In the Journals

Treatment options for severe malaria ‘grim’ in US, clinicians urged to act

In a recent opinion piece published in Annals of Internal Medicine, two experts urged clinicians, hospitals, federal agencies and professional societies to work together to prevent “a catastrophe” related to severe malaria in the United States.

Rebecca A. Krey, MD, of Boston Children's Hospital, and Mark A. Travassos, MD, MSc of the University of Maryland School of Medicine, traced the problem to a lack of quinidine — the only FDA-approved treatment for the disease. Eli Lilly, which is quinidine’s only manufacturer, discontinued the drug in November 2017.

Upon request by a physician, the CDC will provide IV artesunate, which is used in endemic countries but is not approved for use in the U.S., Krey and Travassos said. Although IV artesunate is preferable to oral antimalarials, it must be flown to the nearest airport, where hospital personnel have to transport it to the patient. It could take as long as 24 hours for a patient with severe malaria to receive IV treatment under these conditions. Given these circumstances, they suggested that hospitals should have a preparedness plan in place to more effectively manage patients with severe malaria.

“At triage, patients should be questioned about recent travel outside the country. Those who are febrile and have recently traveled to malaria-endemic regions should immediately have a rapid diagnostic test for malaria. ... If the rapid diagnostic test result is positive and a red flag for severe malaria is present, the CDC Malaria Hotline should be contacted immediately,” Krey and Travassos wrote.

“Hospitals should maintain supplies of oral antimalarial medications, including atovaquone–proguanil, artemether–lumefantrine, and mefloquine. They should have transportation arrangements in place to pick up intravenous artesunate from the airport. ... Nearby hospitals with these capabilities should be identified beforehand,” they added.

Image of Anopheles gambiae mosquito.  
In a recent opinion piece published in Annals of Internal Medicine, two experts urged clinicians, hospitals, federal agencies and professional societies to work together to prevent “a catastrophe” related to severe malaria in the United States.

Source:James Gathany/CDC

To spur drug development, Krey and Travassos said the CDC should identify potential pharmaceutical companies for the manufacture of IV artesunate and evaluate the need for incentives.

In addition, “the CDC should consider forming a panel to periodically evaluate the plan for distribution of IV artesunate and should include representation for clinicians and patient advocates,” they wrote.

The authors also urged professional societies like the Infectious Diseases Society of America and the American Society of Tropical Medicine & Hygiene to advocate on the federal level for patients with severe malaria and to petition Eli Lilly to resume its production of the quinidine until IV artesunate is available.

Krey and Travassos acknowledged that although the prevalence of severe malaria is rare in the U.S., the mortality rate can reach more than 50%.

“At present, the prospects for timely, effective treatment of severe malaria in the United States are grim. Careful preparation and action on the part of clinicians, hospitals, federal agencies, and professional societies are needed to prevent a catastrophe,” they concluded. – by Janel Miller

Disclosures: Krey and Travassos report no relevant financial disclosures.

 

In a recent opinion piece published in Annals of Internal Medicine, two experts urged clinicians, hospitals, federal agencies and professional societies to work together to prevent “a catastrophe” related to severe malaria in the United States.

Rebecca A. Krey, MD, of Boston Children's Hospital, and Mark A. Travassos, MD, MSc of the University of Maryland School of Medicine, traced the problem to a lack of quinidine — the only FDA-approved treatment for the disease. Eli Lilly, which is quinidine’s only manufacturer, discontinued the drug in November 2017.

Upon request by a physician, the CDC will provide IV artesunate, which is used in endemic countries but is not approved for use in the U.S., Krey and Travassos said. Although IV artesunate is preferable to oral antimalarials, it must be flown to the nearest airport, where hospital personnel have to transport it to the patient. It could take as long as 24 hours for a patient with severe malaria to receive IV treatment under these conditions. Given these circumstances, they suggested that hospitals should have a preparedness plan in place to more effectively manage patients with severe malaria.

“At triage, patients should be questioned about recent travel outside the country. Those who are febrile and have recently traveled to malaria-endemic regions should immediately have a rapid diagnostic test for malaria. ... If the rapid diagnostic test result is positive and a red flag for severe malaria is present, the CDC Malaria Hotline should be contacted immediately,” Krey and Travassos wrote.

“Hospitals should maintain supplies of oral antimalarial medications, including atovaquone–proguanil, artemether–lumefantrine, and mefloquine. They should have transportation arrangements in place to pick up intravenous artesunate from the airport. ... Nearby hospitals with these capabilities should be identified beforehand,” they added.

Image of Anopheles gambiae mosquito.  
In a recent opinion piece published in Annals of Internal Medicine, two experts urged clinicians, hospitals, federal agencies and professional societies to work together to prevent “a catastrophe” related to severe malaria in the United States.

Source:James Gathany/CDC

To spur drug development, Krey and Travassos said the CDC should identify potential pharmaceutical companies for the manufacture of IV artesunate and evaluate the need for incentives.

In addition, “the CDC should consider forming a panel to periodically evaluate the plan for distribution of IV artesunate and should include representation for clinicians and patient advocates,” they wrote.

The authors also urged professional societies like the Infectious Diseases Society of America and the American Society of Tropical Medicine & Hygiene to advocate on the federal level for patients with severe malaria and to petition Eli Lilly to resume its production of the quinidine until IV artesunate is available.

Krey and Travassos acknowledged that although the prevalence of severe malaria is rare in the U.S., the mortality rate can reach more than 50%.

“At present, the prospects for timely, effective treatment of severe malaria in the United States are grim. Careful preparation and action on the part of clinicians, hospitals, federal agencies, and professional societies are needed to prevent a catastrophe,” they concluded. – by Janel Miller

Disclosures: Krey and Travassos report no relevant financial disclosures.