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DFID research: New evidence informs WHO guidelines on treating severe malaria in children

Results from a new trial show that artesunate should replace quinine as recommended drug for treating severe malaria in children

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Artesunate should be the drug of choice for treating severe malaria, the World Health Organization has now stated categorically. Whilst they recommended artesunate in adults, the evidence for using the drug to treat children was unclear. Now, with the publication of a new large multicentre trial of African children published in the Lancet in 2010 it is possible to recommend artesunate as the drug of choice for children too. The Cochrane Infectious Diseases Group (CIDG) who published the updated systematic review in March that included the findings of this new trial, has contributed to the process of the rapid adoption of the results from the trial by the World Health Organization (WHO).

The review now includes a total of 1664 adults and 5765 children, from a variety of settings across Africa and Asia. According to the results, taking artesunate reduces the risk of death by 39% in adults and 24% in children compared to quinine. In adults, deaths caused by severe malaria were reduced from 241 per 1000 with quinine to 147 with artesunate. In children, deaths were reduced from 108 per 1000 with quinine to 83 with artesunate.

“There is now enough evidence to be confident of these results in adults and children,” said Peter Olumese of the WHO’s Global Malaria Programme. “Intravenous artesunate is now being recommended as the treatment of choice for adults and children with severe malaria anywhere in the world.”

Although more children given artesunate suffered neurological problems compared to those given quinine, these were largely resolved within a month of treatment, and were outweighed by the increase in survival rates. “The balance of benefits and harms is in favour of treatment with artesunate,” said David Sinclair of the Liverpool School of Tropical Medicine in Liverpool, UK, who led the review team.

Severe malaria occurs when the disease affects the function of vital organs. It is associated with rarer cerebral malaria, which affects the brain and can lead to long-term disability. More than a million people die each year from severe malaria, the majority in Sub-Saharan Africa. Artesunate was recommended as the preferred treatment for adults with severe malaria by the World Health Organization (WHO) in 2006, but there was insufficient evidence at the time to recommend a change from the standard treatment of quinine in children.

The CIDG is also contributing to other areas of policy formulation in WHO. The WHO Essential Medicines Committee met recently in Ghana, and the CIDG submitted reports summarising data from reviews that are currently being updated, to help inform their discussions. Also CIDG authors Mical Paul and Juliana Okwe presented the findings of the iron in malaria review to the Nutrition Guidance Expert Advisory Group (NUGAG) committee who are considering a recommendation change in this area.

The Cochrane Infectious Diseases Group (CIDG) is a partner of the Effective Health Care Research Consortium, funded by DFID. The editorial base of the CIDG is located at the Liverpool School of Tropical Medicine. CIDG has been preparing systematic reviews on the benefits and harms of healthcare interventions for infectious diseases, particularly malaria, tuberculosis, diarrhoea, and tropical diseases, since 1994.

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Published 5 May 2011