Last week, at our UBC Tropical Medicine Rounds, we discussed the management of severe malaria.
Every year, there are approximately 400 cases of malaria reported in Canada. Over 5% of these cases are critically ill (severe malaria) requiring immediate IV therapy, and the incidence of severe malaria in Canada seems to be increasing.*
The safest and most effective drug for the treatment of severe malaria is artsenuate. Unfortunately, due to the way our pharmaceutical system is structured in Canada, hospitals cannot purchase a supply of artesunate to have on hand in case a person arrives in their emergency department critically ill with malaria.*
The barriers in access to artesunate has nothing to do with its cost, or concerns about its safety and efficacy. It all seems due to administrative or bureaucratic barriers in the way we license drugs for distribution in Canada.
Now, I am not a drug licensing or pharmaceutical expert, so please write in a comment and correct me if I am wrong, but the following is my understanding of the limitations:
For a drug to be licensed in Canada it must be profitable for the manufacturer. Pharmaceutical companies have to pay licensing and distributive costs for their product to be sold in Canada. To meet these costs, they first want to be sure they can make a profit. For life-saving medications that may be a problem on several levels. For life-saving, inexpensive drugs for less common infections like malaria, it presents a tremendous problem – and has resulted in a failure of open access to artesunate.
Ways around this could be for the pharmaceutical company to charge extremely high prices for artesunate in order to make a profit. This may to some extent explain why one tablet of albendazole can cost almost 200 dollars in the US but only 2 cents in Africa.
Other ways would be for Canada to change its drug licensing and distribution policies to ensure that patient needs are at the core and never risk being secondary to pharmaceutical profits.
As an interim measure, the Health Canada Special Access Program (SAP) provides a means to access artesunate. There is a nice article describing this in JAMMI. Through the SAP program, the Canadian Malaria Network has arranged to have a supply on hand in 1 or 2 large hospitals in most provinces.*
However, if tomorrow a patient with critical malaria arrives to an emergency department far away from a designated hospital (for example Whitehorse General Hospital which is over 1,000 km flight away from the nearest artesunate depot in Vancouver), although a rare event, the delays in accessing artesunate could be fatal.
To help support these hospitals, especially those that are far from the current designated artesunate depots, and still operate with the confines of the current legislative barriers to access to artesunate, the Canadian Malaria Network (CMN) could be expanded. The SAP program has a “form B”, which offers a way to access emergency medications for future use. Artesunate is not very expensive and has a shelf life of 3 years. Coordinating this through the Canadian Malaria network would provide a way for every hospital that wishes to purchase a supply of artesunate to have on hand in case of emergency can do so. But this has not been done – yet…
What do you think, should every hospital in Canada have an emergency supply of artesunate available?
Ron Mundy MD said:
As an anaesthetist in a small community, it is essential for me to have, prior to allowing anesthetic to be provided, a source of dantrolene immediately available to treat this very uncommon anaesthetic reaction, becoming less common as we change to medications which do not trigger this rare event. ( I have not seen this locally during my 28 years here). I have seen malaria here, and in Whitehorse, as well as my time in Guyana, of course.
We have a network in BC to rotate dantrolene to smaller hospitals, and out then to larger facilities to be used in a timely fashion, where this can be utilized. Would not the answer be to obtain through special legislation, the much needed medication to rotate through other centres, such as Victoria, Prince George, Whitehorse, Kelowna.
The incidence of malaria in Whitehorse surprised me, and was linked to mining/geologists who work winters in malarial zones, summers in the north, as you will know.
Hi Ron, thank you for the comment. Important points about incidence of malaria in Whitehorse – and interesting comparison of artesunate with dantrolene.
There are other depots for artesunate in BC besides Vancouver – e.g., Victoria, Kelowna, and even Surrey – allowing a similar model of hubs allowing the delivery of the medication in emergencies. This was made possible through the Canadian Medical Network – https://www.canada.ca/en/public-health/services/travel-health/medical-access-artesunate-quinine-malaria-treatment.html
But, it is an added burden and sometimes the patient ends up getting transferred to the centre that has the medication rather than the medication. The burden of delivery and delays are especially felt during inclement weather in the interior.
Whitehorse and Prince George should also be provided with a supply of artesunate – we will follow-up on that…
But, if artesunate is inexpensive, has a 3-year shelf life, is recommended as first line for severe malaria, and if delays of several hours can make a difference, shouldn’t we also let smaller hospitals stock 5 vials for an emergency treatment course? The hospital could still be supported by Infectious Diseases specialists through phone consultation, and the patient could still be transferred out to a higher level of care if need, but it would minimize delays in receiving the first dose.