Rectal artesunate for severe malaria, implementation research, Zambia

01 Jun 2023
Cathy Green, Paula Quigley, Tendayi Kureya, Caroline Barber, Ernest Chanda, Busisiwe Moyo, Bernard Mpande, Kenneth Mubuyaeta, Mutinta Mudenda, Likando Mundia, Ruth Nyirenda, Auxilia Piringondo, Hans Rietveld, Sebastian Simpasa, Dennis Simuyuni & Garikai Zinumwe

Objective: To determine whether the positive results of a single-district pilot project focused on rectal artesunate administration at the community level in Zambia could be replicated on a larger scale.

Methods: In partnership with government, in 10 rural districts during 2018–2021 we:
(i) trained community health volunteers to administer rectal artesunate to children with suspected severe malaria and refer them to a health facility;
(ii) supported communities to establish emergency transport, food banks and emergency savings to reduce referral delays;
(iii) ensured adequate drug supplies; (iv) trained healthworkers to treat severe malaria with injectable artesunate; and
(v) monitored severe malaria cases and associated deaths via surveys, health facility data and a community monitoring system.

Results: Intervention communities accessed quality-assured rectal artesunate from trained community health volunteers, and follow-on treatment for severe malaria from health workers. Based on formal data from the health management information system, reported deaths
from severe malaria reduced significantly from 3.1% (22/699; 95% confidence interval, CI: 2.0–4.2) to 0.5% (2/365; 95% CI: 0.0–1.1) in two demonstration districts, and from 6.2% (14/225; 95% CI: 3.6–8.8) to 0.6% (2/321; 95% CI: 0.0–1.3) in eight scale-up districts.

Conclusion: Despite the effects of the coronavirus disease, our results confirmed that pre-referral rectal artesunate administered by community health volunteers can be an effective intervention for severe malaria among young children. Our results strengthen the case
for wider expansion of the pre-referral treatment in Zambia and elsewhere when combined with supporting interventions.