Pre-referral rectal artesunate for severe malaria

Researchers conducted a review of the effects of pre-referral rectal artesunate for people with suspected severe malaria


Cochrane Collaboration researchers conducted a review of the effects of pre-referral rectal artesunate for people with suspected severe malaria, living in rural areas without healthcare services. After searching for all relevant trials up to May 2014 they included only one randomized controlled trial. This trial was conducted at various sites across Ghana, Tanzania and Bangladesh, and enrolled 17,826 children and adults.

Severe malaria is a serious medical condition caused by infection with the Plasmodium parasite which typically causes vomiting, anaemia, fitting, coma, and death. It is treated by giving injections of antimalarial drugs, which need to be started as quickly as possible to reduce the risk of death and brain damage. In some rural areas where malaria is common, people have to travel for several hours to reach healthcare clinics and hospitals, and many die on the way. In these settings, people without formal healthcare education could be trained to give artesunate rectally to start treating malaria before transporting the patient to hospital.

What the research says:

  • Only one trial evaluated rectal artesunate as pre-referral treatment. In the African sites only, children aged 6 to 72 months were included in the trial; while in the Asian trial site, older children and adults were included.

  • Young children in the African and Asian trial sites (aged 6 to 72 months) had fewer deaths with rectal artesunate than with placebo (moderate quality evidence). However, in Asia among older children and adults, there were more deaths in those that received rectal artesunate (low quality evidence).

  • In the African sites, 56% of children took longer than six hours to reach hospital whereas over 90% of people in the Asian site reached hospital within six hours.

  • The unexpected finding of more deaths with rectal artesunate in older children and adults should be taken into account when forming national and local policies about pre-referral treatment.

This research is supported by the Department for International Development’s Evidence Building and Synthesis Research Programme which is led by Liverpool School of Tropical Medicine


Okebe, J.; Eisenhut, M. Pre-referral rectal artesunate for severe malaria. Cochrane Database of Systematic Reviews (2014) Issue 5, Art. No.: CD009964. [DOI: 10.1002/14651858.CD009964.pub2]

Pre-referral rectal artesunate for severe malaria

Published 1 January 2014