Executive summary: Canadian recommendations for the prevention and treatment of malaria

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

The Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers developed by the Committee to Advise on Tropical Medicine and Travel (CATMAT) on behalf of the Public Health Agency of Canada (PHAC), are designed for Canadian health practitioners who are preparing travellers to visit areas with malaria risk and for those who are dealing with ill returned travellers. These recommendations aim to ensure appropriate diagnosis and management of this potentially life threatening infectious disease. Many Canadian practitioners may have limited experience with this “exotic” tropical disease, it is hoped that these guidelines will be of valuable assistance.

PHAC is committed to provide evidenced-based guidelines and to make these accessible to practicing clinicians. The guidelines generally follow the same format as previous editions, addressing specifically the traveller risk assessment, drugs for prophylaxis and treatment, as well as instruction on management of malaria cases. With this edition there have been some important changes and additions.

In the risk assessment section (Chapter 2) we have introduced the use of length of stay threshold whereby optional use of chemoprophylaxis (with personal protective measures) is recommended for short stays (≤ 2 weeks) for certain countries. This same threshold has been applied to Appendix 1: Malaria Risk by Geographic Area. The consensus of the authors was that this will provide practitioners with increased flexibility to better tailor their individualized risk assessment for each traveller.

There has been the addition of a new insect repellent—20% icaridin (recently registered in Canada); this is recognized as an equivalent to DEET as first-line choice for mosquito repellent (Chapter 3).

The section on malaria chemoprophylaxis (Chapter 4) has been refined with an aim to help the practitioner assessing travellers to better navigate the drug choices available. These changes include a simplified step-wise approach to selecting malaria prophylaxis; comprehensive listings of Medications and malaria risk by country/area, presented in easy to understand tables; and expansion of the explanation about differences in approaches to malaria prophylaxis in other jurisdictions.

Chapter 5, Malaria Issues in Special Hosts has been expanded, recognizing the increasing numbers of travellers who may be at increased risk of acquiring malaria, having severe disease, or having more dire consequences. The special host section includes guidelines for diverse populations including children, migrants, travellers visiting friends and relatives (VFRs), management of women who are pregnant or breastfeeding, malaria prevention in expatriates and dealing with individuals with co-morbidities.

The section on treatment of malaria (Chapter 7) includes updated information on the management of severe malaria, including new information on the use of exchange transfusion.

There have been a number of changes to the section on Drugs for the Prevention and Treatment of Malaria (Chapter 8), which outlines the drugs used for malaria prevention and treatment. There is an update on primaquine use for malaria prophylaxis and prevention; additional up to date information on pediatric dosing of atovaquone/proguanil, as well as general updates to Table 8.11: Drugs (generic and trade name) for the treatment and prevention of malaria. Revisions have also been made to the following sub-sections: artemisinins, chloroquine, mefloquine (with increased Emphasis on selection or avoidance of this drug based on individual tolerability), quinine/quinidine.

There has been extensive updating and editing on the appendices, especially Appendix 1.

There has been an important addition to Appendix 1: Malaria Risk by Geographic Area, we now present the option of personal protection measures without anti-malarial medication in some circumstances. This applies to short stays in a small number of countries where malaria risk is low.

There is a new “Malaria Card” that can be given to travellers with information about their malaria chemoprophylaxis, and an important reminder to seek medical attention in the event of a fever illness after travel.

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