Appendix 2 – Pre-travel check list: Canadian recommendations for the prevention and treatment of malaria

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An Advisory Committee Statement (ACS) from the
Committee to Advise on Tropical Medicine and Travel (CATMAT)

Preamble

The Committee to Advise on Tropical Medicine and Travel (CATMAT) provides the Public Health Agency of Canada (PHAC) with ongoing and timely medical, scientific, and public health advice relating to tropical infectious disease and health risks associated with international travel. PHAC acknowledges that the advice and recommendations set out in this statement are based upon the best current available scientific knowledge and medical practices, and is disseminating this document for information purposes to both travellers and the medical community caring for travellers.

Persons administering or using drugs, vaccines, or other products should also be aware of the contents of the product monograph(s) or other similarly approved standards or instructions for use. Recommendations for use and other information set out herein may differ from that set out in the product monograph(s) or other similarly approved standards or instructions for use by the licensed manufacturer(s). Manufacturers have sought approval and provided evidence as to the safety and efficacy of their products only when used in accordance with the product monographs or other similarly approved standards or instructions for use.

Appendix II: Pre-travel checklist for advising travellers to malarial areas

The following checklist highlights points to consider when advising travellers who are planning to travel to regions with a risk of malaria transmission.

Assess the risk of malarial (See Chapter 2 and Appendix I)

Distribution and transmission intensity of malaria in destination country(ies).

1. Seasonal variation in malaria transmission?
2. Species of malaria present/predominant in destination country(ies)?
3. Drug resistance documented/prevalent?

Select appropriate chemoprophylaxis recommendations (Chapter 4)

1. Does the traveller have any drug allergies?
2. Does the traveller have any contraindications to the recommended (first-line) antimalarial agents?
3. If yes, select an alternative.
   1. Does the traveller have any medical conditions that would influence the choice of antimalarial agents?
   2. Does the traveller have any prior experience with antimalarial agents?
   3. Does the traveller have any strong opinions for, or against, a particular agent?
   4. Are there drug/drug interactions to consider?

Education about malaria chemoprophylaxis (Chapter 3)

• Start chemoprophylaxis before travel, as directed.
• Use chemoprophylaxis continuously while in malaria-endemic areas and for four weeks after leaving such areas (except for atovaquone-proguanil and primaquine, which are taken for one week after leaving such areas).
• All antimalarial drugs can cause adverse effects; most minor side effects abate even with continued use of a drug. Seek medical advice if adverse effects persist but continue with the chemoprophylaxis.
• If serious adverse effects occur, seek medical advice promptly and discontinue using the drug. Switch to another effective drug immediately.
• You can still get malaria despite using chemoprophylaxis.
• Colleagues, websites and even health care providers in destination countries may offer conflicting opinions about antimalarial drugs. These sources are often inaccurate and/or based on approaches elaborated for other populations, e.g. residents of malaria-endemic areas. Continue using the chemoprophylactic medications that were prescribed.
• Some popular antimalarial measures (e.g. papaya tea) promoted in endemic areas have not been proven effective and should not be substituted for chemoprophylactic agents with documented efficacy.

Educate about personal protective (Anti-mosquito) measures (Chapter 3)

• Use insecticide-impregnated bed nets, especially if mosquitoes cannot be otherwise excluded, (e.g. by screening on windows).
• 20%–30% DEET or 20% icaridin (a repellent recently registered in Canada) are recommended to protect adults against mosquito bites.
• Icaridin at a concentration of 20% is recommended to protect children (aged 6 months–12 years) against mosquito bites.
• For infants aged less than 6 months, there are no repellents approved for use in Canada. However, if mosquito bites cannot be otherwise prevented, for example by using netting over cribs, strollers, etc., use up to 10% DEET or 20% icaridin.
• Follow label instructions on how and where to apply insect repellent. Reapply insect repellent if you see mosquitoes biting before the recommended reapplication interval noted on the product label.
• P-menthane-3,8-diol is recommended as a second choice after DEET or icaridin.
• Other repellents are not recommended (e.g. citronella, soybean oil) for protection against the bites of malaria vectors.
• Other interventions such as insecticide vaporizers, mosquito coils, electronic devices, etc., are not recommended for protection against the bites of malaria vectors.
• Refer to CATMAT Statement on Personal Protective Measures to Prevent Arthropod Bites for more detailed information.

Educate about malaria illness (See Chapter 3)

• Malaria may become severe and/or lead to death if treatment is delayed. Progression from mild to life-threatening disease can occur at any point in the illness and within hours.
• Symptoms of malaria may be mild and nonspecific and malaria should be considered in any unexplained fever or “flu-like” illness during or after travel to endemic areas. Any such illness during or after travel should prompt the traveller to seek medical help as soon as possible.
• Advise health care providers of travel to malaria-endemic areas.
• Accurate diagnosis of malaria requires laboratory testing (Chapter 6: microscopic examination of blood smears, polymerase chain reaction or rapid diagnostic tests). Diagnosis based on symptoms alone is relatively inaccurate. Nevertheless, if a malaria diagnosis has been made in an endemic area—even if reliable testing has not been done—it is prudent to treat for malaria. This is because malaria can rapidly progress to life-threatening disease if treatment is delayed.
• If malaria is suspected, laboratory testing (microscopic examination of blood smears, polymerase chain reaction or rapid diagnostic tests) should be done on one or more occasions to verify the diagnosis. Self-treatment (if prescribed) should only be taken if medical care is not readily available. Medical advice should still be sought as soon as is possible after self-treatment.
• Chemoprophylaxis should be continued even if malaria has been diagnosed.

Special travellers (See Chapter 5)

• Certain populations are at increased risk of malaria.
• Pregnant women (or women who may become pregnant while travelling or living in endemic areas) should be advised that pregnancy is a time of heightened risk of severe malaria and adverse consequences to both mother and fetus. In addition, certain drugs are contraindicated during pregnancy, (e.g. doxycycline).
• Young children can be at increased risk of malaria and also require special consideration with respect to appropriate chemoprophylactic and personal protection options.
• People with comorbidities can be at increased risk of malaria, and also might require special attention because of drug contraindications and/or interactions.
• People who originate from malaria-endemic areas are often are at higher risk of malaria, for example because they (and their families) visit areas where transmission is intense and/or do not take all appropriate precautions. These travellers should receive specific counselling to address misperceptions about malaria immunity (i.e. they do not have it) and the need for personal protective measures (i.e. they should use them).
• Long-term travellers may choose to discontinue malaria chemoprophylaxis because of concerns about long-term drug use and/or a misguided attempt to build up immunity. Advise these travellers that they remain at risk of malaria (including severe malaria) and that there is no limit on the duration of antimalarial chemoprophylaxis for individuals who tolerate the medication.

(Adapted from International Travel and Health, World Health Organization, Geneva, 2011).

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