Cost-effectiveness of artesunate for the treatment of severe malaria

Economic evaluation of severe malaria in children under 14 years in Zambia

Introduction

Malaria exerts a significant economic burden on health care providers and households and our study attempts to make claims on the cost effectiveness of artesunate against quinine in patients under 14 years of age in Zambia. Also, to find the average total costs involved in the treatment of severe malaria in children and their impact on household expenditure.

Methods

Cost-effectiveness analysis of severe malaria treatment was conducted from a healthcare provider perspective using a Markov model. Standard costing was performed for the identification, measurement and assessment phases with data from quantification reports for anti-malaria commodities as these documents provides drug procurement costs from suppliers and freight costs. Average and incremental cost-effectiveness ratio were estimated and uncertainties were assessed through probabilistic sensitivity analysis.

Results

In Zambia severe malaria in children has been shown to account for over 45% of the total monthly curative healthcare costs incurred by households compared to the mean per capita monthly income. The cost of treating severe malaria depleted 7.67% of the monthly average household income. According, to the cost effectiveness analysis the of artesunate with quinine the ICER was $105 per death averted.

Conclusion

The use of artesunate over quinine in the treatment of severe malaria in children under 14 years is a highly cost-effective strategy for the healthcare provider in Zambia.

Propensity Score Analysis of Artesunate Versus Quinine for Severe Imported Plasmodium falciparum Malaria in France

BACKGROUND

Little is known on the use of artesunate compared with quinine for the treatment of imported malaria cases in nonendemic countries with a high level of care. Therefore, we compared the 2 treatments in terms of mortality and hospital and intensive care unit (ICU) discharge rates.

METHODS

We analyzed the cohort of all severe imported malaria patients reported to the French National Reference Center from 2011 to 2017. After controlling for differences between quinine- and artesunate-treated individuals using the inverse probability of treatment weighting method, 28-day mortality rate was compared between the groups as well as hospital and ICU discharge rates using Kaplan-Meier estimation and weighted Cox proportional hazard models.

RESULTS

Overall, 1544 patients were enrolled. Fifty patients died, 18 in the quinine group (n = 460) and 32 in the artesunate group (n = 1084), corresponding to death rates of 3.9% and 2.9%, respectively. No difference was evident between quinine and artesunate either in mortality or in hospital discharge rate, with hazard ratios (HRs) of 1.03 (95% confidence interval [CI], 0.47-2.25) and 1.12 (95% CI, 0.94-1.34), respectively. Artesunate was associated with a faster ICU discharge rate (HR, 1.18. 95% CI, 1.02-1.36).

CONCLUSIONS

In a country with a high level of care, artesunate was associated with a shorter length of stay in the ICU, which supports the actual therapeutic transition; however, no difference was found in terms of mortality or in hospital discharge rates between artesunate- and quinine-treated patients.

Cost-effectiveness of seasonal malaria chemoprevention in upper west region of Ghana

Background

In Ghana, malaria is endemic and perennial (with significant seasonal variations in the three Northern Regions), accounting for 33 % of all deaths among children under 5 years old, with prevalence rates in children under-five ranging from 11 % in Greater Accra to 40 % in Northern Region. Ghana adopted the WHO-recommended Seasonal Malaria Chemoprevention (SMC) strategy with a trial in the Upper West Region in 2015. The objective of this study was to estimate the cost-effectiveness of seasonal malaria chemoprevention.

Methods

Costs were analysed from provider and societal perspectives and are reported in 2015 US$. Data on resource use (direct and indirect costs) of the SMC intervention were collected from intervention records and a survey in all districts and at regional level. Additional numbers of malaria cases and deaths averted by the intervention were estimated based on prevalence data obtained from an SMC effectiveness study in the region. Incremental cost-effectiveness ratios (ICERs) were estimated for the districts and region. Sensitivity analyses were conducted to test the robustness of the ICERs.

Results

The total financial cost of the intervention was US$1,142,040.80. The total economic cost was estimated to be US$7.96 million and US$2.66 million from the societal and provider perspectives, respectively. The additional numbers of cases estimated to be averted by the intervention were 24,881 and 808, respectively. The economic cost per child dosed was US$67.35 from societal perspective and US$22.53 from the provider perspective. The economic cost per additional case averted was US$107.06 from the provider perspective and US$319.96 from the societal perspective. The economic cost per additional child death averted by the intervention was US$3298.36 from the provider perspective and US$9858.02 from the societal perspective. The financial cost per the SMC intervention delivered to a child under-five was US$9.66. The ICERs were sensitive to mortality rate used.

Conclusions

The SMC intervention is economically beneficial in reducing morbidity in children under-5 years and presents a viable approach to improving under-five health in Ghana.

A Systematic Review of the State of Economic Evaluation for Health Care in India

BACKGROUND AND OBJECTIVE

Economic evaluations are one of the important tools in policy making for rational allocation of resources. Given the very low public investment in the health sector in India, it is critical that resources are used wisely on interventions proven to yield best results. Hence, we undertook this study to assess the extent and quality of evidence for economic evaluation of health-care interventions and programmes in India.

METHODS

A comprehensive search was conducted to search for published full economic evaluations pertaining to India and addressing a health-related intervention or programme. PubMed, Scopus, Embase, ScienceDirect, and York CRD database and websites of important research agencies were identified to search for economic evaluations published from January 1980 to the middle of November 2014. Two researchers independently assessed the quality of the studies based on Drummond and modelling checklist.

RESULTS

Out of a total of 5013 articles enlisted after literature search, a total of 104 met the inclusion criteria for this systematic review. The majority of these papers were cost-effectiveness studies (64%), led by a clinician or public-health professional (77%), using decision analysis-based methods (59%), published in an international journal (80%) and addressing communicable diseases (58%). In addition, 42% were funded by an international funding agency or UN/bilateral aid agency, and 30% focussed on pharmaceuticals. The average quality score of these full economic evaluations was 65.1%. The major limitation was the inability to address uncertainties involved in modelling as only about one-third of the studies assessed modelling structural uncertainties (33%), or ran sub-group analyses to account for heterogeneity (36.5%) or analysed methodological uncertainty (32%).

CONCLUSION

The existing literature on economic evaluations in India is inadequate to feed into sound policy making. There is an urgent need to generate awareness within the government of how economic evaluation can inform and benefit policy making, and at the same time build capacity of health-care professionals in understanding the economic principles of health-care delivery system.

Treating severe malaria in pregnancy: a review of the evidence

Severe malaria in pregnancy is a large contributor to maternal morbidity and mortality. Intravenous quinine has traditionally been the treatment drug of choice for severe malaria in pregnancy. However, recent randomized clinical trials (RCTs) indicate that intravenous artesunate is more efficacious for treating severe malaria, resulting in changes to the World Health Organization (WHO) treatment guidelines. Artemisinins, including artesunate, are embryo-lethal in animal studies and there is limited experience with their use in the first trimester. This review summarizes the current literature supporting 2010 WHO treatment guidelines for severe malaria in pregnancy and the efficacy, pharmacokinetics, and adverse event data for currently used antimalarials available for severe malaria in pregnancy. We identified ten studies on the treatment of severe malaria in pregnancy that reported clinical outcomes. In two studies comparing intravenous quinine with intravenous artesunate, intravenous artesunate was more efficacious and safe for use in pregnant women. No studies detected an increased risk of miscarriage, stillbirth, or congenital anomalies associated with first trimester exposure to artesunate. Although the WHO recommends using either quinine or artesunate for the treatment of severe malaria in first trimester pregnancies, our findings suggest that artesunate should be the preferred treatment option for severe malaria in all trimesters.

Economic Evaluation alongside Multinational Studies: A Systematic Review of Empirical Studies

Purpose of the study

This study seeks to explore methods for conducting economic evaluations alongside multinational trials by conducting a systematic review of the methods used in practice and the challenges that are typically faced by the researchers who conducted the economic evaluations.

Methods

A review was conducted for the period 2002 to 2012, with potentially relevant articles identified by searching the Medline, Embase and NHS EED databases. Studies were included if they were full economic evaluations conducted alongside a multinational trial.

Results

A total of 44 studies out of a possible 2667 met the inclusion criteria. Methods used for the analyses varied between studies, indicating a lack of consensus on how economic evaluation alongside multinational studies should be carried out. The most common challenge appeared to be related to addressing differences between countries, which potentially hinders the generalisability and transferability of results. Other challenges reported included inadequate sample sizes and choosing cost-effectiveness thresholds.

Conclusions

It is recommended that additional guidelines be developed to aid researchers in this area and that these be based on an understanding of the challenges associated with multinational trials and the strengths and limitations of alternative approaches. Guidelines should focus on ensuring that results will aid decision makers in their individual countries.

An operational comparative study of quinine and artesunate for the treatment of severe malaria in hospitals and health centres in the Democratic Republic of Congo: the MATIAS study

Background

The Democratic Republic of the Congo (DRC) has the highest number of severe malaria cases in the world. In early 2012, the National Malaria Control Programme (NMCP) changed the policy for treating severe malaria in children and adults from injectable quinine to injectable artesunate. To inform the scaling up of injectable artesunate nationwide, operational research is needed to identify constraints and challenges in the DRC’s specific setting.

Methods

The implementation of injectable quinine treatment in 350 patients aged 2 months or older in eight health facilities from October 2012 to January 2013 and injectable artesunate in 399 patients in the same facilities from April to June 2013 was compared. Since this was an implementation study, concurrent randomized controls were not possible. Four key components were evaluated during each phase: 1) clinical assessment, 2) time and motion, 3) feasibility and acceptability, and 4) financial cost.

Results

The time to discharge was lower in the artesunate (median = 2, 90 % central range 1–9) compared to the quinine group (3 (1–9) days; p <0.001). Similarly, the interval between admission and the start of intravenous (IV) treatment (2 (0–15) compared to 3 (0–20) hours; p <0.001) and parasite clearance time (23 (11–49) compared to 24 (10–82) hours; p <0.001) were lower in the artesunate group. The overall staff pre-administration time (13 (6–38) compared to 20 (7–50) minutes; p <0.001) and the personnel time spent on patient management (9 (1–24) compared to 12 (3–52) minutes; p <0.001) were lower in the artesunate group. In hospitals and health centres, the mean (standard deviation, SD) total cost per patient treated for severe malaria with injectable artesunate was USD 51.94 (16.20) and 19.51 (9.58); and USD 60.35 (17.73) and 20.36 (6.80) with injectable quinine.

Conclusions

This study demonstrates that injectable artesunate in the DRC is easier to use and it costs less than injectable quinine. These findings provide the basis for practical recommendations for rapid national deployment of injectable artesunate in the DRC.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-015-0732-1) contains supplementary material, which is available to authorized users.

Cost of treating inpatient falciparum malaria on the Thai-Myanmar border

BACKGROUND

Despite demonstrated benefits and World Health Organization (WHO) endorsement, parenteral artesunate is the recommended treatment for patients with severe Plasmodium falciparum malaria in only one fifth of endemic countries. One possible reason for this slow uptake is that a treatment course of parenteral artesunate is costlier than quinine and might, therefore, pose a substantial economic burden to health care systems. This analysis presents a detailed account of the resources used in treating falciparum malaria by either parenteral artesunate or quinine in a hospital on the Thai-Myanmar border.

METHODS

The analysis used data from four studies, with random allocation of inpatients with falciparum malaria to treatment with parenteral artesunate or quinine, conducted in Mae Sot Hospital, Thailand from 1995 to 2001. Detailed resource use data were collected during admission and unit costs from the 2008 hospital price list were applied to these. Total admission costs were broken down into five categories: 1) medication; 2) intravenous fluids; 3) disposables; 4) laboratory tests; and 5) services.

RESULTS

While the medication costs were higher for patients treated with artesunate, total admission costs were similar in those treated with quinine, US$ 243 (95% CI: 167.5-349.7) and in those treated with artesunate US$ 190 (95% CI: 131.0-263.2) (P=0.375). For cases classified as severe malaria (59%), the total cost of admission was US$ 298 (95% CI: 203.6-438.7) in the quinine group as compared with US$ 284 (95% CI: 181.3-407) in the artesunate group (P=0.869).

CONCLUSION

This analysis finds no evidence for a difference in total admission costs for malaria inpatients treated with artesunate as compared with quinine. Assuming this is generalizable to other settings, the higher cost of a course of artesunate should not be considered a barrier for its implementation in the treatment of malaria.

Intravenous artesunate versus intravenous quinine in the treatment of severe falciparum malaria: a retrospective evaluation from a UK centre

INTRODUCTION

Despite evidence from developing world trials that intravenous (IV) artesunate (AS) is superior to IV quinine (Q) in severe falciparum malaria (FM), IV AS remains unlicensed in the UK with national guidelines listing it as an acceptable alternative to IV Q as the drug of choice. We retrospectively evaluate the safety and effectiveness of IV AS in returning travellers with severe FM.

METHODS

We identified adults admitted to the Infectious Diseases unit with severe FM and treated with IV Q (1991-2009) or IV AS (2009-2011). Outcomes included adverse events, mortality, length of stay, admission to intensive care and, where data were available, parasite/fever clearance time and hypoglycaemic events.

RESULTS

Of 167 patients, 24 received IV AS and 143 IV Q. There was one potential AS-associated adverse event, a case of late onset haemolysis. Median length of stay (LOS) was significantly shorter for AS (3·5 versus 5 days, P = 0·017), even after adjusting for African ethnicity (for LOS ≥3 days, mhor = 0·33, P = 0·027; crude OR = 0·29, P = 0·013). In the AS group, there were no fatalities (versus five in Q group, NS) and fewer intensive care unit (ICU) admissions (NS). Median parasite clearance was significantly faster in AS (65 versus 85 hours in Q, P = 0·0045) with no hypoglycaemic episodes (versus five in Q).

DISCUSSION

We found IV AS to be safe and effective, with shorter LOS, faster parasite and fever clearance, no fatalities or hypoglycaemic events, and fewer ICU admissions versus IV Q. This corroborates both developing world trials and smaller European case series (although these lacked comparison groups). As well as obvious benefits for patients, there are potential resource savings. A case of late-onset haemolysis may represent an adverse event, particularly as it has been documented elsewhere, warranting further investigation. Nonetheless, our experience suggests IV AS should be first-line for treating severe FM in the UK.

Integrating global and national knowledge to select medicines for children: the Ghana National Drugs Programme

David Sinclair and colleagues discuss their experience at the Ghana National Drugs Programme reviewing the international evidence base for five priority pediatric medicines and report that applying the global recommendations to Ghana was not straightforward for any of the five medicines. Please see later in the article for the Editors' Summary

The global pipeline of new medicines for the control and elimination of malaria

Over the past decade, there has been a transformation in the portfolio of medicines to combat malaria. New fixed-dose artemisinin combination therapy is available, with four different types having received approval from Stringent Regulatory Authorities or the World Health Organization (WHO). However, there is still scope for improvement. The Malaria Eradication Research agenda identified several gaps in the current portfolio. Simpler regimens, such as a single-dose cure are needed, compared with the current three-day treatment. In addition, new medicines that prevent transmission and also relapse are needed, but with better safety profiles than current medicines. There is also a big opportunity for new medicines to prevent reinfection and to provide chemoprotection. This study reviews the global portfolio of new medicines in development against malaria, as of the summer of 2012. Cell-based phenotypic screening, and 'fast followers' of clinically validated classes, mean that there are now many new classes of molecules starting in clinical development, especially for the blood stages of malaria. There remain significant gaps for medicines blocking transmission, preventing relapse, and long-duration molecules for chemoprotection. The nascent pipeline of new medicines is significantly stronger than five years ago. However, there are still risks ahead in clinical development and sustainable funding of clinical studies is vital if this early promise is going to be delivered.

Artesunate versus quinine for treating severe malaria

BACKGROUND

Severe malaria results in over a million deaths every year, most of them in children aged under five years and living in sub-Saharan Africa. This review examines whether treatment with artesunate, instead of the standard treatment quinine, would result in fewer deaths and better treatment outcomes.

OBJECTIVES

To compare artesunate with quinine for treating severe malaria.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, LILACS, ISI Web of Science, the metaRegister of Controlled trials (mRCT), conference proceedings, and reference lists of articles to November 2010.

SELECTION CRITERIA

Randomized controlled trials comparing intravenous, intramuscular, or rectal artesunate with intravenous or intramuscular quinine for treating adults and children with severe malaria who are unable to take medication by mouth.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the eligibility and risk of bias of trials, and extracted and analysed data. The primary outcome was all-cause death. Dichotomous outcomes were summarized using risk ratios (RR) and continuous outcomes by mean differences (MD). Where appropriate, we combined data in meta-analyses.

MAIN RESULTS

Eight trials enrolling 1664 adults and 5765 children are included in this review.Treatment with artesunate significantly reduced the risk of death both in adults (RR 0.61, 95% Confidence Interval (CI) 0.50 to 0.75; 1664 participants, five trials) and children (RR 0.76, 95% CI 0.65 to 0.90; 5765 participants, four trials)In children, treatment with artesunate increased the incidence of neurological sequelae at the time of hospital discharge. The majority of these sequelae were transient and no significant difference between treatments was seen at later follow up.

AUTHORS' CONCLUSIONS

The evidence clearly supports the superiority of parenteral artesunate over quinine for the treatment of severe malaria in both adults and children and in different regions of the world.

Malaria treatment and prophylaxis in endemic and nonendemic countries: evidence on strategies and their cost–effectiveness

Artemisinin combination treatment is currently the preferred treatment strategy to combat malaria. However, the drug costs are considerably higher than for previously used therapies. This review discusses the cost–effectiveness of current malaria treatment and prophylaxis in endemic and nonendemic countries. For endemic countries, a systematic search for economic evaluations (i.e., cost–effectiveness, cost–utility and cost–benefit analyses) was conducted, looking at the use of Artemisinin combination treatments in children, pregnant women and other adults. In total, 24 studies were identified investigating the cost–effectiveness of malaria treatments with the focus on uncomplicated malaria, severe or prereferral treatment, all in combination with adequate diagnosis, and malaria prevention by intermittent preventive treatment, respectively. In areas with both Plasmodium falciparum and Plasmodium vivax transmission, artemether–lumefantrine and dihydroartemisinin–piperaquine, respectively, are currently the most cost-effective treatment options. Treatment of severe malaria with artesunate is more cost effective compared with treatment with quinine. For patients that live more than 6 h away from an appropriate healthcare facility, prereferral treatment proved to be more cost-effective compared with no prereferral intervention. Cost–effectiveness of intermittent preventive treatment in pregnant women (IPTp) was dependent an clinical attendance. IPT in infants with sulphadoxine–pyrimethamine (SP) is cost effective in sites with high malaria transmission. IPT in children with artesunate (AS + SP), amodiaquine (AQ) + SPQ or SP alone is a cost effective and safe intervention for reducing the burden of malaria in children in areas with markedly seasonal malaria transmission. Although there is a need for it, little is known about the cost–effectiveness of current approaches to malaria therapy in nonendemic countries and the cost–effectiveness of antimalarial chemoprophylaxis.

Cost-effectiveness of parenteral artesunate for treating children with severe malaria in sub-Saharan Africa

OBJECTIVE

To explore the cost-effectiveness of parenteral artesunate for the treatment of severe malaria in children and its potential impact on hospital budgets.

METHODS

The costs of inpatient care of children with severe malaria were assessed in four of the 11 sites included in the African Quinine Artesunate Malaria Treatment trial, conducted with over 5400 children. The drugs, laboratory tests and intravenous fluids provided to 2300 patients from admission to discharge were recorded, as was the length of inpatient stay, to calculate the cost of inpatient care. The data were matched with pooled clinical outcomes and entered into a decision model to calculate the cost per disability-adjusted life year (DALY) averted and the cost per death averted.

FINDINGS

The mean cost of treating severe malaria patients was similar in the two study groups: 63.5 United States dollars (US$) (95% confidence interval, CI: 61.7-65.2) in the quinine arm and US$ 66.5 (95% CI: 63.7-69.2) in the artesunate arm. Children treated with artesunate had 22.5% lower mortality than those treated with quinine and the same rate of neurological sequelae: (artesunate arm: 2.3 DALYs per patient; quinine arm: 3.0 DALYs per patient). Compared with quinine as a baseline, artesunate showed an incremental cost per DALY averted and an incremental cost per death averted of US$ 3.8 and US$ 123, respectively.

CONCLUSION

Artesunate is a highly cost-effective and affordable alternative to quinine for treating children with severe malaria. The budgetary implications of adopting artesunate for routine use in hospital-based care are negligible.

Cost-effectiveness of artemisinin combination therapy for uncomplicated malaria in children: data from Papua New Guinea

OBJECTIVE

To compare the cost-effectiveness of conventional antimalarial therapy with that of three artemisinin combination treatment regimens in children from Papua New Guinea aged 6 to 60 months.

METHODS

An incremental cost-effectiveness analysis was performed using data from 656 children with Plasmodium falciparum and/or P. vivax malaria who participated in a large intervention trial in two clinics in northern Papua New Guinea. The children were randomized to one of the following groups: (i) conventional treatment with chloroquine plus sulfadoxine plus pyrimethamine (CQ+S+P); (ii) artesunate plus S plus P; (iii) dihydroartemisinin plus piperaquine (DHA+PQ); and (iv) artemether plus lumefantrine (A+L). For treatment outcomes, World Health Organization definitions were used. The cost of transport between home and the clinic plus direct health-care costs served as a basis for determining each regimen's incremental cost per incremental treatment success relative to CQ+S+P by day 42 and its cost per life year saved.

FINDINGS

A+L proved to be the most effective regimen against P. falciparum malaria and was highly cost-effective at 6.97 United States dollars (US$) per treatment success (about US$ 58 per life year saved). DHA+PQ was the most effective regimen against P. vivax malaria and was more cost-effective than CQ+S+P.

CONCLUSION

A+L and DHA+PQ are highly cost-effective regimens for the treatment of paediatric P. falciparum and P. vivax malaria, respectively, in parts of Papua New Guinea. Future research will be required to determine if these findings hold true for other territories in Asia and Oceania with similar malaria epidemiology.

Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomised trial

BACKGROUND

Severe malaria is a major cause of childhood death and often the main reason for paediatric hospital admission in sub-Saharan Africa. Quinine is still the established treatment of choice, although evidence from Asia suggests that artesunate is associated with a lower mortality. We compared parenteral treatment with either artesunate or quinine in African children with severe malaria.

METHODS

This open-label, randomised trial was undertaken in 11 centres in nine African countries. Children (<15 years) with severe falciparum malaria were randomly assigned to parenteral artesunate or parenteral quinine. Randomisation was in blocks of 20, with study numbers corresponding to treatment allocations kept inside opaque sealed paper envelopes. The trial was open label at each site, and none of the investigators or trialists, apart from for the trial statistician, had access to the summaries of treatment allocations. The primary outcome measure was in-hospital mortality, analysed by intention to treat. This trial is registered, number ISRCTN50258054.

FINDINGS

5425 children were enrolled; 2712 were assigned to artesunate and 2713 to quinine. All patients were analysed for the primary outcome. 230 (8·5%) patients assigned to artesunate treatment died compared with 297 (10·9%) assigned to quinine treatment (odds ratio [OR] stratified for study site 0·75, 95% CI 0·63-0·90; relative reduction 22·5%, 95% CI 8·1-36·9; p=0·0022). Incidence of neurological sequelae did not differ significantly between groups, but the development of coma (65/1832 [3·5%] with artesunate vs 91/1768 [5·1%] with quinine; OR 0·69 95% CI 0·49-0·95; p=0·0231), convulsions (224/2712 [8·3%] vs 273/2713 [10·1%]; OR 0·80, 0·66-0·97; p=0·0199), and deterioration of the coma score (166/2712 [6·1%] vs 208/2713 [7·7%]; OR 0·78, 0·64-0·97; p=0·0245) were all significantly less frequent in artesunate recipients than in quinine recipients. Post-treatment hypoglycaemia was also less frequent in patients assigned to artesunate than in those assigned to quinine (48/2712 [1·8%] vs 75/2713 [2·8%]; OR 0·63, 0·43-0·91; p=0·0134). Artesunate was well tolerated, with no serious drug-related adverse effects.

INTERPRETATION

Artesunate substantially reduces mortality in African children with severe malaria. These data, together with a meta-analysis of all trials comparing artesunate and quinine, strongly suggest that parenteral artesunate should replace quinine as the treatment of choice for severe falciparum malaria worldwide.

FUNDING

The Wellcome Trust.

Malaria in children

The past decade has seen an unprecedented surge in political commitment and international funding for malaria control. Coverage with existing control methods (ie, vector control and artemisinin-based combination therapy) is increasing, and, in some Asian and African countries, childhood morbidity and mortality from malaria caused by Plasmodium falciparum are starting to decline. Consequently, there is now renewed interest in the possibility of malaria elimination. But the ability of the parasite to develop resistance to antimalarial drugs and increasing insecticide resistance of the vector threaten to reduce and even reverse current gains. Plasmodium vivax, with its dormant liver stage, will be particularly difficult to eliminate, and access to effective and affordable treatment at community level is a key challenge. New drugs and insecticides are needed urgently, while use of an effective vaccine as part of national malaria control programmes remains an elusive goal. This Seminar, which is aimed at clinicians who manage children with malaria, especially in resource-poor settings, discusses present knowledge and controversies in relation to the epidemiology, pathophysiology, diagnosis, treatment, and prevention of malaria in children.