Lancet press release


A rectal application of the inexpensive antimalarial drug artesunate could save the lives of many people who develop severe malaria who live in the world’s remotest locations, eg, rural Africa and Asia. These are the conclusions of an Article published Online first and in an upcoming edition of The Lancet, written by Dr Melba Gomes, WHO, Geneva, Switzerland, and colleagues from the study 13 Research Group.

Most malaria deaths occur among young children in rural areas. An acute episode of malaria can become so severe that the patient cannot swallow and ‘keep down’ oral treatment. If patients with severe malaria who cannot be treated orally are several hours of travel away from facilities for injections, rectal artesunate — which acts rapidly on malaria parasites — could be given before setting out on the journey. The authors investigated whether pre-referral treatment reduced mortality and permanent disability.

In Bangladesh, Ghana, and Tanzania, patients with suspected severe malaria who could not be treated orally were allocated randomly to an artesunate (8954 patients) or placebo (8872) suppository (ie, rectal application). Most had a drop of blood taken beforehand for later examination, and those with no malaria parasites in it were excluded from the main analysis (as they probably had a viral or bacterial infection, which artesunate cannot affect). For patients who were able to reach the injections clinic within six hours, there was no significant difference in mortality or permanent disability between the two groups. However, in patients still not in clinic after six hours (and half of these were still not there after 15 hours), pre-referral rectal artesunate halved the risk death or permanent disability (29 of 1566 patients for artesunate vs 57/1519 for placebo).

The authors say: “Death from malaria reflects delay in administration of effective antimalarial treatment. Our results provide strong evidence that if patients with severe malaria cannot be treated orally and referral is likely to take several hours, an immediate rectal dose of artesunate before referral substantially reduces the risk of death or permanent disability.”

They conclude: “For the foreseeable future, there will be many patients in the community with suspected severe malaria who could, if treated earlier, have been managed orally, but can no longer be treated orally and need immediate help.” They say that rectal treatment in the community can offer this.

In an accompanying Comment, Dr Lorenz von Seidlein, Joint Malaria Project, Tanzania, and Dr Jacqueline L Deen, Joint Malaria Project, Tanzania and Vaccine Institute, Kwanak-gu, Seoul, Korea, say: “If there are a handful of important papers every decade that will influence the way malaria is treated, this study is one of them...The next important step is to develop widescale deployment strategies, through research, and to assess the effectiveness of artesunate suppositories under various real-life settings.”