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Background  Primaquine (PQ) is the only currently licensed antimalarial that prevents  Plasmodium vivax  ( Pv ) relapses. It also clears mature  P .  falciparum  ( Pf ) gametocytes, thereby reducing post-treatment transmission. Randomized PQ treatment in a treatment-to-reinfection cohort in Papua New Guinean children permitted the study of  Pv  and  Pf  gametocyte carriage after radical cure and to investigate the contribution of  Pv  relapses.    Methods  Children received radical cure with Chloroquine, Artemether-Lumefantrine plus either PQ or placebo. Blood samples were subsequently collected in 2-to 4-weekly intervals over 8 months. Gametocytes were detected by quantitative reverse transcription-PCR targeting  pvs25  and  pfs25 .    Results  PQ treatment reduced the incidence of  Pv  gametocytes by 73%, which was comparable to the effect of PQ on incidence of blood-stage infections. 92% of  Pv  and 79% of  Pf  gametocyte-positive infections were asymptomatic.  Pv  and to a lesser extent  Pf  gametocyte positivity and density were associated with high blood-stage parasite densities. Multivariate analysis revealed that the odds of gametocytes were significantly reduced in mixed-species infections compared to single-species infections for both species (OR Pv  = 0.39 [95% CI 0.25–0.62], OR Pf  = 0.33 [95% CI 0.18–0.60], p<0.001). No difference between the PQ and placebo treatment arms was observed in density of  Pv  gametocytes or in the proportion of  Pv  infections that carried gametocytes. First infections after blood-stage and placebo treatment, likely caused by a relapsing hypnozoite, were equally likely to carry gametocytes than first infections after PQ treatment, likely caused by an infective mosquito bite.    Conclusion  Pv relapses and new infections are associated with similar levels of gametocytaemia. Relapses thus contribute considerably to the Pv reservoir highlighting the importance of effective anti-hypnozoite treatment for efficient control of Pv.    Trial registration  ClinicalTrials.gov  NCT02143934

Effects of liver-stage clearance by Primaquine on gametocyte carriage of Plasmodium vivax and P. falciparum