Treatment Algorithm for NHPs Identified with Plasmodium Infections During CDC-mandated Quarantine

1. If the NHP Plasmodium screening test is positive, has the species of Plasmodium that is causing the infection been determined?
   1. If no, then treat blood stage and eliminate potential liver stage parasites using one of the following drug combinations:
      1. Artemether-lumefantrine AND primaquine
      2. Atovaquone-proguanil AND primaquine
      3. Chloroquine** AND tafenoquine‡ AND atovaquone-proguanil
      4. Chloroquine** AND tafenoquine‡ AND artemether-lumefantrine
   2. If yes, then the treatment protocol is based on Plasmodium species†
      1. If P. falciparum, then
         1. treat blood stage parasites using artemether-lumefantrine or atovaquone-proguanil
      2. If P. ovale, P. vivax*, or P. cynomolgi, then
         1. Treat blood stage and liver stage parasites using one of the following drug combinations:
            1. Chloroquine**AND primaquine
            2. Artemether-lumefantrine AND primaquine
            3. Atovaquone-proguanil AND primaquine
            4. Chloroquine** AND tafenoquine‡ (*add artemether-lumefantrine or atovaquone-proguanil if P. vivax in NHPs imported from Indonesia or Papua New Guinea)
      3. If P. malariae, P. knowlesi, or Other simian species, then
         1. Treat blood stage parasites using chloroquine**, artemether-lumefantrine, or atovaquone-proguanil

^† A validated test for simian Plasmodium speciation isn’t currently available.

* Use artemether-lumefantrine or atovaquone-proguanil to treat blood stage of P. vivax in NHPs imported from Indonesia or Papua New Guinea.  P. vivax in Indonesia and Papua New Guinea have resistance to the antimalarial drug chloroquine.

** Hydroxychloroquine can be used as an alternative to chloroquine.

^‡ Dow et al. Malaria Journal 2011, 10:212. http://www.malariajournal.com/content/10/1/212