Malaria in Canadian travellers

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

Malaria continues to be a major cause of death worldwide and remains the principal life-threatening infection facing Canadian travellers in malaria-endemic areas. The majority of malaria deaths in travellers are due to the species Plasmodium Falciparum. The overall case-fatality rate of imported P. Falciparum malaria varies from approximately 1% to 5% and increases to 20% for those with severe malaria, even when the disease is managed in intensive care units.  Progression from asymptomatic infection to severe and complicated malaria can be extremely rapid, with death occurring within 36 to 48 hours. The most important factors that determine patient survival are early diagnosis and appropriate therapy. The majority of infections and deaths due to malaria are preventable.

Research has shown that failure to take an appropriate travel history is the main reason for delays in the diagnosis of malaria. If malaria complications and 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 2009 on the prevention and treatment of malaria in Canadian travellers. [CATMAT, Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers 2009. Can Commun Dis Rep 2009;35(S1):1-82]. These evidence-based recommendations serve as a thorough update of CATMAT's 2004 malaria guidelines.

The Committee to Advise on Tropical Medicine and Travel (CATMAT) provides the Public Health Agency of Canada with ongoing and timely medical, scientific, and public health advice relating to tropical infectious disease and health risks associated with international travel.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 2009 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. Use of parenteral artesunate
   For the treatment of severe or complicated malaria, CATMAT has made new recommendations for the use of parenteral artesunate as treatment of choice over parenteral quinine and parenteral quinidine due to its documented superior efficacy and its lower risk of toxicity. The Committee recommends that health care providers access parenteral artesunate through the Canadian Malaria Network (CMN) initiative. The CMN makes artesunate, as well as quinine easily accessible through 11 established medical centres across Canada and allows for the collection of surveillance information on those patients requiring parenteral therapy for severe falciparum malaria.
2. Antimalarial drug efficacy in mefloquine-resistant malaria
   Based on current antimalarial drug efficacy, tolerance and safety studies, CATMAT recommends two first-line agents as equally efficacious in the prevention of mefloquine-resistant malaria: atovoquone/proguanil (Malarone ®), and doxycycline. CATMAT advises physicians that the decision to choose one drug over another should be based on drug efficacy, tolerance, safety and cost.
3. Prevention - Malaria Education for Travellers
   CATMAT expands its recommendations on prevention and Malaria Education for Travellers.  Particular attention is given to enhancing adherence to antimalarial chemoprophylaxis and personal protective measures.
4. Malaria Diagnosis
   CATMAT expands its recommendations for the diagnosis of Malaria with the inclusion of RDT (Rapid Diagnostic Tests) and PCR (Polymerase Chain Reaction) and their role in the early diagnosis of falciparum malaria.
5. Malaria Risk by Geographic Area in Countries with Endemic Malaria
   This section has been updated to reflect new areas of mefloquine-resistant Plasmodium falciparum.  In addition, information on seasonality as well as percentage of P. falciparum present in the region, have been added to the table.