What is it about?

Severe malaria is a serious and potentially life-threatening illness. It requires prompt medical attention and treatment with intravenous medication to prevent serious complications and reduce the risk of death. Even though there are effective and safe drugs available, many children still die from this disease. One reason for this is that in many countries where malaria is common, many children living in rural areas do not receive medical attention quickly enough. In situations where injectable treatment is not readily available, artesunate suppositories (rectal artesunate) are intended to bridge the time it takes to reach a health facility where intravenous medication is provided. This study was part of the Community Access to Rectal Artesunate for Malaria (CARAMAL) project which investigated the feasibility and effectiveness of administering a single dose of rectal artesunate to children with severe malaria before referring them to a higher-level health facility for further treatment. In this study, we investigated the quality of the treatment given at such facilities in the Democratic Republic of the Congo, Nigeria and Uganda. We found that while injectable treatment for severe malaria was generally given correctly by health workers, the provision of artemisinin-based combination therapy (ACT) to complete treatment was not always followed.

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Why is it important?

Given that the CARAMAL study was not able to show that rectal artesunate had a positive impact on child survival in the three study countries, concerns about the quality of care for children with severe malaria seem justified. Our study shows that many children suffering from severe malaria receive incomplete treatment, often consisting of a monotherapy. This practice poses a big risk as it may result in poor treatment outcomes for affected children. It also bears an increased risk of the malaria parasites developing resistance to effective drugs. The shortcomings identified in the health system need urgent attention to improve the management of severe malaria cases and bring mortality down.


If the health-care system is unable to ensure that patients with severe malaria complete curative treatment, or that complications are promptly and adequately managed, then using rectal artesunate before referring severely ill children to higher-level health facilities will not improve their health outcomes. Unless the quality of care is improved, children will continue to die from severe malaria and promising interventions like the potentially life-saving drug rectal artesunate will not have an impact on malaria case fatality.

Aita Signorell
Swiss Tropical and Public Health Institute

Read the Original

This page is a summary of: Health worker compliance with severe malaria treatment guidelines in the context of implementing pre-referral rectal artesunate in the Democratic Republic of the Congo, Nigeria, and Uganda: An operational study, PLoS Medicine, February 2023, PLOS, DOI: 10.1371/journal.pmed.1004189.
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