Pre-Referral Treatment Strategies for Severe Malaria in Community Settings

Severe malaria remains a leading cause of paediatric mortality in regions with limited access to hospital care. As rapid initiation of antimalarial therapy is essential to prevent death and permanent disability, community-based pre-referral strategies have been developed to bridge the time gap between initial presentation and definitive in-facility treatment. Central to these strategies is the use of rectally administered artemisinin derivatives, which can be given by trained lay providers or community health workers (CHWs) where parenteral administration is not immediately feasible. These interventions are most effective when embedded within a reliable continuum of care that includes prompt diagnosis, safe referral pathways, emergency transport arrangements and adequate stocks of follow-on therapies—typically injectable artesunate followed by an oral artemisinin-based combination therapy (ACT). Integration with rapid diagnostic tests at peripheral level and robust training and supervision of CHWs have been shown to improve adherence to treatment guidelines and reduce delays. However, real-world effectiveness varies by context, and the overall impact depends on the strength of local health systems, caregiver understanding of referral urgency, and consistent availability of post-referral care.

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Pre-Referral Treatment Strategies for Severe Malaria in Community Settings publication trend

The graph below shows the total number of articles in pre-referral treatment strategies for severe malaria in community settings across all publications each year (not limited to Nature Index journals).

Technical terms

Rectal artesunate (RAS): A suppository formulation of an artemisinin derivative used for rapid initial treatment of severe malaria when injectable therapy is not immediately available.

Artemisinin-based combination therapy (ACT): Oral antimalarial regimens combining an artemisinin derivative with a partner drug to ensure complete parasite clearance and deter resistance.

Community health worker (CHW): A lay health provider trained to deliver basic diagnostic tests, administer pre-referral treatments and facilitate referrals within community settings.

Pre-referral treatment: Emergency administration of antimalarial therapy at first contact, prior to transfer to a facility capable of full case management.

Continuum of care: The uninterrupted sequence of appropriate interventions from initial diagnosis and pre-referral treatment through post-referral therapy to ensure complete cure.

References

1. Health worker compliance with severe malaria treatment guidelines in the context of implementing pre-referral rectal artesunate in the Democratic Republic of the Congo, Nigeria, and Uganda: An operational study. PLOS Medicine (2023).
2. Rectal artesunate for severe malaria, implementation research, Zambia. Bulletin of the World Health Organization (2023).
3. The impact of home-based management of malaria on clinical outcomes in sub-Saharan African populations: a systematic review and meta-analysis. Tropical Medicine and Health (2024).
4. Feasibility, acceptability and impact of integrating malaria rapid diagnostic tests and pre-referral rectal artesunate into the integrated community case management programme. A pilot study in Mchinji district, Malawi. Malaria Journal (2016).
5. Community access to rectal artesunate for malaria (CARAMAL): A large-scale observational implementation study in the Democratic Republic of the Congo, Nigeria and Uganda. PLOS Global Public Health (2022).