The societal costs of managing vivax malaria episodes in Cambodia, Ethiopia, Indonesia, and Pakistan

Abstract Background Plasmodium vivax imposes a substantial health and economic burden, largely due to relapsing infections from the parasite’s dormant liver stages. Radical cure prevents relapses, but its implementation is constrained by the need for glucose−6-phosphate dehydrogenase (G6PD) testing and safety monitoring. Evidence on the societal costs of P. vivax case management is limited. This study estimates the societal cost of the management of uncomplicated P. vivax episodes in adults in Cambodia, Ethiopia, Indonesia, and Pakistan. Methods The societal costs of the management of an uncomplicated P. vivax episode were estimated in 2024 United States dollars ($), using prospective data collected alongside the EFFORT trial. This trial evaluated the effectiveness of 14-day low-dose primaquine (3.5 mg/kg total dose), 7-day high-dose primaquine (7.0 mg/kg total dose), and tafenoquine (300 mg). Provider costs were estimated using bottom-up, activity-based costing for malaria diagnosis, G6PD screening, blood- and liver-stage treatment, and a medical review visit. Household costs included direct medical and non-medical costs, and productivity losses collected from patient surveys on days 0, 3, and 21. Results A total of 960 participants were included across the four countries. The mean household costs per episode ranged from $4.15 in Ethiopia to $100.94 in Indonesia, with productivity losses accounting for 24–90% of total household costs. Provider costs without G6PD screening or liver-stage treatment ranged from $6.38 in Ethiopia to $11.81 in Indonesia, driven primarily by malaria diagnosis and blood-stage treatment. Liver-stage medication costs varied by regimen, with low-dose primaquine being consistently the lowest cost treatment option in all settings, while tafenoquine was the most expensive treatment. The total societal costs per episode varied by country and treatment strategy from $10.53 (Ethiopia, low-dose 14-day primaquine without G6PD screening) to $124.74 (Indonesia, tafenoquine with day 3 follow up). Conclusions Uncomplicated episodes of P. vivax impose substantial societal costs across endemic settings, driven primarily by household productivity losses. G6PD screening and medical review visits increase provider costs, however, increases were small relative to the overall economic burden, highlighting the potential economic value of preventing future P. vivax episodes through the strengthening the delivery of safe and effective radical cure. Trial registration The trial was registered at ClinicalTrials.gov (NCT04411836). Funding for this study was obtained from the National Health and Medical Research Council (NHMRC; grant number 1182950) and the Bill and Melinda Gates Foundation (BMGF; INV-024389).