PT  - JOURNAL ARTICLE
AU  - Brunner, Nina C
AU  - Omoluabi, Elizabeth
AU  - Awor, Phyllis
AU  - Okitawutshu, Jean
AU  - Tshefu Kitoto, Antoinette
AU  - Signorell, Aita
AU  - Akano, Babatunde
AU  - Ayodeji, Kazeem
AU  - Okon, Charles
AU  - Yusuf, Ocheche
AU  - Athieno, Proscovia
AU  - Kimera, Joseph
AU  - Tumukunde, Gloria
AU  - Angiro, Irene
AU  - Kalenga, Jean-Claude
AU  - Delvento, Giulia
AU  - Lee, Tristan T
AU  - Lambiris, Mark J
AU  - Ross, Amanda
AU  - Cereghetti, Nadja
AU  - Visser, Theodoor
AU  - Napier, Harriet G
AU  - Buj, Valentina
AU  - Burri, Christian
AU  - Lengeler, Christian
AU  - Hetzel, Manuel W
TI  - Prereferral rectal artesunate and referral completion among children with suspected severe malaria in the Democratic Republic of the Congo, Nigeria and Uganda
AID  - 10.1136/bmjgh-2021-008346
DP  - 2022 May 01
TA  - BMJ Global Health
PG  - e008346
VI  - 7
IP  - 5
4099  - http://gh.bmj.com/content/7/5/e008346.short
4100  - http://gh.bmj.com/content/7/5/e008346.full
SO  - BMJ Global Health2022 May 01; 7
AB  - Introduction Children who receive prereferral rectal artesunate (RAS) require urgent referral to a health facility where appropriate treatment for severe malaria can be provided. However, the rapid improvement of a child’s condition after RAS administration may influence a caregiver’s decision to follow this recommendation. Currently, the evidence on the effect of RAS on referral completion is limited.Methods An observational study accompanied the roll-out of RAS in three malaria endemic settings in the Democratic Republic of the Congo (DRC), Nigeria and Uganda. Community health workers and primary health centres enrolled children under 5 years with suspected severe malaria before and after the roll-out of RAS. All children were followed up 28 days after enrolment to assess their treatment-seeking pathways.Results Referral completion was 67% (1408/2104) in DRC, 48% (287/600) in Nigeria and 58% (2170/3745) in Uganda. In DRC and Uganda, RAS users were less likely to complete referral than RAS non-users in the pre-roll-out phase (adjusted OR (aOR)=0.48, 95% CI 0.30 to 0.77 and aOR=0.72, 95% CI 0.58 to 0.88, respectively). Among children seeking care from a primary health centre in Nigeria, RAS users were less likely to complete referral compared with RAS non-users in the post-roll-out phase (aOR=0.18, 95% CI 0.05 to 0.71). In Uganda, among children who completed referral, RAS users were significantly more likely to complete referral on time than RAS non-users enrolled in the pre-roll-out phase (aOR=1.81, 95% CI 1.17 to 2.79).Conclusions The findings of this study raise legitimate concerns that the roll-out of RAS may lead to lower referral completion in children who were administered prereferral RAS. To ensure that community-based programmes are effectively implemented, barriers to referral completion need to be addressed at all levels. Alternative effective treatment options should be provided to children unable to complete referral.Trial registrstion number NCT03568344; ClinicalTrials.gov.Data are available upon reasonable request. Individual de-identified participant data that underlie the results reported in this article are available at zenodo.org upon reasonable request (DOI: 10.5281/zenodo.5570278).