November 2004
For Immediate Release

Malaria in Canadian travellers

New prevention and treatment recommendations by Canada's leading tropical and travel medicine experts  by Dr. Anne McCarthy, Chair, Malaria Sub-Committee, Committee to Advise on Tropical Medicine and Travel (CATMAT)

Malaria continues to be a major cause of death worldwide and remains the principal life-threatening infection facing Canadian travellers in malaria-endemic areas. Severe P. falciparum malaria infections can have a mortality rate of 20% or higher. Patients require immediate hospitalization and urgent, intensive medical management, including parenteral malaria therapy. Research has shown that failure to take an appropriate travel history is the main reason for delays in the diagnosis of malaria. If malaria deaths are to be prevented, it is crucial that physicians and other health care providers have a high index of suspicion of the disease when seeing a febrile traveller returning from a malarious region. Moreover, they must be aware of all procedures and pertinent information on the correct use of antimalarial drugs and the role of other protective measures, including the use of insect repellents and bednets.

The Public Health Agency of Canada's Committee to Advise on Tropical Medicine and Travel (CATMAT) has just published new guidelines for 2004 on the prevention and treatment of malaria in Canadian travellers. [CATMAT, Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers 2004. Can Commun Dis Rep 2004;30(S1):1-62. These evidence-based recommendations serve as a thorough update of CATMAT's 2000 malaria guidelines.

CATMAT, formed in February 1990, provides the Public Health Agency of Canada with accurate and timely advice on matters related to tropical medicine and travel. Canadian experts in tropical medicine, travel medicine, infectious disease medicine and epidemiology form its membership, and it often works in collaboration with the National Advisory Committee on Immunization (NACI). Widely recognized by the international travel medicine community, CATMAT's recommendations and guidelines support sound travel medicine practices and help to secure the health of the travelling public.

The public health component of travel medicine is an important one. CATMAT encourages all private practitioners, public health clinicians and emergency care professionals involved with the travelling public, both pre- and post-travel, to access the 2004 guidelines. Significant changes have been incorporated to reflect the current global epidemiology of malaria, as well as the current scientific literature. These changes and enhancements include:

1) Antimalarial drug efficacy in chloroquine-resistant malaria

Based on current antimalarial drug efficacy, tolerance and safety studies, CATMAT recommends three first-line agents as equally efficacious in the prevention of chloroquine-resistant malaria: atovoquone/proguanil (Malarone ®), doxycycline and mefloquine (Larium®). CATMAT advises physicians that the decision to choose one drug over another should be based on drug efficacy, tolerance, safety and cost.

2) Special hosts

CATMAT expands its recommendations on the prevention of malaria in special hosts (e.g., infants, breast-feeding women, travellers with underlying medical conditions).

3) Self-treatment

A new table lists drugs that may be used for malaria self-treatment including drugs approved in Canada, as well as drugs not available in Canada but often readily available to Canadians residing in malaria-endemic areas. CATMAT no longer recommends Fansidar® for self-treatment due to the evidence of increased resistance to the drug.

4) Use of parenteral quinine

For the treatment of severe chloroquine-resistant falciparum malaria, CATMAT continues to state its preference for parenteral quinine over parenteral quinidine due to the lower risk of toxicity. The Committee recommends that health care providers access parenteral quinine through the Canadian Malaria Network (CMN) initiative. The CMN makes quinine easily accessible through 11 established medical centres across Canada and allows for the collection of surveillance information on those patients requiring parenteral quinine therapy.

5) Education tools developed for the prevention and management of malaria

• "Frequently Asked Questions About Malaria” assists health care providers when counselling travellers on malaria and the misconceptions that continue to circulate among the travelling public;
• User-friendly instruction tool about the insecticide treatment of clothes and bednets; and
• Algorithm developed as a visual aid for health care providers managing malaria cases.

6) Recommendations about the use of N,N-diethyl-meta-toluamide (DEET)

• CATMAT's recommendations on the use of the pesticide DEET are based on a risk/benefit assessment of its use in the context of malaria as a life-threatening illness. CATMAT recommends that concentrations of DEET up to 35% can be used by any age group.
• Children travelling to malaria-endemic areas are at special risk, and extra diligence is recommended. Alternative personal protective measures, such as insecticide-impregnated mosquito nets, should be the first line of defence, especially for infants younger than 6 months of age. Portable mosquito nets, including self-standing nets, placed over a car seat, crib, playpen, or stroller provide an insect-protected environment for infants. However, as a complement to the other methods of protection, the judicious use of DEET should be considered for children of any age.
• In Canada , 30% DEET is the maximum product concentration allowed for sale by the Pest Management Regulatory Agency (PMRA). Products containing more than 30% DEET are available in other countries, such as the United States . It should be noted, however, that products sold outside Canada have not been evaluated by the PMRA.

To obtain print copies of CATMAT's Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers 2004, contact the Member Service Centre, Canadian Medical Association, 1867 Alta Vista Drive, Ottawa, ON, Canada K1G 3Y6, Tel.: (613) 731-8610 Ext. 2307 or 888-855-2555 or by Fax: (613) 236-8864.