Medical Access to Artesunate or Quinine for Malaria Treatment Streamlined in Canada through the Canadian Malaria Network (CMN)

Malaria continues to be a major cause of death worldwide and is the principal life-threatening infection facing Canadian travellers in malaria-endemic areas. Severe P. falciparum malaria infections may have a mortality rate of 20% or higher. Patients require immediate hospitalization and urgent, intensive medical management, including parenteral malaria therapy. Severe malaria is not a common disease in Canada, with an average of 14 cases per year (range 8-20 cases annually from 2001-2008). However, these cases are dispersed across the country, and attest to the need for distribution of these scarce antimalarial drugs for treatment of severe malaria across the country.

Artesunate,the preferred medication for the treatment of severe and cerebral malaria due to P. falciparum, and quinine, a possible alternative when artesunate is contraindicated, are only available in Canada through Health Canada's Special Access Program, a program that allows practitioners to request access to drugs that are unavailable for sale in Canada. Although quinidine is available and is equally efficacious in treating malaria, it has a risk of life-threatening cardiotoxicity and an associated requirement for cardiac monitoring.

The Canadian Malaria Network was created in collaboration with Health Canada's Special Access Program and the Public Health Agency of Canada due to the potential for adverse outcomes associated with delays in acquiring parenteral malaria therapy. The Canadian Malaria Network (CMN) is established in 13 medical centres across Canada and maintains and facilitates rapid access to strategically-located supplies of intravenous artesunate and quinine for the treatment of severe P. falciparum. In addition, each of the participating centers has a designated physician with experience in treating malaria who is willing to assist and provide guidance in the management of malaria infections. These life-saving drugs are available 24 hours per day by contacting the pharmacies listed below. After-hours assistance can be obtained by contacting the infectious disease consultant on call at the respective center. Each Centre provides surveillance data to Health Canada on all malaria cases treated with these drugs.

Once a request is made to any of the designated CMN centres for either parenteral artesunate or quinine, the attending physician will receive the following via courier delivery:

• treatment dose
• information on treatment and chemotherapy for severe falciparum malaria
• forms to be completed for the collection of surveillance data (Forms A & B).

The attending physician will be asked to complete Form A on day 1 at the time of access / request of intravenous artesuate or quinine and Form B on day 7 at discharge/end of malaria therapy. The forms should be sent to the CMN National Coordinating Office by email (CanadianMalariaNetwork@toh.ca) or by fax (613-737-8164). The information collected on these forms is vital to inform policy for distribution of these drugs, and required by the organizations supplying these drugs for notification of any drug related adverse event.

Note: Fever occurring in a traveller within three months of returning from a malaria-endemic area is a medical emergency and should be investigated urgently with thick and thin blood films for malaria.

Table 1: Criteria for Severe Falciparum Malaria