African Journal of Traditional, Complementary and Alternative Medicines
African Ethnomedicines Network
Vol. 4, Num. 1, 2007, pp. 121-123
African Journal of Traditional, Complimentary and Alternative Medicines,,
Vol.4, No. 1, 2007,
LETTER TO THE EDITOR
ARTEMISIA ANNUA AS A HERBAL TEA FOR MALARIA
1Dr Merlin Willcox
(Secretary), Dr. Jacques Falquet2,Dr.
Jorge F.S. Ferreira 3, 4 Dr
Ben Gilbert,5 Dr.
Elisabeth Hsu,6 Dr
Pedro Melillo de Magalhães,7 Prof.
J. Plaizier-Vercammen, 8Prof
V.P. Sharma,9 Dr
Colin W. Wright, 10 Prof
136 Hare Close, Buckingham
MK18 7EW, UK. email@example.com ,
2Scientific Coordinator, Antenna Technologies,
Geneva, Switzerland. firstname.lastname@example.org
Department of Agriculture -Agricultural Research
Service, 1224 Airport Road, Beaver, West Virginia 25813, USA email@example.com
4Instituto de Technologia em Fármacos, Far-Manguinhos,
Oswaldo Cruz, Rua Sizenando Nabuco 100, Manguinhos, 21041-250, Rio de Janeiro,
RJ, Brazil. firstname.lastname@example.org
5Institute of Social and Cultural Anthropology, University
of Oxford, Oxford, UK. email@example.com
6Coordinator, Divisão de Agrotecnologia,
CPQBA-UNICAMP, Campinas, Brazil. firstname.lastname@example.org
7Vrije Universiteit Brussel,
Farmaceutische Technologie & Fysische Farmacie, Laarbeeklaan 103, B-1090
Brussel, Belgium. e-mail: email@example.com
8 Meghnad Saha Distinguished Fellow, Centre for Rural Development
and Technology, Indian Institute of Technology, Hauz Khas, New Delhi-110016,
9Reader in Pharmacognosy, The School of Pharmacy, University
of Bradford, West Yorks BD7 1DP, U.K. C.W.Wright@Bradford.ac.uk
10Sichuan Institute of Chinese Materia Medica, Chengdu Sichuan,
Code Number: tc07001
Jansen (2006) writes that "the herbal tea approach to artemisinin as a therapy
for malaria is totally misleading and should be forgotten as soon as possible."
We believe that this statement is totally misleading and should be forgotten as soon as possible, for the following reasons.
- The extraction method used was flawed. Boiling water will destroy
most of the artemisinin, instead of extracting it, but artemisinin is better
extracted in hot water (85-90° C)
or milk (because of the fat content). Traditional Chinese texts suggest
that the fresh juice of the plant was used (obtained by maceration and squeezing
in cool water), and at much greater concentrations (Hsu, 2006). Artemisinin
is stable in acid, so will survive passage through the stomach. More
is needed, using a variety of different preparations of Artemisia annua.
- Dry Artemisia annua leaves do not lose their artemisinin
fast. In proper storage conditions, the artemisinin is present in almost
amounts even after one year of storage. Where is Dr Jansen's scientific
evidence that artemisia is susceptible to mould? Artemisinin is stored
in glandular trichomes of leaves and flowers of A. annua. The
essential oils are also stored there. Thus, fungi do not have a pleasant
to grow in. If the plant is stored dry, the artemisinin should be there
from one season to the next.
- No one is suggesting that artemisinin is the only active ingredient
in Artemisia annua. Jansen acknowledges that the effectiveness of
the tea is partly due to other ingredients, as the dose of artemisinin is
too low to account for the observed effect. This is confirmed by in vivo experiments
in mice which showed that A. annua infusion reduces parasitaemia by
50% at day 4, compared to the equivalent dose of pure artemisinin, which
was not significantly more effective than placebo (Plaizier-Vercammen, unpublished).
The presence of other active ingredients suggests that A. annua is
a natural artemisinin combination therapy (Willcox et al, 2004). These other
ingredients also merit further research, to see whether their presence hinders
the development of parasite resistance compared to pure artemisinin.
- In the same experiments, A. annua infusion was less effective
than the full dose of artemisinin (which was tenfold higher), suggesting
that the infusion was not strong enough. The doses used by Jansen (2006),
Mueller et al (2004) and Räth et al (2004) are purely arbitrary, and
lower than those used in traditional chinese medicine (Hsu, 2006). Nine grams
per litre is a very weak infusion: most medicinal infusions are made at the
much higher strength of 50g of dried herb (or 100g of fresh herb) per litre
of water (Green, 2000). If the preparations tested are insufficiently effective,
the dose needs to be increased. Clinical studies in China have shown that
a dose of 72-125g of Artemisia annua per day for three days was highly
effective (Yao-de, unpublished). Experience to date and the literature suggest
that A. annua is safe and non-toxic, though safety in pregnancy has
not been established. Its LD50 is 162.5 g/kg (Chang & But, 1986). Research
is needed on tenfold stronger infusions (to reach 50g of herb per litre of
water) to compare their efficacy and safety with pure artemisinin at the
- As the above statements make clear, further research is needed
annua teas, to try to improve on the results obtained thus
far. Important questions to address include: can the efficacy of A. annua tea
be increased so that it becomes an acceptable complement to ACTs?
How can we ensure that patients receive an adequate dose? Can A. annua tea
be safely used without accelerating the appearance of resistant strains
of Plasmodium? It is not possible to answer these questions with
a single experiment on a single preparation of A. annua tea.
- While "ACTs for all"would be the ideal strategy,
it is most impractical for poor and remote communities, politically
unstable areas, and people who dislike the use of modern medicine.
There are almost five billion febrile episodes resembling malaria
every year (Breman et al, 2004), most of which need to be treated as malaria,
since most areas do not have adequate diagnostic facilities. Even
the cost of $1 per course of treatment (which is half the current
price of ACTs) this would cost almost $5 billion per year, which is ten times
the currently available budget for malaria. Even if this money miraculously
appeared, the health infrastructure is lacking in most of the areas
worst affected by malaria, making it impossible to distribute the
to those who most need them. For example, in the Brazilian Amazon,
patients commonly have to travel for two days before reaching a modern
health facility. Although recrudescence can occur after treatment
with Artemisia annua tea,
is this not preferable to patients dying before they reach the health
facility? Why not recommend the tea as a "first aid"measure
to keep the patient alive while they travel to the health centre?
It is clear that further concerted research is needed to optimise the dose
and preparation of A. annua (including
combinations with other antimalarial plants), to tackle the problem of recrudescence,
and to conduct trials in non-immune populations. If these show sufficient effectiveness,
a sustainable treatment for malaria could be made available to those in remote
areas who cannot rapidly access modern health care. If the herbal approach
is "forgotten", those remote populations will also remain forgotten.
In any case, they cannot access the products of the pharmaceutical industry,
so it need not feel threatened by this approach. There is one point where A.
preparations will never reach the efficiency of pure artemisinin: …business,
RITAM Artemisia annua Task Force (
© Copyright 2007 -African Journal of Traditional, Complementary
and Alternative Medicines
- Breman, J. G., Alilio, M. S. and Mills, A. (2004). Conquering the intolerable
burden of malaria: what's new, what's needed: a summary. Am J Trop Med
Hyg 71 (suppl 2): 1-15.
- Chang, H. M., But PPH (1986). Pharmacology and applications
of Chinese Materia Medica; Vol 1. Singapore: World Scientific Publishing.
- Green J (2000).
Herbal Medicine-Maker's Handbook. Berkeley, California: The Crossing Press.
- Hsu E (2006). The history of qing hao in the Chinese materia medica.
Trans Roy Soc Trop Med Hyg 100: 505-508.
- Jansen, F. H. (2006). The herbal tea approach for artemisinin as
a therapy for malaria? Trans. R. Soc. Med. Hyg. 100: 285-286.
- Mueller, M.S., Runyambo, N.,Wagner, I., Borrmann, S., Dietz, K. and
Heide, L. (2004. Randomized controlled trial of a traditional
preparation of Artemisia annua L. (Annual Wormwood) in the treatment of malaria.
Trans. R. Soc. Trop. Med. Hyg. 98:318,321.
- Räth, K., Taxis, K., Walz, G., Gleiter, C.H., Li, S.-M. and
Heide, L. (2004). Pharmacokinetic study of artemisinin after oral
intake of a traditional preparation of Artemisia annua L. (annual wormwood).
Am. J. Trop. Med. Hyg. 70: 128-132.
- Willcox ML, Bodeker G, Bourdy G et. al. (2004). Artemisia annua as
a traditional herbal antimalarial. In: Willcox ML, Bodeker G.
and Rasoanaivo P (2004). Traditional Medicinal Plants and Malaria. Boca Raton: