Rectal artesunate suppositories for the prereferral treatment of suspected severe malaria

Abstract

• The World Health Organization Malaria Policy Advisory Group (WHO MPAG) has recently advised against deployment of rectal artesunate suppositories (RAS) for the treatment of severe malaria in remote areas where efficient referral to hospital is not possible. • Untreated severe malaria is almost always fatal. In these remote areas, no RAS availability will very likely mean no treatment at all. These are the areas where childhood mortality from malaria is greatest. • The earlier artesunate is given in the course of severe malaria illness, the greater the life-saving benefit. • Most of the life-saving benefit of artesunate follows the first dose. The route of administration does not change the antimalarial effect of artesunate. • In places where referral is not possible, treatment with RAS only, followed by oral artemisinin combination therapy when the patient can take oral medications is likely to be sufficient in most cases. • Selection of artemisinin resistance following a single RAS dose is highly unlikely. • Bacterial septicaemia is frequently misdiagnosed as severe malaria. There are no broad-spectrum antibiotics that can be rectally administered-a major therapeutics gap for community treatment of severe febrile illness. • We urge the WHO MPAG to reconsider their recommendation against deployment of RAS in places where efficient referral to hospital is not possible and to promote development of the community health worker infrastructure that would support effective deployment of RAS in remote areas where it will save the most young lives.