In uncomplicated malaria, the WHO recommends Artemisinin-based combination therapy (ACT) (1) for infants and children. However, the Government of India recommends chloroquine for P.vivax and also P.falciparum in areas without resistance; ACT is advised only for confirmed P.falciparum in 117 districts with documented chloroquine resistance(2).

In contrast, the treatment of severe/complicated childhood malaria appears to be evolving. The 2005 IAP Guideline followed the National Malaria Programme and recommended quinine, suggesting artesunate/artemether as less preferred alternatives(3). In 2008, it was modified as quinine with tetracycline/doxycycline/clindamycin(4) in line with the WHO 2006 statement. The National Guideline 2009(2) suggests artesunate, quinine, artemether, in that order, contraindicating arteether and doxycycline in children. The WHO’s 2010 Guideline(1) strongly recommends aresunate in adults with severe malaria, positioning quinine only as an alternative; however, it cites lack of evidence to frame a similar recommendation for children.

Despite appropriate therapy with parenteral quinine, the case fatality rate in severe malaria exceeds 20-30%. In addition, quinine administration requires hospital facilities for controlled infusion under close monitoring, owing to the risk of potentially serious (albeit treatable) side effects. Therefore alternate therapies are sought, to improve clinical outcomes and also simplify administration. Artemisinin derivatives appear to hold promise in this direction.

This systematic review of evidence addresses the question: "In children with severe/complicated malaria (population), do Artemisinin derivatives (intervention), improve clinical outcome in terms of mortality, clinical recovery, parasite clearance, adverse effects, etc (outcome), as compared to standard parenteral quinine therapy (comparison)?

A Medline search updated on 25 March 2010, with "severe malaria" and Limits: Humans, Randomized Controlled Trial, Meta-Analysis, All Child (0-18 years), yielded 175 citations. A simultaneous Cochrane Library search for "severe malaria" in ‘Record Title’ listed 4 Cochrane reviews, 7 other systematic reviews and 98 clinical trials. Three relevant Cochrane reviews compared quinine with (i) artesunate(5), (ii) arteether(6) and (iii) artemisinin derivatives(7). The artesunate review(5) included one pediatric trial, but examined effects across all age groups together. The arteether review(6) examined only the intramuscular route, and the third review(7) was closed by the authors in 2009 in view of more recent reviews. Six of seven non-Cochrane reviews compared artesunate or artemether, but all were outdated. This necessitates a fresh systematic review to generate current best evidence.

From the literature search, 45 randomized trials were short-listed, but 42 excluded for the following reasons: (i) not RCT comparing artemisinin derivatives vs quinine (n=16), (ii) adult participants (n=12), (iii) trials included children also, but presented data for adults and children together (n=3), (iv) outdated meta-analysis of trials (n=3), (v) trials compared different preparations/routes of Artemisinin without a quinine comparator (n=6), and (vi) severe malaria not defined as per standard criteria (n=2). Hand-searching of short-listed citations identified 7 additional trials; thus a total of 10 trials were included in this review.

Table I summarizes the trial characteristics. Two trials compared quinine with artesunate(8,9), six with artemether(10-15), and two with arteether(16,17). Four trials recruited only participants with cerebral malaria(10,11,13,14). The trials examined mortality, clinical outcomes (fever clearance time, coma recovery time, neurological sequelae), parasite clearance and some side effects.

Table I



Characteristics of Included Trials

Risk of bias (Table II) was low for three trials(11,12,14), moderate for another three(8,10,17) and high for four trials(9,13,15,16). Only one trial(11) provided a sample size calculation. None of the trials was blinded.

Table II



Risk of Bias and Other Design Characteristics of Included Trials (Cochrane Risk of Bias Tool)

All the ten trials demonstrated comparable mortality between artemisinin derivatives and quinine; irrespective of the type of derivative, route of administration, type of severe malaria (cerebral or otherwise), or methodological quality of trial. Meta-analysis(Figure I) confirmed this for artemisinin derivatives individually and collectively (both random effects and fixed effect model). The trials together included a sample size sufficient for demonstrating a statistically significant mortality reduction, suggesting that the result is robust.

Seven trials reported fever clearance time, though three(8,11,12) presented data in a format that precluded meta-analysis; the remainder(9,15-17) showed comparable results between all three artemisinin derivatives and quinine. All trials reported coma recovery time, though three(8,11,12) could not be included in meta-analysis. Only one trial(13) suggested a favourable effect with artemether; the remainder showed no difference between groups. Likewise parasite clearance time was comparable between groups in five trials(8,9,11,12,17). Six trials(10,12-14,16,17) examined neurological sequelae at follow-up, and all showed comparable effect between artemisinin and quinine.

This is the first systematic review examining the scope of artemisinin derivatives for severe malaria in children. Despite several methodological strengths (multiple database search, hand-searching, methodo-logical grading, standard reporting format, meta-analysis, etc), one of its limitations was the inability to obtain separate pediatric data from trials(18-20) combining adult and pediatric data.

On the face of it, this systematic review appears to corroborate the WHO position that there is inadequate evidence favouring artemisinin derivatives in severe childhood malaria, suggesting the need for more RCTs(1). However, this may be an over-simplification, because although the review does not demonstrate superior efficacy of artemisinin derivatives, comparable effect across all outcomes suggests that either therapy could be equally efficacious. Given that quinine administration requires controlled infusion in a hospital setting, artemisinin could have an edge in terms of simpler administration and potentially greater safety (lower risk of quinine adverse events). Since treatment of severe malaria in the real-world setting is often presumptive (before confirmation of diagnosis), and urgent (required before transferring patients to hospital), unlike in randomized trials, Artemisinin may result in greater effectiveness, despite equivalent efficacy. This is especially important because neither the absence of P.falciparum on peripheral smear nor the presence of P.vivax, rule out severe malaria(2).

However, potentially better ‘effectiveness’ has to be counterbalanced against the possible risk of encouraging Plasmodium resistance through relatively unrestricted use of artemisinin derivatives. Thus a dichotomy between the interests of the individual child and the community could emerge over time. This suggests that a formal Health Technology Assessment rather than the simplistic decision models described earlier(2-4) is needed to make an informed choice.

All the trials were conducted in developing countries, although mostly in Africa where the severity and outcome of malaria could be different from our country. However, the type of participants, clinical classification of severity, outcome parameters and overall results were similar between the Indian(9,15) and other trials. This suggests that the findings of this systematic review can be extended to our country in general.

1. Guidelines for the treatment of malaria. Second Edition. World Health Organization, 2010. Available at http://www.rollbackmalaria.org/docs/hbsm.pdf on 25 March, 2010.

2. Guidelines for diagnosis and treatment of malaria in India. Government of India, 2009. Available at http://www.mrcindia.org/Guidelines_for _Diagnosis_Treatment.pdf. Accessed on 25 March, 2010.

3. Kundu R, Ganguly N, Ghosh TK, Choudhury P, Shah RC. Diagnosis and management of malaria in children. Recommendations and IAP plan of action. Indian Pediatr 2005; 42: 1101-1114.

4. Infectious Diseases Chapter, Indian Academy of Pediatrics. Management of malaria in children: Update 2008. Indian Pediatr 2008; 45: 731-735.

5. Jones KL, Donegan S, Lalloo DG. Artesunate versus quinine for treating severe malaria. Cochrane Database Syst Rev 2007; 4: CD005967.

6. Afolabi BB, Okoromah CAN. Intramuscular arteether for treating severe malaria. Cochrane Database Syst Rev 2004; 4: CD004391.

7. McIntosh H, Olliaro P. Artemisinin derivatives for treating severe malaria. Cochrane Database Syst Rev 2000; 2: CD000527.

8. Phuong CXT, Bethell DB, Phuong PT, Mai TTT, Thuy TTN, Ha NTT, et al. Comparison of artemisinin suppositories, intramuscular artesunate and intravenous quinine for the treatment of severe childhood malaria. Trans R Soc Trop Med Hyg 1997; 91: 335-342.

9. Mohanty AK, Rath BK, Mohanty R, Samal AK, Mishra K. Randomized control trial of quinine and artesunate in complicated malaria. Indian J Pediatr 2004; 71: 291-295.

10. Murphy S, English M, Waruriu C, Mwangi I, Amoukoye E, Crawley J, et al. An open randomised trial of artemether versus quinine in the treatment of cerebral malaria in African children. Trans R Soc Trop Med Hyg 1996; 90: 298-301.

11. van Hensbroek MB, Onyiorah E, Jaffar S. A trial of artemether or quinine in children with cerebral malaria. N Engl JMed 1996; 335: 69-75.

12. Taylor TE, Wills BA, Courval JM, Molyneux ME. Intramuscular artemether vs intravenous quinine: An open, randomized trial in Malawian children with cerebral malaria. Trop Med Int Health 1998; 3: 3–8.

13. Ojuawo A, Adegboye AR, Oyewalw O. Clinical response and parasite clearance in childhood cerebral malaria: A comparison between intramuscular artemether and intravenous quinine. East Afr Med J 1998; 75: 450-452.

14. Olumese PE, Bjorkman A, Gbadegesin RA, Adeyemo AA, Walker O. Comparative efficacy of intramuscular artemether and intravenous quinine in Nigerian children with cerebral malaria. Acta Tropica 1999; 73: 231-236.

15. Huda SN, Shahab T, Ali SM, Afzal K, Khan HM. A comparative clinical trial of artemether and quinine in children with severe malaria. Indian Pediatr 2003; 40: 939-945.

16. Moyou-Somo R, Tietche F, Ondoa M, Kouemeni LE, Ekoe T, Mbonda E, et al. Clinical trial of beta-arteether versus quinine for the treatment of cerebral malaria in children in Yaounde, Cameroon. Am J Trop Med Hyg 2001; 64: 229-232.

17. Thuma PE, Bhat GJ, Mabeza GF, Osborne C, Biemba G, Shakankale GM, et al. A randomized controlled trial of artemotil (beta-arteether) in Zambian children with cerebral malaria. Am J Trop Med Hyg 2000; 62: 524-529.

18. Dondorp A, Nosten F, Stepniewska K, Day N, White N; South East Asian Quinine Artesunate Malaria Trial (SEAQUAMAT) group. Artesunate versus quinine for treatment of severe falciparum malaria: a randomised trial. Lancet 2005; 366: 717-725.

19. Esamai F, Ayuo P, Owino-Ongor W, Rotich J, Ngindu A, Obala A, et al. Rectal dihydroartemisinin versus intravenous quinine in the treatment of severe malaria: a randomised clinical trial. East Afr Med J 2000; 77: 273-278.