SEMA ReACT

The challenge

Children living in remote rural locations who develop severe malaria are at high risk of dying before they get to health facilities for treatment. As they may be unable to take oral medicines, rectal artesunate suppositories have been developed, which can be administered by community health workers to keep children alive while they are transported to a health facility. 

In trials, rectal artesunate suppositories have been shown to be highly effective at reducing parasite numbers, and dramatically cut death rates in remote settings. However, a programmatic evaluation following introduction of rectal artesunate in the Democratic Republic of the Congo (DRC), Nigeria and Uganda found that, after introduction, survival rates actually fell. This led WHO to suspend its recommendation of rectal artesunate use where it wasn’t introduced. 

The programmatic evaluation was a ‘before and after’ comparison rather than a controlled trial, complicating interpretation of the data. Other factors may have affected survival rates after introduction of rectal artesunate use, including delays in transporting children to facilities to complete their antimalarial treatment, for example because of geographic challenges or financial barriers such as transport costs.  

The project

The SEMA ReACT project is carrying out a study to evaluate a revised treatment strategy for severe malaria, incorporating rectal artesunate, in settings where access to health facilities is challenging.  

In many rural settings, non-severe malaria is already treated by community health workers, who use rapid diagnostic tests to identify cases of malaria and then administer oral artemisinin combination therapy (ACT). However, they are not able to administer injectable artesunate. For severe malaria, the recommended approach has been to immediately administer rectal artesunate then refer children to health facilities, for the administration of injectable artesunate followed by three days of oral ACT. 

Focused on remote rural areas of DRC and Zambia, the SEMA ReACT project will compare this approach to one based solely on treatment in the community. After initial administration of rectal artesunate, community health workers will provide children with oral ACT in the community.  

The project will compare the efficacy of each approach and survival rates. It will also assess whether the two approaches lead to any differences in drug resistance, as there are concerns that use of artesunate as a monotherapy could promote the development of resistance. The feasibility and acceptability of the two approaches will also be investigated. 

Impact

The SEMA ReACT project will generate critical data on a community-based strategy for treatment of severe malaria in remote rural settings where transport to a health facility is challenging. It will: 

• Demonstrate whether the community-based approach delivers outcomes similar to those achieved when children are transported to health facilities to complete their treatment.
• Generate evidence to inform WHO policymaking and recommendations on strategies to optimise the use of rectal artesunate for severe malaria.  

If the study shows that severe malaria can be effectively treated by community health workers, this would provide an important new option for remote rural settings, with the potential to reduce deaths of some of the most vulnerable children in Africa.