BackgroundBhutan has made substantial progress in reducing malaria incidence. The national guidelines recommend chloroquine (CQ) and primaquine (PQ) for radical cure of uncomplicated Plasmodium vivax, but the local efficacy has not been assessed. The impact of cases imported from India on the genetic make-up of the local vivax populations is currently unknown.MethodsPatients over 4 years of age with uncomplicated P. vivax mono-infection were enrolled into a clinical efficacy study and molecular survey. Study participants received a standard dose of CQ (25 mg/kg over 3 days) followed by weekly review until day 28. On day 28 a 14-day regimen of PQ (0.25 mg/kg/day) was commenced under direct observation. After day 42, patients were followed up monthly for a year. The primary and secondary endpoints were risk of treatment failure at day 28 and at 1 year. Parasite genotyping was undertaken at nine tandem repeat markers, and standard population genetic metrics were applied to examine population diversity and structure in infections thought to be acquired inside or outside of Bhutan.ResultsA total of 24 patients were enrolled in the clinical study between April 2013 and October 2015. Eight patients (33.3 %) were lost to follow-up in the first 6 months and another eight patients lost between 6 and 12 months. No (0/24) treatment failures occurred by day 28 and no (0/8) parasitaemia was detected following PQ treatment. Some 95.8 % (23/24) of patients were aparasitaemic by day 2. There were no haemolytic or serious events. Genotyping was undertaken on parasites from 12 autochthonous cases and 16 suspected imported cases. Diversity was high (HE 0.87 and 0.90) in both populations. There was no notable differentiation between the autochthonous and imported populations.ConclusionsCQ and PQ remains effective for radical cure of P. vivax in Bhutan. The genetic analyses indicate that imported infections are sustaining the local vivax population, with concomitant risk of introducing drug-resistant strains.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-016-1320-8) contains supplementary material, which is available to authorized users.

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Bhutanese population have access to both traditional and modern medicine. The record published in Annual Health Bulletin (AHB), Ministry of Health (MoH) recorded the number of people seeking modern medicine has drastically escalated over the past few years. Gelephu based Central Regional Referral Hospital (CRRH), established in 1960’s, sees the second highest number of outpatient department OPD cases in the country. As a result the number of clinical laboratory testing has also increased over the time. The ratio of annual OPD attendance and annual laboratory test recorded at the medical record and AHB depicted at the ratio of 1:1 until 2013 and the ratio increased to 1:1.9 in 2017, significant at p<0.05. The annual total laboratory test increased from n=118567 in 2013 to n=234869 in 2017, with almost an increase by average of 2% annually. The increasing number of test order, increases the probabilities for error. Hence, laboratory quality system is of paramount importance. The introduction of automation in Biochemistry (2014) and Hematology (2015), has significantly reduced analytical errors and has generated reliable, and quality assured reports. No reports have been published until now from CRRH to indicate the increasing clinical laboratory tests. Therefore, the data analysis from this study will present the ever increasing annual laboratory testing conducted at CRRH and would also provide the national medical procurement and supply division with information critical for annual supply forecasting.