Severely ill patients with malaria with vomiting, prostration, and altered consciousness cannot be treated orally and need injections. In rural areas, access to health facilities that provide parenteral antimalarial treatment is poor. Safe and effective treatment of most severe malaria cases is delayed or not achieved. Rectal artesunate interrupts disease progression by rapidly reducing parasite density, but should be followed by further antimalarial treatment. We estimated the cost-effectiveness of community-based prereferral artesunate treatment of children suspected to have severe malaria in areas with poor access to formal health care. We assessed the cost-effectiveness (in international dollars) of the intervention from the provider perspective. We studied a cohort of 1000 newborn babies until 5 years of age. The analysis assessed how the cost-effectiveness results changed with low (25), moderate (50), high (75), and full (100) referral compliance and intervention uptake. At low intervention uptake and referral compliance (25), the intervention was estimated to avert 19 disability-adjusted life-years (DALYs; 95 CI 16-21) and to cost I$1173 (95 CI 1050-1297) per DALY averted. Under the full uptake and compliance scenario (100), the intervention could avert 967 DALYs (884-1050) at a cost of I$77 (73-81) per DALY averted. Prereferral artesunate treatment is a cost-effective, life-saving intervention, which can substantially improve the management of severe childhood malaria in rural African settings in which programmes for community health workers are in place. The Disease Control Priorities Project; Fogarty International Center; US National Institutes of Health; and the Peter Paul Career Development Professorship, Boston University.
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