Scaling up an improved treatment for severe malaria

Prof. Olugbenga A Mokuolu, Centre for International Education, University of Ilorin, Nigeria

The long-awaited results of the AQUAMAT1 trial were announced in Atlanta at the ASTMH2 annual meeting in November 2010. This study clearly demonstrated that artesunate injection offered a 22% reduction in mortality compared to intravenous quinine for children suffering from severe malaria.

Based on the AQUAMAT trial, in 2011 the WHO revised its Standard Treatment Guidelines3 to recommend artesunate injection as the preferred treatment for severe malaria in both adults and children. Throughout 2011, MMV and partners developed plans to increase uptake and use of this critically important medicine across the malaria-endemic world.

1. Nigeria is the first country in Africa to recommend artesunate injection over quinine in the treatment of severe malaria. How did this come about?

Ilorin University Hospital was one of the AQUAMAT trial sites. Although the researchers were not privy to the results until the end of the study, we were able to see at first hand the advantages of artesunate over quinine. As soon as the trial findings were out in November 2010 we communicated them directly to the National Malaria Control Programme (NMCP). Together with MMV we then set up a meeting to present the data to the NMCP, who were fortunately in the process of updating the country’s treatment guidelines. The change was then made in April 2011.

2. What has been the impact to date of the update in the guidelines?

It is probably too early to assess the general impact across the country – we are still in the active phase of making the change a reality. Here at Ilorin Hospital, however, we have recently completed our annual review of malaria mortality; it is now below 5% whereas last year it was between 8% and 11%. This is a significant drop. I consider this to be partly the result of improved diagnosis, such that all non-malaria deaths have been removed from the pack, but there is no doubt that the use of artesunate injection has also made a difference.

3. What challenges lie ahead now for Nigeria to ensure the guidelines are followed throughout the country? How can MMV help?

First, we must ensure the guideline change is communicated and understood by health-care workers across the country. We can do so by systematically engaging key groups to help disseminate the news, such as the Paediatric Association of Nigeria, the Nigerian Medical Association and the Pharmaceutical Society of Nigeria. MMV can and has helped with this.

The second hurdle is that the cost per treatment unit of artesunate is greater than that of quinine. To overcome this, countries will likely need to seek donor support. Additionally, by facilitating and encouraging other producers of artesunate injection to go through the WHO prequalification process, as MMV did with Guilin, we ensure there is competition which will help to keep the costs down.

Prof. Olugbenga A Mokuolu is a Paediatrician and Director of the Centre for International Education at the University of Ilorin, Nigeria.

1. Dondorp AM et al. ‘‘Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomised trial’’. Lancet. 376(9753):1647-57 (2010).

2. ASTMH: American Society of Tropical Medicine and Hygiene.

3. World Health Organization ‘‘Guidelines for the treatment of malaria, 2nd edition – Rev. 1 revised37’’