Opinion: Why we must prioritize malaria treatment for children

Malaria hits children the hardest. As stated in the latest “World Malaria Report” launched late last year in Mozambique, malaria continues to take the life of a child under 5 years of age every two minutes. That’s more than a quarter of a million young lives needlessly lost each year.

Children are particularly vulnerable to malaria, unlike adults that have grown up in endemic regions, children haven’t yet developed the immunity needed to prevent malaria from progressing to a severe, life-threatening stage. Those children that survive an episode of malaria in some parts of Africa can go on to be re-infected up to 13 times a year, according to research in Uganda.

Although children are the main victims of malaria, few antimalarial medicines have been developed with their needs in mind.

Children are often given adult tablets crushed into powder and added to water, an inadequate solution for young patients for several reasons: Children are not simply “little adults,” they absorb and metabolize medicines differently, some antimalarial medicines are bitter and a child already nauseous from malaria may vomit the medicine and not receive a complete curative dose. In addition, incomplete dosing also increases the risk of developing resistance. Children need palatable, easy-to-take medicines adapted to weight and age.

The global health community has recognized this area of neglected drug development, not only for malaria but in all areas of child health. In 2007, the World Health Assembly issued a resolution on better medicines for children, which promoted child-friendly medicines that meet requirements for dosing, tolerability, and ease-of-administration.

Today, child-friendly antimalarials are available, but those medicines are still not reaching the children that need them. Research covering sub-Saharan Africa estimated that in 2015, only 1 in 5 children younger than 5 years old with malaria infection and fever were treated with a World Health Organization-recommended first-line treatment. Even fewer receive a quality-assured, child-friendly version. The use of better medicines for children needs to be maximized.

In Zambia, we have seen firsthand the difference that getting the right medicines to children at the right time can make. In July 2017, the Medicines for Malaria Venture and Zambia National Malaria Elimination Centre joined forces in a collaboration with consortium partners, led by Transaid on the More Mobilising Access to Maternal Health Services, or MAM project, to improve severe malaria case management.

Specifically, MAM leveraged the existing program that uses bicycle ambulances to help women with distressed pregnancies to get a higher level of care. MAM expanded on the original mission to ensure that children dangerously ill with malaria can receive a prereferral intervention with a rectal administration of the antimalarial artesunate at the community level before being transferred to facilities equipped to administer injectable artesunate. MAM thus helps buy time by slowing down the progress of severe malaria, while ensuring children are transported to appropriate care facilities for severe malaria.

In addition to its expanded use of bicycle ambulances, the MAM project adopted innovative approaches, including community theatre, and song and dance to create awareness of malaria danger signs in the community. The 12-month pilot project came to an end in 2018 having successfully reduced severe malaria case fatality by 96 percent — from 97 anticipated deaths to three. 

When 1-year-old Alexandria Katontoka fell sick, his mother took him to see a community health care volunteer, Charity Mumba, trained through the MAM project in the Serenje district. Charity used a rapid diagnostic test to confirm malaria, gave him an antimalarial and paracetamol, and sent him home. Later that day, when Alexandria wouldn’t wake up, Charity was called again, and this time administered rectal artesunate. Five minutes after receiving the rectal artesunate Alexandria opened his eyes and was taken to a hospital. There, he received three courses of the WHO-recommended treatment — injectable artesunate — and the following day could be discharged, with a course of artemisinin-based combination therapy and vitamins to be taken at home.

Based on the MAM project’s success, rectal artesunate has been adopted as part of the Zambian national policy for country-wide scale-up, with ongoing efforts to mobilize the resources to make it happen. But the work cannot and will not end there.

As of October 2018, just over half of the most affected countries in Africa have included WHO-approved rectal artesunate in their national malaria treatment guidelines. Given this, and the significant impact demonstrated by MAM, it is clear more needs to be done to roll out these initiatives in other countries. The governments of Malawi, Liberia, Madagascar, and Angola are also eager to introduce rectal and injectable artesunate and are looking to Medicines for Malaria Venture for guidance.

Better medicines for children do exist and their correct use at the right time makes the difference between life and death. Their use alongside appropriate diagnostics can ensure that children receive the best care possible. Dedicated players, including drug developers, policymakers, health care professionals, and procurement agencies all have key roles to play. We must all continue to collaborate to maintain and accelerate the gains made in treating children with malaria.