ARCHIVED - Supplement: Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers

Appendix II Checklist for Advising Travellers to Malarial Areas

The following is a checklist of key issues to be considered in advising travellers.

Assess the Risk of Malaria (see Chapter 2 and Appendix I)

• Destination and distribution of malaria within destination country
• Is the malaria in the destination country seasonal?
• What species of malaria is/are present at the destination?
• Is drug resistance documented?

Travellers should be informed about their individual risk of malaria infection and the presence of drug-resistant P. Falciparum malaria in their travel destinations.

Those who are pregnant, travelling with young children or who have medical conditions that put them at increased risk (see Chapter 5) should carefully evaluate the risks/benefits of choosing a malaria-endemic destination.

Chemoprophylaxis Recommendations

• Does the traveller have any drug allergies?
• Does the traveller have any contraindications to antimalarial agents?
• Does the traveller have any medical conditions that would influence the choice of antimalarial agents?
• Does the traveller have any prior experience with antimalarial agents?
• Does the traveller have any strong opinions for, or against, a particular agent?

Provide Education Regarding Malaria Chemoprophylaxis

• Start chemoprophylaxis before travel as directed.
• Use chemoprophylaxis continuously while in malaria-endemic areas and for 4 weeks after leaving such areas (except for atovaquone/ proguanil and primaquine, which are taken for 1 week after leaving such areas).
• Be aware that all antimalarial drugs can cause side effects; most minor side effects abate even with continued use of the drugs and should not prompt discontinuation of chemoprophylaxis. If side effects persist, medical advice should be sought.
• If serious side effects occur, medical advice should be sought promptly and use of the drug discontinued.
• Travellers who discontinue antimalarial medications because of side effects should take an effective alternative drug.
• Travellers should be aware that they may acquire malaria even if chemoprophylaxis is used.
• Travellers should be advised that they may receive conflicting information regarding antimalarial drugs from almost any source, including other travellers, websites and health providers in endemic countries. Such advice is often inaccurate or based on an understanding of malaria in semiimmune populations. Travellers should continue their prescribed medication unless they are experiencing at least moderate to severe adverse effects.
• Travellers should be advised that some popular antimalarial measures (e.g., papaya tea and others) promoted in endemic areas have not been proven effective and should not be used as a substitute for chemoprophylactic agents with documented efficacy.

Provide Education Regarding Personal Protective (Anti-mosquito) Measures

Travellers should be instructed on how to protect themselves against mosquito bites.

• All travellers to endemic areas should be encouraged to use insecticide-impregnated bednets if not in air-conditioned sleeping accommodation.
• DEET is the most effective available mosquito repellent. Extended-duration DEET preparations are recommended for malaria-endemic areas. If extended-duration formulations are not available, products containing 30%-35% DEET should be used.
• DEET should be evenly applied to all exposed skin and should be reapplied if biting activity is observed prior to the recommended reapplication interval noted on the product label.
• Alternatives when DEET cannot be used include Picaridin (Bayrepel™), lemon eucalyptus oil and soybean oil 2%. Since the duration of action of these products varies, product use instructions should be consulted and followed carefully.
• Many other non-DEET repellents are of limited efficacy and usually provide only transient protection. Avoid using citronella oil-based repellents because of very short durations of action.

Refer to CATMAT Statement on Personal Protective Measures to Prevent Arthropod Bites for more detailed information: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/05vol31asc-dcc-13/index-eng.php

Provide Education About Malaria Illness (see Chapter 6)

• 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.
• Travellers should advise health care providers of their travel to malaria-endemic areas.
• Diagnosis of malaria requires laboratory testing (blood smears, PCR or rapid diagnostic tests). Diagnosis based on symptoms alone is highly inaccurate.
• Medical help should be sought promptly if malaria is suspected, and diagnostic testing should be done on one or more occasions. If the patient is travelling when symptoms develop, they should request blood smears that can be brought home for review.
• 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.
• Self-treatment (if prescribed) should be taken only if prompt medical care is not available. Medical advice should still be sought as soon as possible after self-treatment.
• Chemoprophylaxis should be continued even if malaria occurs (proven or suspect case).

Special Travellers (see Chapters 4 and 5)

• Pregnant women, young children and those with underlying medical conditions require special attention because of the potential effects of malaria illness and the contraindication of certain drugs (e.g., doxycycline in pregnant women and young children).
• Pregnant women (or women who may become pregnant while travelling or residing in endemic areas) should be advised that pregnancy is a time of heightened risk for malaria infection and adverse consequences to both mother and fetus.
• Individuals who have spent many years in malaria-endemic areas often consider themselves immune to malaria. Such individuals who return to endemic areas often choose not to take malaria precautions and are at risk of infection and severe disease. Immunity to malaria is strain specific, short-lived and always incomplete. Even those with extensive past exposure to malaria should use effective malaria prevention, including chemoprophylaxis
• Long-term travellers may choose to discontinue malaria chemoprophylaxis because of concerns about long-term drug use or a misguided attempt to “build up immunity to malaria”. Such travellers should be advised 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 are tolerating the medication without significant side effects.

(Adapted from International Travel and Health, World Health Organization, Geneva, 2006).