Supplement

Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers

Appendix V

Frequently Asked Questions About Malaria From the Committee to Advise on Tropical Medicine and Travel, 2003

1. Is malaria a serious infection for healthy people?
   Malaria is a major killer worldwide and is the principal life-threatening infectious disease that Canadian travellers face when travelling to high-risk areas of the world. In recent years, there has been a dramatic increase in malaria cases among Canadian travellers, including several deaths.
2. Do all travellers to the developing world need malaria prophylaxis?
   Many destinations in the developing world are either free of malaria or the risk is so low that malaria prophylaxis is not needed. Furthermore, some travellers to countries with known malaria risk may not need to take malaria prophylaxis because malaria transmission is often confined to particular areas of a country (usually rural) and may be seasonal. For example, most individuals travelling only to urban centres or resort areas in Central and South America or Southeast Asia do not require malaria prophylaxis. However, ALL travellers (adults and children) to any area with any risk of malaria should use personal protective measures, such as treated mosquito nets and insect repellents, to avoid mosquito bites.
3. Should pregnant women, babies and children receive malaria prophylaxis?
   Pregnant women, babies and small children are at particular risk of serious malaria; if they must go to high-risk areas they should take malaria prophylaxis. Several effective prophylaxis regimens are known to be safe in these groups. It is important to remember that drugs taken by nursing mothers will not provide protection for the nursing child.
4. Do most people who take malaria prophylaxis have serious side effects?
   For travellers to high-risk areas, the risk of acquiring malaria and dying is significantly greater than the risk of experiencing a serious side effect from malaria prophylaxis. The great majority of people taking malaria prophylaxis (95% to 99%) have either no side effects or only mild and temporary ones, and in most studies only 1% to 4% of people have to change to an alternative drug because of side effects. These reactions are almost always reversible. Death from malaria, however, is not. The final choice of which antimalarial drug to use should be based on an individual risk assessment from a knowledgeable travel medicine provider, which should include issues such as the drug's effectiveness, the traveller's willingness to accept potential side effects, the convenience of dosing (weekly versus daily), the cost, and whether or not the traveller has any contraindications to the drug.
5. Are there safer and/or more effective antimalarial drugs available?
   For high-risk regions of the world with chloroquine-resistant malaria there are three drugs that are equally effective and currently licensed in Canada - atovaquone/proguanil (Malarone®), doxycycline (Vibra-tab®), and mefloquine (Lariam®). Each has advantages and disadvantages. Travellers should be cautious about drugs that are available and offered in other countries, since these drugs may be ineffective or more toxic, such as chloroquine, proguanil (Paludrine®), amodiaquine, pyrimethamine (Daraprim®), pyrimethamine plus sulfadoxine (Fansidar®), pyrimethamine plus dapsone (Maloprim®). Before departure, travellers should consult a health care provider with knowledge of travel medicine for an informed recommendation regarding malaria prophylaxis for their planned itinerary.
6. If I take prophylaxis, will the malaria I get be more resistant to treatment?
   The prevention of malaria in travellers using prophylactic drugs does not promote the development of resistant malaria parasites. Appropriately used prophylaxis can actually reduce resistance by lowering the burden of malaria disease.
7. Is there a limited period in which one can take prophylaxis safely?
   There is no absolute time limit on how long one can take any antimalarial prophylactic drug. The small number of individuals who will experience significant side effects from antimalarial drugs usually do so within the first few weeks of use. If side effects are significant, then an alternative drug for malaria prevention should be used. Many mild side effects decrease with continued use of prophylaxis. If travellers consult a health care provider with knowledge of travel medicine early, then there may be time for a trial of the malaria prophylaxis before departure, to ensure tolerance.
8. Is it true that some malaria cannot be treated?
   If identified early and treated appropriately, almost all malaria can be completely cured. However, even short delays in the diagnosis of malaria can make treatment more difficult and less successful.
9. Once you are infected with malaria, are you are infected for life?
   Appropriate treatment and follow-up can ensure complete cure of malaria.
10. Is it true that individuals born and raised in a malaria country are immune for life?
    Over time, individuals raised in areas where malaria is common either die from the disease or become partially immune to its most serious manifestations. However, this immunity is short lived once an individual leaves a malarial area. Although avoidance of mosquito bites is important for protection (e.g., appropriate clothing, screens and mosquito nets, repellents), antimalarial prophylactic drugs are essential for optimal protection in most settings. Any individual who has travelled to malarial areas and subsequently develops fever should urgently seek medical advice (even if the fever appears many months after returning to Canada) and request blood films to rule out malaria.

Further information on issues related to travel medicine and contact information for travel medicine providers in your area is available through Health Canada's Travel Medicine Program at <www.travelhealth.gc.ca>.

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