5°C • Resident in the trial area and willingness to reside for the duration of the trial • Written informed consent (plus an assent in children = 12 years of age) Exclusion criteria: • G6PD deficiency haemoglobin < 8 g/dL • Known allergy to any of the trial medications • Known pregnancy or breastfeeding • Clear/documented history of anti-malarial treatment two weeks before contact with trial team • History of blood transfusion in the previous three months • Any chronic or acute conditions that might interfere with the trial as judged by the research clinician • History of sickle cell anaemia Interventions 1. Control: complete course of DHA-PPQ (Eurartesim) 2. Experimental: DHA-PPQ plus single dose PQ at 0.75 mg/kg body weight 3. Experimental: DHA-PPQ plus single dose PQ at 0.4 mg base/kg body weight 4. Experimental: DHA-PPQ plus single dose PQ at 0.2 mg base/kg body weight Outcomes Primary: Prevalence of P. falciparum gametocyte carriers (QT-NASBA) (time frame: Day 7) Secondary: 1. Prevalence of P. falciparum gametocytes carriers on days 3, 10, 14, 28 and 42 as determined by QT-NASBA 2. Proportion of individuals infectious to mosquitoes (DMFA) on day 7, with direct membrane feeding assay 3. Haemoglobin change from day 0 on days 3, 7, 10, 14, 21, 28, 35 and 42, as mean (±SD) difference in haemoglobin measured between baseline (day 0) and each follow-up visit day by trial arm 4. Prevalence of infection (asexual stages) on day 3 5. Proportion of participants with recurrent infection (PCR adjusted and unadjusted) from day 7 to day 42 6. Occurrence of adverse events and serious adverse events

difference in haemoglobin measured between baseline (day 0) and each follow-up visit day by trial arm 4. Prevalence of infection (asexual stages) on day 3 5. Proportion of participants with recurrent infection (PCR adjusted and unadjusted) from day 7 to day 42 6. Occurrence of adverse events and serious adverse events Starting date August 2013; December 2014 (final data collection date for primary outcome measure) Contact information udalessandro@mrc.gm +220-4495442-6 ext 4001 (Umberto D'Alessandro) jokebe@mrc.gm +220-4495442-6 ext 4009 (Joseph Okebe) Notes ClinicalTrials.gov identifier: NCT01838902 Gosling (recruitment ended 2014) Trial name or title Phase 2a Dose Escalation Study of the Efficacy, Safety, and Pharmacokinetics of Low Dose Primaquine for Gametocytocidal Activity Against P. falciparum in Sub-Saharan Africa and South East Asia Methods Randomized, single blind (outcomes assessor blinded) Participants 50 participants being recruited Inclusion criteria: • Male • Age ≥ 18 years and < 50 years • Malaria blood thick film positive • Presence of gametocytes on thick blood film • Agrees to admission to trial ward for 26 hours post diagnosis and available for follow-up visits • No allergies to trial drugs • Hemoglobin ≥ 8 g/dL • No evidence of severe or chronic disease • Written, informed consent Interventions Group 1: Active comparator: dihydroartemisinin-piperaquine (DP) only Group 2: Experimental: DP and 0.125 mg/kg PQ Group 3: Experimental: DP and 0.5 mg/kg PQ

Participants 50 participants being recruited Inclusion criteria: • Male • Age ≥ 18 years and < 50 years • Malaria blood thick film positive • Presence of gametocytes on thick blood film • Agrees to admission to trial ward for 26 hours post diagnosis and available for follow-up visits • No allergies to trial drugs • Hemoglobin ≥ 8 g/dL • No evidence of severe or chronic disease • Written, informed consent Interventions Group 1: Active comparator: dihydroartemisinin-piperaquine (DP) only Group 2: Experimental: DP and 0.125 mg/kg PQ Group 3: Experimental: DP and 0.5 mg/kg PQ Outcomes Primary: mosquito infectivity assessed through membrane feeding at baseline, and 1, 2 and 7 days Secondary: 1. Gametocyte prevalence and density, at baseline, 2, 6, 12 and 24 hours, and at 2, 3, 7, 14 and 28 days 2. PQ pharmacokinetics - AUC of parent drug and metabolite at 1, 2, 3, 4, 6, 8, 12 and 24 hours 3. Asexual parasite prevalence and density baseline at baseline, 2, 6, 12, and 24 hours, and at 2, 3, 7, 14 and 28 days 4. Safety measurements including haemoglobin and signs of haemolysis baseline at baseline, 1, 2, 3, 7 14 and 28 days Starting date September 2014 (final data collection date for primary outcome measure) Contact information goslingr@globalhealth.ucsf.edu 415 597 8114 Notes ClinicalTrials.gov identifier: NCT01743820 Sites in Mali and Thailand Indonesia (started 2013)

Outcomes Primary: mosquito infectivity assessed through membrane feeding at baseline, and 1, 2 and 7 days Secondary: 1. Gametocyte prevalence and density, at baseline, 2, 6, 12 and 24 hours, and at 2, 3, 7, 14 and 28 days 2. PQ pharmacokinetics - AUC of parent drug and metabolite at 1, 2, 3, 4, 6, 8, 12 and 24 hours 3. Asexual parasite prevalence and density baseline at baseline, 2, 6, 12, and 24 hours, and at 2, 3, 7, 14 and 28 days 4. Safety measurements including haemoglobin and signs of haemolysis baseline at baseline, 1, 2, 3, 7 14 and 28 days Starting date September 2014 (final data collection date for primary outcome measure) Contact information goslingr@globalhealth.ucsf.edu 415 597 8114 Notes ClinicalTrials.gov identifier: NCT01743820 Sites in Mali and Thailand Indonesia (started 2013) Trial name or title Surveillance and Treatment With Dihydroartemisinin-piperaquine Plus Primaquine (MTC Belu) Sub-title: Impact of Mass Screening and Selective Treatment With Dihydroartemisinin-piperaquine Plus Primaquine on Malaria Transmission in High Endemic Area, Belu Regency, Nusa Tenggara Timur Province, Indonesia: a Randomized Cluster Trial Methods Allocation: randomized; endpoint classification: efficacy study; intervention model: parallel assignment; masking: open label, primary purpose: treatment Cluster randomized.

Trial name or title Surveillance and Treatment With Dihydroartemisinin-piperaquine Plus Primaquine (MTC Belu) Sub-title: Impact of Mass Screening and Selective Treatment With Dihydroartemisinin-piperaquine Plus Primaquine on Malaria Transmission in High Endemic Area, Belu Regency, Nusa Tenggara Timur Province, Indonesia: a Randomized Cluster Trial Methods Allocation: randomized; endpoint classification: efficacy study; intervention model: parallel assignment; masking: open label, primary purpose: treatment Cluster randomized. Participants Target sample size: 1488 participants Inclusion criteria: • All villagers of all the selected clusters Exclusion criteria: • Pregnant women during their first trimester • Single dose PQ should not be given for infants under 1 year-old, pregnant women in all trimesters of pregnancy, breast-feeding mothers and patients with G6PD deficiency Age minimum: N/AAge maximum: N/A Gender: Both Interventions Drug: dihydroartemisinin-piperaquine Drug: PQ 1. Intervention arm of mass screening and treatment with interval of 6 weeks 2. Intervention arm of mass screening and treatment with interval of three months 3. Control arm without mass screening and treatment. The intervention arm with six weeks interval represents a new proposed method to detection malaria infections, while the intervention arm with three month interval represents the Ministry of Health current policy of active case detection in Indonesia, and the third arm will serve as the control for Ministry of Health's policy. No arm without PQ

six weeks interval represents a new proposed method to detection malaria infections, while the intervention arm with three month interval represents the Ministry of Health current policy of active case detection in Indonesia, and the third arm will serve as the control for Ministry of Health's policy. No arm without PQ Outcomes Malaria incidence (time frame: six months) Anaemia (time frame: six months) Starting date June 2013 Contact information Indonesia University/Walter and Eliza Hall Institute of Medical Research Notes ClinicalTrials.gov identifier: NCT01878357 Stated to be completed Mwaiswelo (started 2014) Trial name or title Efficacy and Safety of a Single Low-dose Primaquine Added to Standard Artemether-lumefantrine Treatment for the Clearance of Plasmodium Falciparum Gametocytes Methods Phase 4, randomized, safety/efficacy study, parallel assignment, single blind (subject). Primary purpose: Prevention Participants Target sample size (N = 220) in Tanzania Inclusion criteria: 1. Gender: Both 2. Age of 1 year and above and neither pregnant nor breast feeding 3. Weight over 10 kg 4. Body temperature = 37.5°C or history of fever in the last 24 hours 5. P. falciparum mono-infection Exclusion criteria: 1. Evidence of severe illness malaria or danger signs 2. Known allergy to study medications 3. Hemoglobin < 8 g/dL 4. Antimalarials taken within last 2 weeks 5. Blood transfusion within last 90 days and evidence of recent use (within 14 days) of or will be taking other drugs known to cause hemolysis in G6PD-deficient subjects

ence of severe illness malaria or danger signs 2. Known allergy to study medications 3. Hemoglobin < 8 g/dL 4. Antimalarials taken within last 2 weeks 5. Blood transfusion within last 90 days and evidence of recent use (within 14 days) of or will be taking other drugs known to cause hemolysis in G6PD-deficient subjects Interventions Control: AL + placebo. The first dose of AL will be administered concomitantly with a single-dose placebo. A volume of normal saline will be measured based on weight bands and then will be given to patients. Intervention: AL+PQ. All the recruited patients will be treated with a six doses, 3 days AL treatment regimen. However, patients randomized to the AL+PQ arm will be given 0.25 mg/kg single-dose PQ concomitantly with AL first dose. Outcomes Primary outcome: Number of days per treatment arm for gametocytes to become undetectable using Quantitative nucleic acid sequence based assay (QT-NASBA) (time frame: 14 days) Secondary outcome: Mean maximal fall in haemoglobin (g/dL) from enrolment to day 28 of follow-up defined as mean greatest negative difference in haemoglobin per treatment arm (time frame: 28 days) Starting date Date of registration 16 March 2014 Date of first enrolment July 2014 Contact information richiemwai@yahoo.com +255 717 043 970 (Richard O Mwaiswelo, MSc. PE) Andreas Martensson, PhD, Karolinska Institutet Notes ClinicalTrials.gov identifier: NCT02090036 Primary sponsor: Muhimbili University of Health and Allied Sciences Secondary sponsor: Karolinska Institutet Sarr (started 2014)

Starting date Date of registration 16 March 2014 Date of first enrolment July 2014 Contact information richiemwai@yahoo.com +255 717 043 970 (Richard O Mwaiswelo, MSc. PE) Andreas Martensson, PhD, Karolinska Institutet Notes ClinicalTrials.gov identifier: NCT02090036 Primary sponsor: Muhimbili University of Health and Allied Sciences Secondary sponsor: Karolinska Institutet Sarr (started 2014) Trial name or title A trial of the safety of low dose primaquine in addition to ACTs commonly used in Senegal Methods Parallel, randomized Participants 300 participants will be recruited in Senegal Inclusion criteria: 1. Age minimum: 20 years old, age maximum: 50 years old 2. Gender: Both 3. Adult patients with acute uncomplicated P. falciparum malaria 4. P. falciparum monospecific infection with parasite density ranged from 1000 to 100,000 trophozoite/µL 5. Willingness to participate in the planed study investigations and to remain in the study area for the duration of the study 6. Participants informed consent 7. Absence of known chronic illness such as hypertension, diabetes, renal and liver disease Exclusion criteria: 1. Known allergy to the study medications 2. Presence of severe anaemia (haemoglobin 8 g/dL) at enrolment 3. Pregnancy, or breastfeeding Interventions Control: ACT treatment, standard malaria treatment, 1 daily dose, 3 days duration (N = 150) Experimental: ACT plus PQ treatment; ACT treatment 1 daily dose for 3 days, PQ single low dose 0.25 mg/kg at day 1 (N = 150)

Participants 300 participants will be recruited in Senegal Inclusion criteria: 1. Age minimum: 20 years old, age maximum: 50 years old 2. Gender: Both 3. Adult patients with acute uncomplicated P. falciparum malaria 4. P. falciparum monospecific infection with parasite density ranged from 1000 to 100,000 trophozoite/µL 5. Willingness to participate in the planed study investigations and to remain in the study area for the duration of the study 6. Participants informed consent 7. Absence of known chronic illness such as hypertension, diabetes, renal and liver disease Exclusion criteria: 1. Known allergy to the study medications 2. Presence of severe anaemia (haemoglobin 8 g/dL) at enrolment 3. Pregnancy, or breastfeeding Interventions Control: ACT treatment, standard malaria treatment, 1 daily dose, 3 days duration (N = 150) Experimental: ACT plus PQ treatment; ACT treatment 1 daily dose for 3 days, PQ single low dose 0.25 mg/kg at day 1 (N = 150) Outcomes Primary outcome 1. Mean haemoglobin difference from day 0 to day 7 after treatment with ACT and PQ Secondary outcomes 1. Mean haemoglobin level at day 14 of follow-up in each treatment arm 2. Mean haemoglobin level at day 28 of follow-up in each treatment arm Starting date Registered 10/11/2014; Date of first enrolment 15 November 2014 Contact information roger.tine@ucad.edu.sn +00 221 77 637 05 31 (Prof Roger Tine) bathie65@yahoo.fr +00 221 77 647 09 99 (Dr Samba Cor Sarr) khadimesylla@yahoo.fr +00 221 77 521 76 44 (Dr Khadime Sylla)

Outcomes Primary outcome 1. Mean haemoglobin difference from day 0 to day 7 after treatment with ACT and PQ Secondary outcomes 1. Mean haemoglobin level at day 14 of follow-up in each treatment arm 2. Mean haemoglobin level at day 28 of follow-up in each treatment arm Starting date Registered 10/11/2014; Date of first enrolment 15 November 2014 Contact information roger.tine@ucad.edu.sn +00 221 77 637 05 31 (Prof Roger Tine) bathie65@yahoo.fr +00 221 77 647 09 99 (Dr Samba Cor Sarr) khadimesylla@yahoo.fr +00 221 77 521 76 44 (Dr Khadime Sylla) Notes Pan African Clinical Trials identifier: PACTR201411000937373 Primary sponsor: University Cheikh Anta DIOP of Dakar Saunders (started 2012) Trial name or title Active Surveillance for P. falciparum Drug Resistance With Assessment of Transmission Blocking Activity of Single Dose Primaquine in Cambodia Methods Randomized, open label

Notes Pan African Clinical Trials identifier: PACTR201411000937373 Primary sponsor: University Cheikh Anta DIOP of Dakar Saunders (started 2012) Trial name or title Active Surveillance for P. falciparum Drug Resistance With Assessment of Transmission Blocking Activity of Single Dose Primaquine in Cambodia Methods Randomized, open label Participants 150 male and female participants Inclusion criteria: 1. Volunteer with uncomplicated P. falciparum malaria (volunteers with mixed P. falciparum and P. vivax infections may be enrolled), 18 to 65 years of age 2. Baseline asexual parasite density between 1000 to 200,000 parasites/µL 3. Able to provide informed consent 4. Available and agree to follow-up for anticipated trial duration including three day treatment course at the MTF and weekly follow-up for the 42-day period 5. Authorized by local commander to participate if active duty military Exclusion criteria: 1. Allergic reaction or contraindication to DHA, piperaquine or PQ 2. Significant acute comorbidity requiring urgent medical intervention 3. Signs or symptoms and parasitological confirmation of severe malaria 4. Use of any antimalarial within the past 14 days. 5. Class I or II G6PD deficiency (defined as severe) as determined at screening 6. Pregnant or lactating female, or female of childbearing age, up to 50 years of age, who does not agree to use an acceptable form of contraception during the trial 7. Clinically significant abnormal EKG, including a QTcF interval = 500 ms at enrolment. 8. Known or suspected concomitant use of QTc prolonging medications. 9. Judged by the investigator to be otherwise unsuitable for trial participation

e, who does not agree to use an acceptable form of contraception during the trial 7. Clinically significant abnormal EKG, including a QTcF interval = 500 ms at enrolment. 8. Known or suspected concomitant use of QTc prolonging medications. 9. Judged by the investigator to be otherwise unsuitable for trial participation Interventions Group 1: DHA-piperaquine 3-day course plus 45 mg single dose PQ Group 2: DHA-piperaquine 3-day course of DHA-piperaquine Outcomes Primary: Efficacy rates at 42 days for DP with and without single dose PQ for uncomplicated P. falciparum diagnosed by positive PCR-corrected malaria microscopy Secondary: Efficacy of PQ to treat sexual stage gametocyte infection and prevent transmission of P. falciparum gametocytes to mosquitoes. Starting date December 2012; December 2014 (final data collection date for primary outcome measure) Contact information David Saunders, MD, MPH 66-2-696-2798 david.saunders@afrims.org Chanthap Lon, MD, MCTM 855 23 881 845 chanthapl@afrims.org Notes ClinicalTrials.gov identifier: NCT01849640 Sawa DAPPI-1 (started 2014) Trial name or title A Double Blind Randomized Controlled Trial of Dihydroartemisinin-Piperaquine Alone and in Combination With Single Dose Primaquine to Reduce Post-treatment Malaria Transmission Methods Phase 3 randomized, safety/efficacy study, parallel assignment, double blind (subject, caregiver, investigator, outcomes assessor)

Trial name or title A Double Blind Randomized Controlled Trial of Dihydroartemisinin-Piperaquine Alone and in Combination With Single Dose Primaquine to Reduce Post-treatment Malaria Transmission Methods Phase 3 randomized, safety/efficacy study, parallel assignment, double blind (subject, caregiver, investigator, outcomes assessor) Participants 120 participants will be recruited in Kenya Inclusion criteria: 1. Microscopically detectableP. falciparum gametocyte carriage 2. Age 5 years to 15 years 3. Gender: both Exclusion criteria: 1. Age < 5 years or = 15 years 2. Non-falciparum malaria co-infection 3. Malaria parasite density = 200,000 parasites/µL 4. Clinical symptoms indicating severe malaria 5. Axillary temperature = 39°C 6. Body Mass Index (BMI) below 16 or above 32 kg/m2 7. Haemoglobin concentration below 9.5 g/dL 8. Antimalarials taken in last 2 days 9. For women: Pregnancy (assessed by clinical examination and urine pregnancy test) or lactation 10. Known hypersensitivity to DP or PQ 11. History or symptoms, or both indicating chronic illness 12. Current use of tuberculosis or anti-retroviral medication 13. Unable to give written informed consent 14. Unwillingness to participate in two membrane feeding assays 15. Travel history to Angola, Cameroon, Chad, Central African Republic, Congo, DR Congo, Equatorial Guinea, Ethiopia, Gabon, Nigeria and Sudan 16. Family history of congenital prolongation of the QTc interval or sudden death or with any other clinical condition known to prolong the QTc interval such as history of symptomatic cardiac arrhythmias, with clinically relevant bradycardia or with severe cardiac disease 17. Taking drugs that are known to influence cardiac function and to prolong QTc interval, such as class IA and III: neuroleptics, antidepressant agents, certain antibiotics including some agents of the following classes - macrolides, fluoroquinolones, imidazole, and triazole antifungal agents, certain non-sedating antihistaminics (terfenadine, astemizole) and cisapride 18. Known disturbances of electrolyte balance, eg hypokalaemia or hypomagnesaemia 19. Taking drugs which may be metabolized by cytochrome enzyme CYP2D6 (for example, flecainide, metoprolol, imipramine, amitriptyline, clomipramine) 20. Blood transfusion within last 90 days

aminics (terfenadine, astemizole) and cisapride 18. Known disturbances of electrolyte balance, eg hypokalaemia or hypomagnesaemia 19. Taking drugs which may be metabolized by cytochrome enzyme CYP2D6 (for example, flecainide, metoprolol, imipramine, amitriptyline, clomipramine) 20. Blood transfusion within last 90 days Interventions Control: DHAP (Artekin) combination alone Experimental: DHAP (Artekin) combination alone plus single-dose 0.25 mg/kg PQ Outcomes Primary outcome 1. Gametocyte prevalence on day 7 after initiation of treatment (time frame: day 7 of follow-up) Secondary outcomes 1. Gametocyte carriage during follow-up (time frame: 14 days during follow-up) 2. Gametocyte sex-ratio (time frame: 14 days of follow-up) 3. Haematological recovery (time frame: 14 days during follow-up) 4. Transmission to An. gambiae mosquitoes (time frame: day 3 and 7 during follow-up) Starting date Registration date 29 September 2014; first enrolment October 2014 Contact information psawa@icipe.org +254 59 22620 (Patrick Sawa MD, ICIPE) teun.bousema@lshtm.ac.uk +31243617574 (Teun J Bousema, PhD) Notes ClinicalTrials.gov identifier: NCT02259426 Primary sponsor: London School of Hygiene and Tropical Medicine Shekalaghe (started 2013) Trial name or title The Optimal Timing of Primaquine to Prevent Malaria Transmission After Artemisinin-Combination Therapy Methods Randomized, open label

Contact information psawa@icipe.org +254 59 22620 (Patrick Sawa MD, ICIPE) teun.bousema@lshtm.ac.uk +31243617574 (Teun J Bousema, PhD) Notes ClinicalTrials.gov identifier: NCT02259426 Primary sponsor: London School of Hygiene and Tropical Medicine Shekalaghe (started 2013) Trial name or title The Optimal Timing of Primaquine to Prevent Malaria Transmission After Artemisinin-Combination Therapy Methods Randomized, open label Participants 250 male and female participants Inclusion criteria: • Age 3 years to 17 years • Residents of research area • Willingness to come for complete scheduled follow-up • Uncomplicated malaria with P. falciparum mono-infection • Axillary temperature = 37.5°C and < 39.5°C, or history of fever in previous 48 hours • No history of adverse reactions to trial medication • Understanding of the trial procedures by parent or guardian and willing to participate by signing written informed consent forms Exclusion criteria: • Haemoglobin below 9 g/dL • Inability to take drugs orally • Known hypersensitivity to any of the drugs given • Reported treatment with antimalarial chemotherapy in the past two weeks • Evidence of chronic disease or acute infection other than malaria • Domicile outside the trial area • Signs of severe malaria (such as respiratory distress, altered consciousness deep breathing, anaemia) • Participating in other malaria studies conducted in the region • Mixed malaria parasite species infection • Positive pregnant test by urine (UPT) if participant is female aged above 12 years • G6PD deficient using the fluorescence spot test

(such as respiratory distress, altered consciousness deep breathing, anaemia) • Participating in other malaria studies conducted in the region • Mixed malaria parasite species infection • Positive pregnant test by urine (UPT) if participant is female aged above 12 years • G6PD deficient using the fluorescence spot test Interventions Group 1: AL 6 dose regime orally Group 2: AL 6 dose regime plus single dose PQ (0.75/kg) on day 0 Group 3: AL 6 dose regimen plus single dose PQ (0.75/kg) on day 2 Outcomes Primary: Gametocyte prevalence and density by microscopy and QT-NASBA on day 14 Secondary: • Haemoglobin level on days 3, 7, 10 and 14 • Proportion of infected mosquitoes on day 7 after initiation of treatment and the intensity of infection (oocyst burden) by membrane feeding assay Starting date May 2013; October 2013 (final data collection date for primary outcome measure) Contact information Seif Shekalaghe, MD, PhD sshekalaghe@ihi.or.tz +255 755 470472 Notes ClinicalTrials.gov identifier: NCT01906788 Tanzania KCMC and Ifakara Sirima SAFEPRIM (started 2014) Trial name or title Evaluation of the Safety of Primaquine in Combination With Artemether-lumefantrine in Glucose-6-phosphate Dehydrogynase Deficient Males With an Asymptomatic Malaria Infection in Burkina Faso (SAFEPRIM) Methods Phase 2/3 randomized, safety study, parallel assignment, open label. Primary purpose: treatment

Trial name or title Evaluation of the Safety of Primaquine in Combination With Artemether-lumefantrine in Glucose-6-phosphate Dehydrogynase Deficient Males With an Asymptomatic Malaria Infection in Burkina Faso (SAFEPRIM) Methods Phase 2/3 randomized, safety study, parallel assignment, open label. Primary purpose: treatment Participants Target sample size (N = 70) in Burkina Faso Inclusion criteria: 1. Male gender 2. Aged ≥ 18 years to ≤ 45 years 3. BMI ≥ 16 4. P. falciparum parasitaemia at any density 5. G6PD deficiency by Beutler Fluorescent Spot test for intervention groups and control group receiving AL only (N = 50) 6. G6PD normal activity by Beutler Fluorescent Spot test for control groups (N = 20) 7. Informed consent by participant Exclusion criteria: 1. Enrolled in another clinical trial 2. Fever = 37.5°C (tympanic) or history of fever in the last 24 hours 3. Evidence of severe illness/danger signs or active infection other than malaria 4. Known allergy to study medications 5. Hb < 11 g/dL 6. Antimalarials taken within the last 2 weeks 7. PQ taken within the last 4 weeks and blood transfusion within the last 90 days 8. Non-falciparum malaria co-infection 9. Current use of tuberculosis or anti-retroviral medication, sulphonamides, dapsone, nitrofurantoin, nalidixic acid, ciprofloxacin, methylene blue, toluidine blue phenazopyridine and co-trimoxazole. 10. History of severe chronic illness Interventions 1. AL + 0.25 mg/kg PQ 2. AL + 0.4 mg/kg PQ 3. AL combination

Participants Target sample size (N = 70) in Burkina Faso Inclusion criteria: 1. Male gender 2. Aged ≥ 18 years to ≤ 45 years 3. BMI ≥ 16 4. P. falciparum parasitaemia at any density 5. G6PD deficiency by Beutler Fluorescent Spot test for intervention groups and control group receiving AL only (N = 50) 6. G6PD normal activity by Beutler Fluorescent Spot test for control groups (N = 20) 7. Informed consent by participant Exclusion criteria: 1. Enrolled in another clinical trial 2. Fever = 37.5°C (tympanic) or history of fever in the last 24 hours 3. Evidence of severe illness/danger signs or active infection other than malaria 4. Known allergy to study medications 5. Hb < 11 g/dL 6. Antimalarials taken within the last 2 weeks 7. PQ taken within the last 4 weeks and blood transfusion within the last 90 days 8. Non-falciparum malaria co-infection 9. Current use of tuberculosis or anti-retroviral medication, sulphonamides, dapsone, nitrofurantoin, nalidixic acid, ciprofloxacin, methylene blue, toluidine blue phenazopyridine and co-trimoxazole. 10. History of severe chronic illness Interventions 1. AL + 0.25 mg/kg PQ 2. AL + 0.4 mg/kg PQ 3. AL combination Outcomes Primary outcome: Haemoglobin concentration relative to baseline value (time frame: 28 days) Secondary outcome: Gametocyte clearance time (time frame: 14 days) Starting date Date of registration 11 June 2014. Date of first enrolment October 2014 Contact information s.sirima.cnlp@fasonet.bf + 226 50 32 46 95/96 (Sodiomon Sirima, MD, PhD) teun.bousema@lshtm.ac.uk +31243613663 (Teun Bousema, PhD)

Outcomes Primary outcome: Haemoglobin concentration relative to baseline value (time frame: 28 days) Secondary outcome: Gametocyte clearance time (time frame: 14 days) Starting date Date of registration 11 June 2014. Date of first enrolment October 2014 Contact information s.sirima.cnlp@fasonet.bf + 226 50 32 46 95/96 (Sodiomon Sirima, MD, PhD) teun.bousema@lshtm.ac.uk +31243613663 (Teun Bousema, PhD) Notes ClinicalTrials.gov identifier: NCT02174900 Primary sponsor: London School of Hygiene and Tropical Medicine Secondary sponsors: Centre National de Recherche et de Formation sur le Paludisme, Burkina Faso; University Medical Center Nijmegen Spring (recruitment ended 2014) Trial name or title Evaluation of DHAP with and without single dose primaquine: an open-label randomized, controlled trial in anlong Veng, Cambodia Methods Randomized, open-label clinical trial to evaluate the safety and therapeutic efficacy of DP, and transmission blocking potential in combination with single dose primaquine (PQ) in northern Cambodia. Participants Up to 150 volunteers, including those with mild-moderate G6PD deficiency with uncomplicated P. falciparum or mixed malaria infections Interventions Consecutive daily oral doses of 120/960 mg of DP with or without a single 45 mg dose of PQ Outcomes Mosquito membrane-feeding assay Serial electrocardiograms and time-matched drug levels Starting date Not known - trial registration not yet located. Contact information M Spring Notes Identifed from preliminary results in 63rd Annual Meeting of the American Society of Tropical Medicine and Hygiene, ASTMH 2013 New Orleans

Outcomes Mosquito membrane-feeding assay Serial electrocardiograms and time-matched drug levels Starting date Not known - trial registration not yet located. Contact information M Spring Notes Identifed from preliminary results in 63rd Annual Meeting of the American Society of Tropical Medicine and Hygiene, ASTMH 2013 New Orleans Thailand (started 2012) Trial name or title Pharmacokinetic Study of Primaquine and Dihydroartemisinin-Piperaquine in Healthy Subjects Methods Phase 1 Randomized, crossover, open label safety/efficacy study. Primary purpose: treatment

Notes Identifed from preliminary results in 63rd Annual Meeting of the American Society of Tropical Medicine and Hygiene, ASTMH 2013 New Orleans Thailand (started 2012) Trial name or title Pharmacokinetic Study of Primaquine and Dihydroartemisinin-Piperaquine in Healthy Subjects Methods Phase 1 Randomized, crossover, open label safety/efficacy study. Primary purpose: treatment Participants Target sample size (N = 16) Inclusion criteria: 1. Healthy as judged by a responsible physician with no abnormality identified on a medical evaluation including medical history and physical examination. 2. Male and female non-smokers aged between 18 years to 60 years. 3. Males and females weight between 36 to 75 kg. 4. A female is eligible to enter and participate in this study if she is: of non-childbearing potential including pre-menopausal females with documented (medical report verification) hysterectomy or double oophorectomy; or postmenopausal defined as 12 months of spontaneous amenorrhoea or 6 months of spontaneous amenorrhoea with serum follicle stimulating hormone levels = 40 mIU/mL or 6 weeks postsurgical bilateral oophorectomy with or without hysterectomy; or of childbearing potential, has a negative serum pregnancy test at screening and prior to start the study drug in each period, and abstain from sexual intercourse or agrees to using effective contraceptive methods (for example, intrauterine device, hormonal contraceptive drug, tubal ligation or female barrier method with spermicide) during the study until completion of the follow-up procedures. 5. A male is eligible to enter and participate in this study if he: agrees to abstain from (or uses a condom during) sexual intercourse with females of childbearing potential or lactating females; or is willing to use a condom/spermicide, during the study until completion of the follow-up procedures. 6. Provide a signed and dated written informed consent prior to study participation. 7. Normal electrocardiogram (ECG) with QTc < 450 msec. 8. Willingness and ability to comply with the study protocol for the duration of the trial. Exclusion criteria: 1. Females who are pregnant, trying to get pregnant, or are lactating. 2. The subject has evidence of active substance abuse that may compromise safety, pharmacokinetics or ability to adhere with protocol instructions. 3. A positive pre-study hepatitis B surface antigen, positive hepatitis C antibody, or positive human immunodeficiency virus-1 (HIV-1) antibody result at screening. 4.

ing. 2. The subject has evidence of active substance abuse that may compromise safety, pharmacokinetics or ability to adhere with protocol instructions. 3. A positive pre-study hepatitis B surface antigen, positive hepatitis C antibody, or positive human immunodeficiency virus-1 (HIV-1) antibody result at screening. 4. Subjects with a personal history of cardiac disease, symptomatic or asymptomatic arrhythmias, syncopal episodes or additional risk factors for torsades de points (heart failure, hypokalaemia) or with a family history of sudden cardiac death. 5. A creatinine clearance < 70 mL/min as determined by Cockcroft-Gault equation: CLcr (mL/min) = (140 - age) * Wt/(72 * Scr) (multiply answer by 0.85 for females) where age is in years, weight (wt) is in kg, and serum creatinine (Scr) is in units of mg/dL (Cockroft 1976). 6. History of alcohol or substance abuse or dependence within 6 months of the study. 7. Use of prescription or non-prescription drugs except paracetamol at doses of up to 2 g/day, including vitamins, herbal and dietary supplements (including St. John's Wort) within 7 days (or 14 days if the drug is a potential enzyme inducer) or five times the drug half-life (whichever is longer) prior to the first dose of study medication until the completion of the follow-up procedure, unless in the opinion of investigator, the medication will not interfere with the study procedures or compromise subject safety; the investigator will take advice from the manufacturer representative as necessary. 8. The subject has participated in a clinical trial and has received a drug or a new chemical entity within 30 days, or 5 half-lives, or twice the duration of the biological effect of any drug (whichever is longer) prior to the first dose of study medication. 9. The subject is unwilling to abstain from ingesting alcohol within 48 hours prior to the first dose of study medication until collection of the final pharmacokinetic sample during each regimen. 10. Subjects who have donated blood to the extent that participation in the study would result in more than 300 mL blood donated within a 30-day period. Note: This does not include plasma donation. 11. Subjects who have a history of allergy to the study drug or drugs of this class, or a history of drug or other allergy that, in the opinion of the investigator, contraindicates participation in the trial.

d result in more than 300 mL blood donated within a 30-day period. Note: This does not include plasma donation. 11. Subjects who have a history of allergy to the study drug or drugs of this class, or a history of drug or other allergy that, in the opinion of the investigator, contraindicates participation in the trial. In addition, if heparin is used during pharmacokinetic sampling, subjects with a history of sensitivity to heparin or heparin-induced thrombocytopenia should not be enrolled. 12. Lack of suitability for participation in this study, including but not limited to, unstable medical conditions, systemic disease manifested by tendency to granulocytopenia for example rheumatoid arthritis and lupus erythematosus that in the opinion of the investigator would compromise their participation in the trial. 13. AST or ALT = 1.5 upper limit of normal (ULN). 14. Subjects with history of renal disease, hepatic disease or cholecystectomy or both. 15. G6PD deficient detected by Beutler's dye test. 16. Abnormal methaemoglobin level. 17. History of antimalarial drugs use including but not limited to MQ, chloroquine, PQ, artesunate, piperaquine and pyronaridine treatment within 12 months. 18. Subject who received quinacrine in last 30 days.

cholecystectomy or both. 15. G6PD deficient detected by Beutler's dye test. 16. Abnormal methaemoglobin level. 17. History of antimalarial drugs use including but not limited to MQ, chloroquine, PQ, artesunate, piperaquine and pyronaridine treatment within 12 months. 18. Subject who received quinacrine in last 30 days. Interventions This study is planned to evaluate potential pharmacokinetic interaction of orally administered PQ and dihydroartemisinin-piperaquine (DHA-PQP) in healthy adult subjects. The results of these interaction studies are important in order to provide clinical guidance for the optimum combination of PQ and DHA-PQP treatment regimens in malaria infections.

ate potential pharmacokinetic interaction of orally administered PQ and dihydroartemisinin-piperaquine (DHA-PQP) in healthy adult subjects. The results of these interaction studies are important in order to provide clinical guidance for the optimum combination of PQ and DHA-PQP treatment regimens in malaria infections. Outcomes Primary • AUC for PQ (Time frame: 36 days; designated as safety issue: no). Area under the concentration-time curve [(AUC(0-∞) and AUC(0-last)] and maximal concentration (Cmax) for PQ and metabolites when given alone or together with DHA-PQP. • AUC for dihydroartemisinin (DHA) and piperaquine (PQP) (Time frame: 36 days; designated as safety issue: no). Area under the concentration-time curve [(AUC(0-∞) and AUC(0-last)] and maximal concentration (Cmax) for piperaquine and dihydroartemisinin when given alone as DHA-PQP or together with PQ. Secondary • Clearance rate and half life of PQ and its metabolites (Time frame: 36 days; designated as safety issue: no). PQ, carboxyprimaquine (and other detectable major metabolites) elimination clearance rate (CL/F), terminal elimination half-life (t1/2) and apparent volume of distribution (Vd) • Dihydroartemisinin and piperaquine elimination clearance rate (CL/F), terminal elimination half-life (t1/2) and apparent volume of distribution (Vd). Safety of dihydroartemisinin-piperaquine (DHA-PQP) (Time frame: 36 days; designated as safety issue: yes). Safety and tolerability parameters, including adverse events, clinical laboratory, and vital signs assessments, in particular QTc prolongation for DHA-PQP. • Pharmacogenetic polymorphisms (Time frame: 36 days; designated as safety issue: yes) in the case of unusually high or low drug levels.

ated as safety issue: yes). Safety and tolerability parameters, including adverse events, clinical laboratory, and vital signs assessments, in particular QTc prolongation for DHA-PQP. • Pharmacogenetic polymorphisms (Time frame: 36 days; designated as safety issue: yes) in the case of unusually high or low drug levels. Starting date June 2012 Contact information Sasithon Pukrittayakamee, MD, Principal Investigator, Mahidol University Salwaluk Panapipat, MBA salwaluk@tropmedres.ac Notes ClinicalTrials.gov identifier: NCT01525511 University of Oxford Tiono (started 2013) Trial name or title Low Dose Primaquine for Clearance of Gametocytes: LOPRIM-1 Methods Randomized, parallel assignment, double blind (subject, caregiver, investigator, outcomes assessor); safety/efficacy study Participants Target sample size 360 participants Inclusion criteria • Age = 2 and < 15 years • P. falciparum parasitaemia = 1000 and < 200,000 parasites/µL • P. falciparum gametocytes • Normal G6PD • Informed consent by legally acceptable representative Exclusion criteria • Enrolled in another study • Fever or history of fever in last 24 hours • Evidence of severe illness/danger signs • Known allergy to study medications • Hb < 8 g/dL • Started menstruation • Pregnancy or breastfeeding • Antimalarials taken within last 2 days • PQ taken within last 4 weeks • Blood transfusion within the last 90 days • Non-falciparum malaria co-infection Interventions Group 1: AL Group 2: AL with a single dose of 0.25 mg/kg PQ Group 3: AL with a single dose of 0.4 mg/kg PQ

Participants Target sample size 360 participants Inclusion criteria • Age = 2 and < 15 years • P. falciparum parasitaemia = 1000 and < 200,000 parasites/µL • P. falciparum gametocytes • Normal G6PD • Informed consent by legally acceptable representative Exclusion criteria • Enrolled in another study • Fever or history of fever in last 24 hours • Evidence of severe illness/danger signs • Known allergy to study medications • Hb < 8 g/dL • Started menstruation • Pregnancy or breastfeeding • Antimalarials taken within last 2 days • PQ taken within last 4 weeks • Blood transfusion within the last 90 days • Non-falciparum malaria co-infection Interventions Group 1: AL Group 2: AL with a single dose of 0.25 mg/kg PQ Group 3: AL with a single dose of 0.4 mg/kg PQ Outcomes Primary: Gametocyte carriage (time frame: 14 days during follow-up) Secondary: • Haematological recovery (time frame: 14 days during follow-up) • Transmission to An. gambiae mosquitoes (time frame: day 1, 3, and 7 Starting date September 2013 Contact information t.alfred@fasonet.bf; teun.bousema@lshtm.ac.uk Notes ClinicalTrials.gov identifier: NCT01935882 Burkina Faso, Centre National de Recherche et de Formation sur le Paludisme, Ougadougou, Burkina Faso. DATA AND ANALYSES Comparison 1. Non-artemisinin treatment regimen: PQ versus no PQ Outcome or subgroup title No. of studies No.

Contact information t.alfred@fasonet.bf; teun.bousema@lshtm.ac.uk Notes ClinicalTrials.gov identifier: NCT01935882 Burkina Faso, Centre National de Recherche et de Formation sur le Paludisme, Ougadougou, Burkina Faso. DATA AND ANALYSES Comparison 1. Non-artemisinin treatment regimen: PQ versus no PQ Outcome or subgroup title No. of studies No. of participants Statistical method Effect size 1 Participants with gametocytes 5 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only 1.1 Day 2 2 96 Risk Ratio (M-H, Fixed, 95% CI) 0.72 [0.46, 1.12] 1.2 Day 3 1 83 Risk Ratio (M-H, Fixed, 95% CI) 0.75 [0.45, 1.27] 1.3 Day 4 or 5 3 273 Risk Ratio (M-H, Fixed, 95% CI) 0.84 [0.64, 1.09] 1.4 Day 8 5 402 Risk Ratio (M-H, Fixed, 95% CI) 0.54 [0.44, 0.65] 1.5 Day 15 4 366 Risk Ratio (M-H, Fixed, 95% CI) 0.31 [0.22, 0.43] 1.6 Day 22 4 323 Risk Ratio (M-H, Fixed, 95% CI) 0.30 [0.20, 0.46] 1.7 Day 29 4 290 Risk Ratio (M-H, Fixed, 95% CI) 0.34 [0.19, 0.60] 1.8 Day 36 1 81 Risk Ratio (M-H, Fixed, 95% CI) 0.37 [0.15, 0.94] 1.9 Day 43 1 73 Risk Ratio (M-H, Fixed, 95% CI) 0.27 [0.04, 1.71] 2 Gametocyte clearance time (days) 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected 3 Participants infectious 2 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only 3.1 Day 5 2 30 Risk Ratio (M-H, Fixed, 95% CI) 0.06 [0.01, 0.42] 3.2 Day 8 2 30 Risk Ratio (M-H, Fixed, 95% CI) 0.07 [0.01, 0.45] 3.3 Day 15 2 30 Risk Ratio (M-H, Fixed, 95% CI) 0.14 [0.02, 1.04] 3.4 Day 22 2 30 Risk Ratio (M-H, Fixed, 95% CI) 0.33 [0.02, 7.24] 4 Mosquitoes infected 1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected 4.1 Day 5 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 4.2 Day 8 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 4.3 Day 15 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 4.4 Day 22 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 5 Participants with asexual parasites at day 29 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only 5.1 Not PCR adjusted 1 209 Risk Ratio (M-H, Fixed, 95% CI) 0.94 [0.78, 1.15] 5.2 PCR adjusted 1 209 Risk Ratio (M-H, Fixed, 95% CI) 0.92 [0.69, 1.23] 6 Asexual parasite clearance time (hrs) 2 144 Mean Difference (IV, Fixed, 95% CI) -1.68 [-9.60, 6.25] 7 Adverse effects 1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected 7.1 Nausea 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 7.2 Vomiting 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 7.3 Dizziness 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 7.4 Any adverse effect 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 8 By dose: Participants with gametocytes at day 8

not selected 7.1 Nausea 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 7.2 Vomiting 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 7.3 Dizziness 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 7.4 Any adverse effect 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 8 By dose: Participants with gametocytes at day 8 (microscopy) 5 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only 8.1 < 0.4 mg/kg PQ per day 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 8.2 ≥ 0.4 to < 0.6 mg/kg PQ per day 1 216 Risk Ratio (M-H, Fixed, 95% CI) 0.60 [0.49, 0.75] 8.3 ≥ 0.6 mg/kg PQ per day 4 186 Risk Ratio (M-H, Fixed, 95% CI) 0.39 [0.25, 0.62] 9 By schedule: Participants with gametocytes at day 8 5 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only 9.1 Single dose day 1 or 2 4 191 Risk Ratio (M-H, Fixed, 95% CI) 0.64 [0.49, 0.84] 9.2 Single dose day 3 or 4 3 243 Risk Ratio (M-H, Fixed, 95% CI) 0.45 [0.33, 0.60] 9.3 Multiple dose days 1 to 7 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] Comparison 2. Artemisinin treatment regimen: PQ versus no PQ Outcome or subgroup title No. of studies No.

(microscopy) 5 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only 8.1 < 0.4 mg/kg PQ per day 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 8.2 ≥ 0.4 to < 0.6 mg/kg PQ per day 1 216 Risk Ratio (M-H, Fixed, 95% CI) 0.60 [0.49, 0.75] 8.3 ≥ 0.6 mg/kg PQ per day 4 186 Risk Ratio (M-H, Fixed, 95% CI) 0.39 [0.25, 0.62] 9 By schedule: Participants with gametocytes at day 8 5 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only 9.1 Single dose day 1 or 2 4 191 Risk Ratio (M-H, Fixed, 95% CI) 0.64 [0.49, 0.84] 9.2 Single dose day 3 or 4 3 243 Risk Ratio (M-H, Fixed, 95% CI) 0.45 [0.33, 0.60] 9.3 Multiple dose days 1 to 7 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] Comparison 2. Artemisinin treatment regimen: PQ versus no PQ Outcome or subgroup title No. of studies No. of participants Statistical method Effect size 1 Participants with gametocytes (microscopy) 5 Risk Ratio (M-H, Random, 95% CI) Subtotals only 1.1 Day 4 4 971 Risk Ratio (M-H, Random, 95% CI) 1.00 [0.95, 1.05] 1.2 Day 8 5 1071 Risk Ratio (M-H, Random, 95% CI) 0.21 [0.08, 0.54] 1.3 Day 15 4 995 Risk Ratio (M-H, Random, 95% CI) 0.09 [0.04, 0.19] 1.4 Day 22 3 858 Risk Ratio (M-H, Random, 95% CI) 0.10 [0.03, 0.32] 1.5 Day 29 4 945 Risk Ratio (M-H, Random, 95% CI) 0.17 [0.04, 0.72] 1.6 Day 36 3 838 Risk Ratio (M-H, Random, 95% CI) 0.21 [0.01, 4.32] 1.7 Day 43 4 917 Risk Ratio (M-H, Random, 95% CI) 0.41 [0.04, 3.89] 2 Participants with gametocytes (PCR) 3 Risk Ratio (M-H, Random, 95% CI) Subtotals only 2.1 Day 8 3 627 Risk Ratio (M-H, Random, 95% CI) 0.42 [0.26, 0.69] 2.2 Day 15 3 609 Risk Ratio (M-H, Random, 95% CI) 0.27 [0.11, 0.70] 2.3 Day 29 1 90 Risk Ratio (M-H, Random, 95% CI) 0.23 [0.08, 0.62] 2.4 Day 43 1 79 Risk Ratio (M-H, Random, 95% CI) 0.44 [0.17, 1.16] 3 Participants with asexual parasites 5 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only 3.1 Day 8 1 94 Risk Ratio (M-H, Fixed, 95% CI) 1.28 [0.30, 5.40] 3.2 Day 15 2 198 Risk Ratio (M-H, Fixed, 95% CI) 0.97 [0.23, 4.15] 3.3 Day 29 3 747 Risk Ratio (M-H, Fixed, 95% CI) 0.54 [0.33, 0.88] 3.4 Day 43 2 178 Risk Ratio (M-H, Fixed, 95% CI) 1.03 [0.59, 1.81] 4 Asexual parasite clearance time (hrs) 1 50 Mean Difference (IV, Fixed, 95% CI) -6.0 [-16.31, 4.31] 5 Haemoglobin concentration 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected 5.1 Day 8 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0] 5.2 Day 15 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0] 5.3 Day 29 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0] 5.4 Day 43 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0] 6 % change in haemoglobin concentration 1 Mean Difference (IV, Fixed, 95% CI) Totals not selected 6.1 Day 8 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0] 6.2 Day 15 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0] 6.3 Day 29 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0] 6.4 Day 43 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0] 7 Other adverse effects 2 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected

ean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0] 6.2 Day 15 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0] 6.3 Day 29 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0] 6.4 Day 43 1 Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0] 7 Other adverse effects 2 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected 7.1 Headache 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 7.2 Fatigue 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 7.3 Nausea 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 7.4 Vomiting 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 7.5 Abdominal pain 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 7.6 Diarrhea 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 7.7 Pruritis 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 7.8 Paresthesia 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 7.9 Unspecified 1 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] 8 By dose: Participants with gametocytes at day 8 (microscopy or PCR) 7 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only 8.1 < 0.4 mg/kg PQ per day 1 223 Risk Ratio (M-H, Fixed, 95% CI) 0.67 [0.44, 1.02] 8.2 ≥ 0.4 to < 0.6 mg/kg PQ per day 1 219 Risk Ratio (M-H, Fixed, 95% CI) 0.30 [0.16, 0.56] 8.3 ≥ 0.6 mg/kg PQ per day 7 1380 Risk Ratio (M-H, Fixed, 95% CI) 0.29 [0.22, 0.37] 9 By schedule: Participants with gametocytes at day 8 (microscopy or PCR) 7 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only 9.1 Single dose day 1 or 2 2 843 Risk Ratio (M-H, Fixed, 95% CI) 0.13 [0.07, 0.22] 9.2 Single dose day 3 or 4 5 748 Risk Ratio (M-H, Fixed, 95% CI) 0.47 [0.37, 0.59] 9.3 Multiple dose days 1 to 7 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]

ay 8 (microscopy or PCR) 7 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only 9.1 Single dose day 1 or 2 2 843 Risk Ratio (M-H, Fixed, 95% CI) 0.13 [0.07, 0.22] 9.2 Single dose day 3 or 4 5 748 Risk Ratio (M-H, Fixed, 95% CI) 0.47 [0.37, 0.59] 9.3 Multiple dose days 1 to 7 0 0 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0] Comparison 3. PQ versus no PQ; gametocytes at day 8 (microscopy or PCR); stratified by non-artemisinin versus artemisinin regimen Outcome or subgroup title No. of studies No. of participants Statistical method Effect size 1 Participants with gametocytes at day 8 (microscopy or PCR) 11 1994 Risk Ratio (M-H, Random, 95% CI) 0.38 [0.27, 0.52] 1.1 Non-artemisinin-based partner drug 5 402 Risk Ratio (M-H, Random, 95% CI) 0.54 [0.38, 0.77] 1.2 Artemisinin-based partner drug 7 1592 Risk Ratio (M-H, Random, 95% CI) 0.32 [0.20, 0.51] Comparison 4. PQ versus other 8AQ Outcome or subgroup title No. of studies No. of participants Statistical method Effect size 1 Participants with gametocytes on day 8 2 112 Risk Ratio (M-H, Fixed, 95% CI) 0.41 [0.26, 0.66] Analysis 1.1. Comparison 1 Non-artemisinin treatment regimen: PQ versus no PQ, Outcome 1 Participants with gametocytes. Analysis 1.2. Comparison 1 Non-artemisinin treatment regimen: PQ versus no PQ, Outcome 2 Gametocyte clearance time (days). Analysis 1.3. Comparison 1 Non-artemisinin treatment regimen: PQ versus no PQ, Outcome 3 Participants infectious. Analysis 1.4. Comparison 1 Non-artemisinin treatment regimen: PQ versus no PQ, Outcome 4 Mosquitoes infected.

Analysis 1.2. Comparison 1 Non-artemisinin treatment regimen: PQ versus no PQ, Outcome 2 Gametocyte clearance time (days). Analysis 1.3. Comparison 1 Non-artemisinin treatment regimen: PQ versus no PQ, Outcome 3 Participants infectious. Analysis 1.4. Comparison 1 Non-artemisinin treatment regimen: PQ versus no PQ, Outcome 4 Mosquitoes infected. Analysis 1.5. Comparison 1 Non-artemisinin treatment regimen: PQ versus no PQ, Outcome 5 Participants with asexual parasites at day 29. Analysis 1.6. Comparison 1 Non-artemisinin treatment regimen: PQ versus no PQ, Outcome 6 Asexual parasite clearance time (hrs). Analysis 1.7. Comparison 1 Non-artemisinin treatment regimen: PQ versus no PQ, Outcome 7 Adverse effects. Analysis 1.8. Comparison 1 Non-artemisinin treatment regimen: PQ versus no PQ, Outcome 8 By dose: Participants with gametocytes at day 8 (microscopy). Analysis 1.9. Comparison 1 Non-artemisinin treatment regimen: PQ versus no PQ, Outcome 9 By schedule: Participants with gametocytes at day 8. Analysis 2.1. Comparison 2 Artemisinin treatment regimen: PQ versus no PQ, Outcome 1 Participants with gametocytes (microscopy). Analysis 2.2. Comparison 2 Artemisinin treatment regimen: PQ versus no PQ, Outcome 2 Participants with gametocytes (PCR). Analysis 2.3. Comparison 2 Artemisinin treatment regimen: PQ versus no PQ, Outcome 3 Participants with asexual parasites. Analysis 2.4. Comparison 2 Artemisinin treatment regimen: PQ versus no PQ, Outcome 4 Asexual parasite clearance time (hrs). Analysis 2.5. Comparison 2 Artemisinin treatment regimen: PQ versus no PQ, Outcome 5 Haemoglobin concentration.

Analysis 2.3. Comparison 2 Artemisinin treatment regimen: PQ versus no PQ, Outcome 3 Participants with asexual parasites. Analysis 2.4. Comparison 2 Artemisinin treatment regimen: PQ versus no PQ, Outcome 4 Asexual parasite clearance time (hrs). Analysis 2.5. Comparison 2 Artemisinin treatment regimen: PQ versus no PQ, Outcome 5 Haemoglobin concentration. Analysis 2.6. Comparison 2 Artemisinin treatment regimen: PQ versus no PQ, Outcome 6 % change in haemoglobin concentration. Analysis 2.7. Comparison 2 Artemisinin treatment regimen: PQ versus no PQ, Outcome 7 Other adverse effects. Analysis 2.8. Comparison 2 Artemisinin treatment regimen: PQ versus no PQ, Outcome 8 By dose: Participants with gametocytes at day 8 (microscopy or PCR). Analysis 2.9. Comparison 2 Artemisinin treatment regimen: PQ versus no PQ, Outcome 9 By schedule: Participants with gametocytes at day 8 (microscopy or PCR). Analysis 3.1. Comparison 3 PQ versus no PQ; gametocytes at day 8 (microscopy or PCR); stratified by non-artemisinin versus artemisinin regimen, Outcome 1 Participants with gametocytes at day 8 (microscopy or PCR). Analysis 4.1. Comparison 4 PQ versus other 8AQ, Outcome 1 Participants with gametocytes on day 8. CONTRIBUTIONS OF AUTHORS 2015 edition: PMG, HG and PG contributed to adjusting the data and updating the text. Graves 2014: PMG and HG added the new studies. PG helped rewrite the review. All review authors contributed to the interpretation of the results and the conclusions drawn.

Analysis 4.1. Comparison 4 PQ versus other 8AQ, Outcome 1 Participants with gametocytes on day 8. CONTRIBUTIONS OF AUTHORS 2015 edition: PMG, HG and PG contributed to adjusting the data and updating the text. Graves 2014: PMG and HG added the new studies. PG helped rewrite the review. All review authors contributed to the interpretation of the results and the conclusions drawn. Graves 2012: Two review authors (PMG and HG) independently screened all abstracts, applied inclusion criteria and extracted data. PG helped structure the review and contributed to the logic framework of the 'Summary of findings' tables. All review authors contributed to the writing of the review, the interpretation of the results and the conclusions drawn. DECLARATIONS OF INTEREST We have no affiliations with or involvement in any organization or entity with a direct financial interest in the subject matter of the review (for example, employment, consultancy, stock ownership, honoraria or expert testimony). This review and the salary of PG is supported by a DFID grant aimed at ensuring the best possible systematic reviews, particularly Cochrane Reviews, are completed on topics relevant to the poor in low- and middle-income countries. DFID does not participate in the selection of topics, in the conduct of the review or in the interpretation of findings.

G is supported by a DFID grant aimed at ensuring the best possible systematic reviews, particularly Cochrane Reviews, are completed on topics relevant to the poor in low- and middle-income countries. DFID does not participate in the selection of topics, in the conduct of the review or in the interpretation of findings. PMG is a member of the WHO Malaria Policy Advisory Committee, to provide independent strategic advice in forming WHO policies in malaria. PG is a member of the WHO Guidelines for the Treatment of Malaria Group that made the recommendation for PQ to reduce P. falciparum malaria transmission. None of the review authors are investigators on any of the included trials. SOURCES OF SUPPORT Internal sources Liverpool School of Tropical Medicine, UK. External sources Department for International Development, UK. DIFFERENCES BETWEEN PROTOCOL AND REVIEW 1. After reading the trials, we added several new outcomes and modified some outcomes; we deleted two outcomes. Changes to primary outcomes: Proportion of participants with gametocytes: we added: by microscopy and PCR; We added: Proportion of participants infectious; We included: Gametocyte density (by microscopy and PCR); We added: Gametocyte clearance time and duration of gametocyte carriage. We arranged the primary outcomes to capture the three categories: transmission intensity, infectiousness and potential infectiousness. Changes to secondary outcomes: We deleted AUC of asexual parasite density over time. We did not identify any relevant data; We added asexual clearance time. Changes to Adverse events:

We added: Gametocyte clearance time and duration of gametocyte carriage. We arranged the primary outcomes to capture the three categories: transmission intensity, infectiousness and potential infectiousness. Changes to secondary outcomes: We deleted AUC of asexual parasite density over time. We did not identify any relevant data; We added asexual clearance time. Changes to Adverse events: We deleted: All adverse events (data reported was minimal and not in a form that was easily summarised. The main question is whether there are serious adverse events); We modified haemolysis or drop in haemoglobin or PCV (as assessed/defined in each trial) by deleting reference to G6PD since these outcomes occur in non-G6PD people too. We also added PCV since this was used in some trials as a measure of anaemia. 2. In the first version of the review, we deleted the objective: "To compare the effects of different doses and schedules of PQ given to reduce infectiousness" and we modified the definition of control in comparisons accordingly. We only included controls without PQ. We deleted the comparison of different doses of PQ with identical other treatment regimens since it does not answer the important question of whether adding PQ is effective. We included one trial with two arms using different doses of PQ with same other treatment regimens as two separate arms within the same comparison. In the June 2014 update, we reversed this decision. 3. We planned to use the following comparisons described in the protocol: CQ (with and without PQ, or with different doses of PQ);

2. In the first version of the review, we deleted the objective: "To compare the effects of different doses and schedules of PQ given to reduce infectiousness" and we modified the definition of control in comparisons accordingly. We only included controls without PQ. We deleted the comparison of different doses of PQ with identical other treatment regimens since it does not answer the important question of whether adding PQ is effective. We included one trial with two arms using different doses of PQ with same other treatment regimens as two separate arms within the same comparison. In the June 2014 update, we reversed this decision. 3. We planned to use the following comparisons described in the protocol: CQ (with and without PQ, or with different doses of PQ); SP (with and without PQ, or with different doses of PQ); CQ plus sulfadoxine + pyrimethamine (with and without PQ, or with different doses of PQ); Artemisinin derivatives (with and without PQ, or with different doses of PQ); Other drugs (with and without PQ, or with different doses of PQ). In the review, we changed the groups, added some, and combined some for the following reasons: a. some trials combined two types of malaria treatment regimens, not distinguishing the patients who received each one (for example, CQ or CQ plus SP); b. there were many different artemisinin derivatives and combinations tested, with few trials of each, so these were grouped within the same comparison. We also grouped combinations of an artemisinin derivative with SP here.

a. some trials combined two types of malaria treatment regimens, not distinguishing the patients who received each one (for example, CQ or CQ plus SP); b. there were many different artemisinin derivatives and combinations tested, with few trials of each, so these were grouped within the same comparison. We also grouped combinations of an artemisinin derivative with SP here. 3. There were no eligible cluster-RCTs so we deleted how we would manage them from the Methods section. If we include any cluster-RCTs in future editions, we will check that trials have correctly adjusted for clustering and, if not, attempt to make this adjustment. When the analyses have not adjusted for clustering, we will attempt to adjust the results for clustering by multiplying the standard errors of the estimates by the square root of the design effect, where the design effect is calculated as DEff=1+(m-1)*ICC. This assumes that the necessary information is reported, the average cluster size (m) and the intra-cluster correlation coefficient (ICC). 4. We intended a sensitivity analysis to investigate the robustness of the results to the quality (risk of bias) components, but were unable to do so as there were insufficient trials. If appropriate and necessary, we will conduct sensitivity analysis on cluster-RCTs using a range of estimates for the ICC to see if clustering could influence the individual trial's result.

he robustness of the results to the quality (risk of bias) components, but were unable to do so as there were insufficient trials. If appropriate and necessary, we will conduct sensitivity analysis on cluster-RCTs using a range of estimates for the ICC to see if clustering could influence the individual trial's result. NOTES We received comments from Professor Nick White, who has published extensively on using PQ to prevent transmission. Professor White sent some helpful comments on the use of the data and its interpretation. These were considered by the authorship team and disaggregated into key points that needed to be addressed by the review. The Cochrane Contact Editor moderated the process. The main points raised and addressed were: The lack of effect in low dose categories of PQ does not mean there is no effect and the data suggests a dose response relationship. Response: we have adjusted the wording within the review. Data from Pukrittayakamee 2004 has been incorrectly extracted/interpreted. Response: Two review authors working independently assumed "after treatment" meant after the seven day course, and it was helpful to have it clarified that this was not the case. Therefore we excluded the data for day 8 gametocyte prevalence from this analysis. We inserted additional text on the gametocyte clearance time and duration of gametocyte carriage to the Results section. Professor White's comments subsequently appeared in a publication about the topic (White 2014). We have corrected all points of factual detail in this current review version.

Data from Pukrittayakamee 2004 has been incorrectly extracted/interpreted. Response: Two review authors working independently assumed "after treatment" meant after the seven day course, and it was helpful to have it clarified that this was not the case. Therefore we excluded the data for day 8 gametocyte prevalence from this analysis. We inserted additional text on the gametocyte clearance time and duration of gametocyte carriage to the Results section. Professor White's comments subsequently appeared in a publication about the topic (White 2014). We have corrected all points of factual detail in this current review version. INDEX TERMS Medical Subject Headings (MeSH) Antimalarials [*administration & dosage]; Artemisinins [therapeutic use]; Chloroquine [therapeutic use]; Drug Combinations; Glucosephosphate Dehydrogenase Deficiency [diagnosis]; Malaria, Falciparum [*prevention & control; transmission]; Mefloquine [therapeutic use]; Plasmodium falciparum [*drug effects]; Primaquine [*administration & dosage]; Pyrimethamine; Quinine [therapeutic use]; Randomized Controlled Trials as Topic; Sulfadoxine MeSH check words Humans