Increasing uptake of rectal artesunate to buy time against severe malaria

27 Sep 2017

Pierre Hugo and Elizabeth Poll

Africa Health

MMV’s Pierre Hugo and Elizabeth Poll discuss the steps being taken to increase the use of rectal artesunate as a pre-referral intervention for children with severe malaria

More than 400 000 people still die each year from malaria. The vast majority are African children living in remote or rural areas far from health facilities. One of the key issues is timely access to life-saving treatment. The malaria parasite multiplies exponentially in the body and if left untreated can quickly progress to severe malaria, which can kill within hours. This is particularly the case in young children without sufficient immunity.

The first point-of-care for many severe malaria patients—particularly from rural areas—is a healthcare worker either at the community-level or at a primary care facility. Those presenting with severe malaria should be treated as quickly as possible with injectable artesunate (Inj AS), followed by full oral treatment with an artemisinin combination therapy (ACT) when the patient is sufficiently well; however, most community health workers or community health posts do not have access to Inj AS or personnel trained in its administration. As a result, patients need to be referred to higher-level facilities, creating delays in access to critically-needed treatment, often resulting in disability or death.

In such cases, the World Health Organization (WHO) Guidelines for the treatment of malaria1 recommend the use of rectal artesunate (RAS) for pre-referral management of severe malaria. A single dose reduces the risk of death and permanent disability significantly.2,3 RAS starts to cure the disease and therefore ‘buys time’ until Inj AS can be administered. It can mean the difference between life and death.4 As such, RAS is potentially the most important and powerful new intervention for severe malaria since the WHO prequalification of Inj AS.

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  1. World Health Organization. Guidelines for the treatment of malaria. Second edition (2010) 
  2. World Health Organization. Malaria in children under five (2016)
  3. Gomes MF et al. “Pre-referral rectal artesunate to prevent death and disability in severe malaria: a placebo-controlled trial.” The Lancet 2009; 373 (9663): 557–566.
  4. World Health Organization. Rectal artesunate testing and delivery (2016)