Parenteral Therapy for Severe Malaria - Form A

To be completed by the Attending Physician

1. Date of request (D/M/Y):
2. Drug requested: Artesunate   Quinine
3. Requesting/Attending physician:
4. Requesting site:
   Province of diagnosis:
5. Patient initials (first/middle/last):
   Date of birth:                              Sex:  Male   Female
6. Canadian born: 

   Yes  No

   If no, country of birth:
   
   

   Canadian resident: 

   Yes  No

   Visitor: 

   Yes  No
7. If <18 years of age, country of parental origin:
8. Presumed country(ies) of acquisition:
9. Reasons for travel (check all that apply):
   Business
   Immigration
   Vacation
   Education
   Other (specify):

   Medical tourism
   Visiting friends/relatives
   Volunteer/missionary
   Military
10. Travel dates (note for new immigrants and visitors, will only have date arrived in Canada)
    Date departed Canada (D/M/Y):         
    Date returned to or arrived in Canada (D/M/Y):
11. Date became ill (D/M/Y):
12. Date of 1^st physician visit (D/M/Y):
13. Was the patient admitted to hospital?:
    Yes

    No
14. Malaria prevention:
    1. Pre-travel advice sought:
       Yes

       No

       If yes, with whom?

       GP/family physician
       Other (specify):

       Travel medicine clinic
    2. Insect precautions?
       Yes

       No

       Inconsistent
    3. Chemoprophylaxis:
       Suggested?
       Yes

       No

       Unknown
       Prescribed?

       Yes

       No

       Unknown
       Used?

       Yes

       No

       Unknown
       Adherence: Did they take the drug as prescribed (before, during, after travel, missed ≤2 doses)?

       Yes

       No

       Unknown
       Chemoprophylaxis type:

       chloroquine

       doxycycline

       malarone

       mefloquine

       other (specify):
15. Diagnosis:
    Lab-confirmed:
    Yes

    No

    Date (D/M/Y):                                      Time:
    Test used (check all that apply):

    RDT

    Thick and thin smear

    Other (specify):

    
    Malaria species (check all that apply):

    P. falciparum
    P. malariae
    P. knowlesii
    

    P. vivax
    P. ovale
    Unknown
    Percent parasitemia (%):
    At initial diagnosis:          
    At time of starting IV therapy:
16. Has the patient had other medical treatment for this episode of malaria?
    Yes

    No

    Unknown

    If yes, specify what drug(s):
    Who prescribed the drug?
    Self prescribed
    MD in Canada
    MD in country of acquisition
    Other (specify):
17. Indication for use of IV antimalarial therapy (Check all that apply):
    Continued vomiting or unable to tolerate oral therapy (Note: if this is the only indication for IV therapy, then QUININE preferred)
    Impaired consciousness or coma
    Abnormal bleeding/DIC
    Severe anemia (Hb ≤50 g/L)
    Hemoglobinuria (macroscopic)
    Renal failure (Cr >265µmol/L or >upper limit for age for children
    Pulmonary edema/ARDS/respiratory failure
    Hypoglycemia (<2.2mmol/L)
    Parasitemia (≥2% in non-immune, ≥5% in semi-immune)
    Acidemia/acidosis (pH<7.25, HCO₃<15mmol/L or venous lacate>5mmol/L)
    Repeated generalized convulsions (≥3 in 24hrs)
    Circulatory collapse/shock (SBP<80mmHg + cold extremities
    Jaundice (Total bilirubin >45µmol/L)
    Other (specify):
    
    The following refer to time taken to begin IV therapy and is used to establish where/why delays occur.
18. Number of hours to contact individual responsible for dispensing IV malaria therapy through the Canadian Malaria Network
    (# hours):
19. Number of hours from request until drug received by pharmacy
    (# hours):
20. Number of hours from time received in pharmacy until drug administered
    (# hours):
21. Comments/perceived reasons for the delay(s):
    
    
    

Thank you very much for completing this form.

Please complete Form B (follow-up) at day 7 and send it in.
Your cooperation is greatly appreciated.

PLEASE COMPLETE AND RETURN TO THE CMN COORDINATING CENTRE
BY E-MAIL: jlevine@ohri.ca OR BY FAX: 613-737-8164 WITHIN 48 HOURS OF IV DRUG REQUEST.

Parenteral artesunate and quinine are provided by Health Canada’s Special Access Program through the Canada Malaria Network (CMN).