WHO should accelerate, not stall, rectal artesunate deployment for pre-referral treatment of severe malaria

13 Feb 2023
Thomas J. Peto a,b,∗, James A. Watson a,b, Nicholas J. White a,b, and Arjen M. Dondorp
  • The recent World Health Organization moratorium on rectal artesunate (RAS) for pre-referral treatment of severe childhood malaria is costing young lives.
  • Parenteral artesunate reduces severe malaria mortality and a large body of evidence also shows RAS has lifesaving efficacy. There is now more than a decade of delay in conducting the necessary engagement and training required for successful deployment of RAS. Further delays will result in more preventable deaths.
  • Nobody would wish to leave a child with severe malaria untreated for hours or days until they can reach a healthcare facility where parenteral antimalarial treatment is available. Rectal artesunate (RAS) allows early treatment to be given in or near the home. Its lifesaving efficacy was demonstrated in a very large randomized controlled trial (RCT).
  • The correct response to the disappointing results from the CARAMAL observational study would be to recognize deployment problems and focus on how to improve them rather than the scientifically unsound and ethically questionable recommendation that has resulted in withholding of a potentially lifesaving drug from severely ill children.
  • RAS is likely to have the greatest impact where health services are weakest. 
  • Early treatment of severe malaria will reduce childhood mortality in rural Africa. Artesunate is the best available treatment for life-threatening P. falciparum malaria. The training and support mechanisms for community health workers to use RAS appropriately and effectively are important, so the correct approach, if they are inadequate, is to strengthen them—not to withdraw RAS. Preventing children with potentially life-threatening malaria from receiving an effective treatment is wrong. The WHO moratorium on RAS should be lifted.

This publication is yet another confirmation that our work on the SEvere MAlaria treatment with Rectal artesunate and Artemisinin-based Combination Therapy in remote settings (SEMA ReACT) project is timely and relevant.