Abstract
Background
On behalf of the Public Health Agency of Canada, the Committee to Advise on Tropical Medicine and Travel (CATMAT) developed the Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers for Canadian health care providers who are preparing patients for travel to malaria-endemic areas and treating travellers who have returned ill.
Objective
To provide guidelines on risk assessment and prevention of malaria
Methods
CATMAT reviewed all major sources of information on malaria prevention, as well as recent research and national and international epidemiological data, to tailor guidelines to the Canadian context. The evidence-based medicine recommendations were developed with associated rating scales for the strength and quality of the evidence.
Recommendations
Used together and correctly, personal protective measures (PPM) and chemoprophylaxis very effectively protect against malaria infection. PPM include protecting accommodation areas from mosquitoes, wearing appropriate clothing, using bed nets pre-treated with insecticide and applying topical insect repellant (containing 20%–30% DEET or 20% icaridin) to exposed skin. Selecting the most appropriate chemoprophylaxis involves assessment of the traveller’s itinerary to establish his/her malaria risk profile as well as potential drug resistance issues. Antimalarials available on prescription in Canada include chloroquine (or hydroxychloroquine), atovaquone-proguanil, doxycycline, mefloquine and primaquine.
Introduction
Malaria is a serious infection caused by five different species of the genus Plasmodium: falciparum, vivax, ovale, malariae and knowlesi. Malaria is transmitted by the bite of infected female anopheline mosquitoes.
In 2009, 35% of Canadian travellers who went to a destination other than the United States visited a country that presented a risk of malaria, an increase of 131% from 2000 (1-2). Between September 2009 and September 2011, 94 cases of malaria were diagnosed among returned Canadian travellers (3).
According to the Centers for Disease Control and Prevention (CDC), malaria risk for travellers from the United States (4-6) varied as follows:
Highest in west Africa and parts of Oceania;
Moderate for other parts of Africa, parts of South America and South Asia;
Lower for much of Central America, the Caribbean, Mexico and other parts of Asia and South America;
Minimal in urban centres of southeast Asia and Central and South America, and in large resort areas in the Caribbean and Mexico.
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 disease and health risks associated with international travel. This is a summary of the CATMAT Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers, developed for Canadian health care providers who are preparing patients for travel to malaria-endemic areas and treating travellers who have returned ill (7). These guidelines include a full description of the recommendations on risk assessment and prevention of malaria, a disease that is still uncommon in Canada.
Methods
The Malaria Subcommittee, a working group of CATMAT, developed the guidelines. Each member is a volunteer, and none declared a relevant conflict of interest. Each chapter was updated by one to two members of the subcommittee and reviewed and approved by the full membership of CATMAT. The update was based on a thorough review of the literature. In addition, the Malaria Subcommittee reviewed all major sources of information on malaria prevention and treatment, including the World Health Organization (8), Centers for Disease Control and Prevention (CDC) (6) and the Health Protection Agency Advisory Committee on Malaria Prevention (9). The Malaria Subcommittee reviewed recent research, and national and international epidemiological data in order to tailor the recommendations to the Canadian context. Influencing factors include drug licensure, Canadian-specific travel patterns and related malaria epidemiology, and the anticipated values and preferences of travellers and health care providers. The evidence-based medicine recommendations for prevention of malaria were developed with associated rating scales for the strength and quality of the evidence.
CATMAT has taken into consideration both the need for protection and the potential for adverse effects of chemoprophylaxis. The guidelines also emphasize the varying degrees of endemicity in different regions. The health care provider should be properly informed to be able to provide appropriate guidance for the individual traveller.
Recommendations
The evidence-based CATMAT recommendations for malaria prevention are summarized in Table 1. A discussion of some of the key recommendations follows.
Table 1. Evidence-based medicine recommendations for prevention of malaria.
Recommendation | EBM rating1 |
---|---|
|
A I |
|
B III |
B III | |
|
B III |
B III | |
|
A I |
A I | |
|
A I |
|
A I |
|
C III |
|
B III |
|
B III |
|
A I |
|
A I |
|
A II |
|
A II |
|
E II |
|
B I |
|
B II |
|
B II |
|
E II |
|
B II |
1 EBM = Evidence based medicine. The EBM ratings are as follows: Strength of recommendation: A = Good evidence to support a recommendation for use B = Moderate evidence to support a recommendation for use C = Poor evidence to support a recommendation for or against use D = Moderate evidence to support a recommendation against use E = Good evidence to support a recommendation against use Quality of evidence: I = Evidence from at least one properly randomized, controlled trial II = Evidence from at least one well-designed clinical trial without randomization; from cohort or case-controlled analytic studies, preferably from more than one centre; from multiple time series; or from dramatic results in uncontrolled experiments III = Evidence from opinions of respected authorities on the basis of clinical experience, descriptive studies, or reports of expert committees
Risk assessment
CATMAT suggests a two-component process for malaria risk assessment: an exposure assessment and a host assessment.
An exposure assessment evaluates the probability of being bitten by infected mosquitoes. It takes three factors into account:
Expected level(s) of endemicity in the travel itinerary;
Presence/predominance of P. falciparum;
Duration of exposure.
A host assessment evaluates the traveller’s health in relation to the potential hazard(s) of clinical malaria and the indications for specific malaria chemoprophylactic agents while taking into account personal preferences regarding risk management. Factors to consider include the following:
General health of the traveller;
Drug–drug interactions;
Likelihood of access to appropriate medical care;
Risk tolerance and individual preferences.
The completed risk assessment can be used to decide whether to use malaria chemoprophylaxis and which chemoprophylactic agent to prescribe:
If malaria risk is minimal and the incidence of P. falciparum is nil or very low, CATMAT recommends using chemoprophylaxis (with PPM) for a stay longer than two weeks.
If malaria risk is minimal and the incidence of P. falciparum is higher, CATMAT recommends chemoprophylaxis (with PPM) for a stay longer than one week.
Travellers who decide not to use chemoprophylaxis have a higher risk of malaria but lower risk of chemoprophylaxis-associated adverse effects; the opposite is true for those who decide to use it.
A country-by-country characterization of malaria transmission areas is available in the complete guidelines (7). The Appendix provides chemoprophylaxis recommendations for the top 25 destinations with risk of malaria transmission that are visited by Canadians.
Personal protective measures
The risk of being bitten by a mosquito can be reduced by using physical and/or chemical barriers.
-
Physical barriers:
-
Chemical barriers repel mosquitoes and/or kill them (34,35). The main chemical modalities currently available are topical insect repellents for use on exposed skin and insecticides that impregnate bed nets and clothing (36-40).
Topical repellents should contain 20%–30% DEET or 20% icaridin.
Alternatively, second-choice topical repellents are those containing p-menthane-3,8-diol that are registered in Canada.
Travellers should also be encouraged to plan activities during periods when risk is reduced (e.g. during the daytime where the principal vectors are active in the evening) and to visit areas where transmission is less likely (e.g. urban centres, highland areas > 2000 m/6500 ft).
Chemoprophylaxis
Prescribing antimalarial drugs
Prescribe antimalarial chemoprophylaxis only after completing an individual risk assessment. For detailed descriptions of chemoprophylaxis and of chemotherapy see Chapter 8 of the Canadian Recommendations for the Prevention and Treatment of Malaria Among International Travellers (7). Selecting the most appropriate chemoprophylactic agent involves the following:
Evaluate the traveller’s exact travel itinerary to determine his or her malaria risk profile.
-
Review the advantages and disadvantages of different regimens:
Take into account the traveller's health status, other medications and the risks and character of adverse drug effects.
Consider only those medications that are least likely to exacerbate any past or present medical problem(s).
Present all the available options to the traveller and, unless any medication is contraindicated, let travellers choose which first-line malaria chemoprophylactic regimens they prefer.
-
Select the appropriate dosage of the medication:
Explain the dosing schedule, including the need to take the drug before, during and after visiting the area of risk, the desirability of taking the drug at the same time each day and advice on whether the prescribed medication should be taken with food, as well as any precautions regarding drug-specific side effects (e.g. sun exposure with doxycycline) (41-47).
Suggest a drug trial to check for possible medication-associated adverse reactions.
-
Discuss strategies to change medication if serious adverse effects arise during travel.
Advise the traveller to continue to take the prescribed malaria medication if it is well tolerated regardless of negative anecdotes about it. Long-term use of the chemoprophylactic agents currently recommended in Canada does not result in additional risks of severe adverse effects.
Discuss the importance of seeking medical advice urgently if a fever develops while the traveller is in a malaria-endemic area or within one year of leaving.
Selecting antimalarial drugs for specific regions of drug resistance
Monitor appropriate sources (e.g. Public Health Agency of Canada, CDC, ProMED) to stay abreast of new information about malaria risks before giving pre-travel care. This is especially relevant for minimal-risk regions because changes may directly affect the recommendations for chemoprophylaxis.
Table 2. Selecting antimalarial drugs for specific regions of drug resistance.
Area/region (6,48-50) | Drugs of choice |
---|---|
Chloroquine-sensitive regions: Haiti, the Dominican Republic, Central America north of the Panama Canal, parts of Mexico, parts of South America, north Africa, parts of the Middle East, and west/central China |
Chloroquine (Aralen®) Hydroxychloroquine (Plaquenil®) is an acceptable equivalent alternative (51), as are the three drugs used in chloroquine-resistant areas (see below). |
Chloroquine-resistant regions: Most of sub-Saharan Africa, South America, Oceania and Asia. See below for regions that are both chloroquine- and mefloquine-resistant. |
Atovaquone-proguanil (41,42,44-47,52) Doxycycline (41,42,44-47,52) Mefloquine (41,42,44-47,52) |
Chloroquine- and mefloquine-resistant regions: Various countries in Asia, Africa and the Amazon basin. However, it is a significant problem only in rural, wooded regions where Thailand borders with Myanmar (Burma), Cambodia and Laos, and in southern Vietnam. |
Atovaquone-proguanil (44,53,54) Doxycycline (44,53,54) |
Discontinuing antimalarial drugs
Fatal malaria has occurred in travellers who have discontinued all chemoprophylaxis or effective chemoprophylaxis in favour of something less protective (24,51,55,56). Discontinuation of all chemoprophylaxis is NOT a reasonable option.
Other travellers and/or health care providers may suggest changing or stopping antimalarial medication. For the most part, such advice should be ignored or questioned. Medications used in other areas of the world may be less effective, may be associated with serious adverse effects or may not be manufactured to Canadian standards. Examples include proguanil alone (Paludrine®), pyrimethamine (Daraprim®), dapsone-pyrimethamine (Maloprim®) and mefloquine-sulfadoxine-pyrimethamine (Fansimef®).
However, if the traveller experiences significant adverse events because of the chemoprophylactic agent, the medication can be changed, especially if the advice is provided by a health care provider (preferably the one who provided the initial advice).
Adherence to chemoprophylaxis
The reasons for non-adherence include lack of knowledge that malaria was a threat; fear of or past experience with adverse effects of chemoprophylactic agents; the false belief that prior malaria infections have conferred long-term immunity; the cost of medications; and confusion arising from contradictory recommendations. However, there is little information on how to enhance adherence.
Non-adherence to or suboptimal use of chemoprophylaxis and other preventive interventions is common, particularly among backpacking travellers; immigrants returning to visit their country of origin; people travelling for longer than one month; travellers aged 40 years or less; and those using chemoprophylactic agents that must be taken daily (12-21,23,25-27,57).
Health care providers themselves need to be properly informed to be able to provide appropriate guidance (58). Travellers who use one qualified information source, such as a family physician trained in travel medicine, are significantly more likely to be compliant with malaria prophylaxis than those who collect information from multiple sources that could contradict each other (58,59).
Summary
A summary of the key changes made to the 2014 Guidelines are noted in Table 3.
Table 3. Summary of key additions and changes to the 2014 Guidelines pertaining to prevention of malaria (7).
Additions |
---|
|
|
|
|
Changes |
|
|
Acknowledgements
CATMAT acknowledges and appreciates the contribution of Joanna Odrowaz, Elspeth Payne to the development of the summaries and Manisha Kulkarni for her contribution to the statement.
CATMAT Members: Boggild A, Brophy J, Bui YG, Crockett M, Ghesquiere W, Greenaway C, Henteleff A, Libman M, Teitelbaum P and McCarthy A (Chair).
Liaison members: Hui C (Canadian Paediatric Society) and Gershman M (US Centers for Disease Control and Prevention).
Ex-officio members: Marion D (Canadian Forces Health Services Centre, Department of National Defence), McDonald P (Division of Anti-Infective Drugs, Health Canada), Schofield S (Directorate of Force Health Protection, Department of National Defence), and Tepper M (Directorate of Force Health Protection, Department of National Defence).
Member Emeritus: Jeanes CWL.
Appendix.
Appendix: Malaria risk and recommended chemoprophylaxis in top 25 malaria-endemic travel destinations visited by Canadians in 2012 (6,60-67)
Country | Malaria transmission areas (2-4) | Chemoprophylaxis recommended by CATMAT* (2-9) | Season (3,4) | Plasmodium falciparum (2-4), % | |
---|---|---|---|---|---|
1 | Mexico | Minimal or no malaria transmission in major resort areas on the coasts, including the city of Acapulco or along the Mayan Riviera, including the cities of Cancún, Cozumel, and Playa del Carmen. None along the border with the United States. | None. | Year-round | 0 |
Little malaria transmission in the states of Jalisco, Quintana Roo, Sonora and Tabasco. | Use PPM. | ||||
Moderate risk in parts of the states of Chiapas and Oaxaca. | Chloroquine. | ||||
Low risk in rural areas of the states of Nayarit, Sinaloa, Chihuahua, and Durango. | Chloroquine for stays > 1 week; chloroquine or PPM alone for stays of ≤ 1 week. | ||||
2 | Dominican Republic | Little to no malaria transmission in the resort areas of Romana and Samaná and the cities of Santo Domingo, Santiago, and Puerto Plata. | None; use PPM. | Year-round | 100 |
Some transmission has previously occurred in La Altagracia province, including resort areas such as Punta Cana. | In the absence of any further outbreaks in La Altagracia, PPM alone for resorts in that province. Seek medical attention if a fever develops. | ||||
Rural areas, with the highest risk in the provinces of Dajabón, Elias Piña, and San Juan bordering Haiti. | Chloroquine. | ||||
3 | China | No malaria transmission in urban areas or northern China. | None. | n/a | n/a |
Limited transmission of P. vivax malaria occurs in the southern provinces and some central provinces, including Anhui, Ghuizhou, Henan, Hubei, and Jiangsu. | For travellers visiting major cities and making daytime excursions into the countryside or on Yangtze river cruises: none; use PPM. | Year-round | 9 | ||
The risk of contracting malaria in central China is small. | For those travelling extensively in or through rural southern China: chloroquine. | ||||
Transmission of P.falciparum malaria occurs in the province of Yunnan and, to a lesser extent, in the province of Hainan. P. falciparum resistance to chloroquine and sulfadoxine-pyrimethamine reported. | ATQ-PG, DOXY or MFQ. | ||||
P. falciparum resistance to mefloquine reported in the province of Yunnan in the areas bordering Burma (Myanmar). | ATQ-PG or DOXY. | ||||
4 | India | No malaria transmission at elevations > 2000 m in parts of the states of Himachal Pradesh, Jammu and Kashmir, and Sikkim. | None. | n/a | n/a |
All other areas - including most urban areas such as Bombay (Mumbai) and Delhi. Risk is lower in most of the southernmost regions of India. |
ATQ-PG, DOXY or MFQ. | Year-round | > 40 | ||
Risk is low in central urban areas of Agra and Bangalore. | PPM alone can be considered for stays of <1 week in central urban areas of Delhi, Agra and Bangalore. | ||||
5 | Costa Rica | Little to no risk of malaria transmission in most of the country, with exception noted below. No malaria transmission in the city of Limón (Puerto Limón). | None; use PPM. | Year-round | Predominantly P vivax |
Limón province (except the city of Limón), mostly in the canton of Matina. | Chloroquine. | ||||
6 | Thailand | No malaria transmission in cities, including Bangkok, Chiang Mai, Chiang Rai, Pattaya, Koh Samui, Phang Nga, Town of Phuket and Koh Phangan, or in major tourist resorts. | None. | n/a | n/a |
Rural forested areas near the borders with Cambodia, Burma (Myanmar) and Laos. Rural forested areas in districts of Phang Nga and Phuket. Some islands have malaria risk. | ATQ-PG or DOXY. | Year-round | 50–75 | ||
Mefloquine resistance reported. | |||||
7 | Philippines | Little to no malaria transmission in urban areas or on islands not listed below. | None; use PPM. | Year-round | 70–80 |
Rural areas at elevations < 600 m on islands of Basilu, Luzon, Mindanao, Mindoro, Palawan, Sulu (Jolo) and Tawi-Tawi. | ATQ-PG, DOXY or MFQ. | ||||
8 | South Africa | No malaria transmission in most of the country including the Garden Route and major cities. | None. | n/a | n/a |
Low-altitude areas in the provinces of Mpumalanga (including the Kruger National Park), Limpopo (formerly Northern), and north-eastern Kwa Zulu-Natal as far south as the Tugela River. | ATQ-PG, DOXY or MFQ. | Year-round | 90 | ||
(risk is highest from Oct– May) | |||||
9 | Peru | No malaria risk at elevations > 2000 m, including the highland tourist areas (Machu Picchu, Lake Titicaca, and the cities of Arequipa, Cuzco, Puno) or in the cities of Limaand south of Lima including Moquegua, Nazca, and Tacna. | None. | n/a | n/a |
All areas < 2000 m (except cities listed above). This includes the cities of Puerto Maldonado and Iquitos. Most P.falciparum cases occur in the region of Loreto. | ATQ-PG, DOXY or MFQ. | Year-round | 15 | ||
10 | Turkey | No malaria transmission in western and northeastern parts of the country, including the common tourist destinations of the cities of Izmir and Istanbul and the Cappadocia region. | None. | n/a | n/a |
Limited malaria transmission in the southeastern part of the country. | Chloroquine for stays > 2 weeks; chloroquine or PPM alone for stays of ≤2 weeks. | May–Oct | Sporadically | ||
11 | Argentina | No malaria transmission in urban areas, Iguassu Falls, or provinces not listed below. | None. | n/a | n/a |
Rare in Misiones province along the border with Paraguay. | None; use PPM. | Oct–May | 0 | ||
Rural areas of northern Jujuy and Salta Province (along Bolivian border). | Chloroquine for stays > 2 weeks; chloroquine or PPM alone for stays of 2 weeks. | ||||
12 | Brazil | Little to no malaria transmission at Iguazu Falls; in the Pantanal region; in the cities of Brasília, Recife, Rio de Janeiro, São Paulo, and Salvador; or in other areas not listed below. | None; use PPM. | Year-round | 15 |
Areas at elevations < 900 m in most forested areas of the states of Acre, Amapá, Amazonas, Rondônia, Roraima and Tocantins (western part) and parts of states of Maranhāo (western part), Mato Grosso (northern part), Pará (except Belém City) and Tocantins (western part). Transmission also occurs in some peripheral urban areas of - Boa Vista, Cruziero do Sul, Macapá, Manaus, Maraba, Pôrto Velho, Rio Branco, and Santarém. | ATQ-PG, DOXY or MFQ. | ||||
13 | Belize | No malaria transmission in Belize City and islands frequented by tourists. | None. | n/a | n/a |
Low risk in Belize, Corozal, and Orange Walk Districts. | None; use PPM. | Year-round | 0–5 | ||
Moderate risk in Cayo, Stann Creek, and Toledo Districts. | Chloroquine. | ||||
14 | Ecuador | No malaria transmission at elevations > 1500 m, including Cuenca, Quito, and other cities and villages in the Andean highlands; in the city of Guayaquil or on the Galápagos Islands. | None. | n/a | n/a |
All other areas at elevations < 1500 m. Higher risk along the coast, in the north. | ATQ-PG, DOXY or MFQ. | Year-round | 10 | ||
15 | Colombia | No malaria transmission in urban areas, including Bogotá and vicinity and Cartagena; at elevations > 1600 m; or on the islands of San Andrés and Providencia in the Caribbean Sea. | None. | n/a | n/a |
Rural or jungle areas at elevations < 1600m. | ATQ-PG, DOXY or MFQ. | Year-round | 35–40 | ||
16 | Guatemala | No malaria transmission in urban areas or areas at elevations > 1500 m none in Guatemala City, Antigua, and Lake Atitlán. | None. | n/a | n/a |
Rural areas at elevations < 1500 m. | Chloroquine. | Year-round | 3 | ||
17 | Honduras | No malaria transmission - in the cities of Tegucigalpa and San Pedro Sula. Risk is low in higher mountainous areas in the west where PPM can be considered. |
None. | n/a | n/a |
Risk is high in departments of Gracias a Dios and Islas de la Bahia (Bay Islands), and moderate in Atlantida, Colon, Olancho, and Yoro. | Chloroquine. | Year-round | 7 | ||
18 | Vietnam | None in urban areas, Red River Delta and coastal plain of central Vietnam. Rare cases in Mekong Delta. The common coastal itinerary between Ho Chi Minh City and Hanoi with overnights mainly in urban areas does not typically require chemoprophylaxis. |
Use PPM. | Year-round | 50–90 |
Rural areas, excluding those listed above. Risk in the town of Sapa in the hills to the northwest of Hanoi is lower; PPM can be considered for stays <1 week, particularly in the winter months. |
ATQ-PG, DOXY or MFQ. | ||||
Mefloquine resistance reported in the southern part of the country in the provinces of Dac Lac, Gia Lai, Khanh Hoa (western part), Kon Tum, Lam Dong, Ninh Thuan (western part), Song Be, and Tay Ninh. | ATQ-PG or DOXY. | ||||
19 | Cambodia | No malaria transmission in the city of Phnom Penh and the area around Lake Tonlé Sap (Siem Reap). Negligible transmission in the tourist area of Angkor Wat and Siem Reap. | None; use PPM. | Year-round | 86 |
Mefloquine resistance is reported in the western provinces of Banteay Meanchey, Battambang, Koh Kong, Odder Meanchey, Pailin, Kampot, PreahVihear, Pursat, and Siemreap bordering Thailand. | Doxycycline or atovaquone–proguanil. | ||||
All other areas. | ATQ-PG, DOXY or MFQ. | ||||
20 | Panama | Little to no malaria transmission in Panama City, the Canal zone, or regions not listed below. | None; use PPM. | Year-round | 1 |
Provinces and indigenous territories (comarcas) along the Caribbean coast and the borders with Costa Rica and Colombia: Bocas del Toro, Chiriquí, Colón, Ngöbe-Buglé, Panamá, and Veraguas. | Chloroquine for stays > 1 week; chloroquine or PPM alone for stays of <1 week. | ||||
Most transmission in provinces east of the Panama Canal toward the border with Colombia.P. falciparum resistance to chloroquine has been reported in Darién and Kuna Yala (San Blas). | ATQ-PG, DOXY or MFQ. | ||||
21 | Pakistan | All areas at elevations < 2000 m. Risk is due to both P. vivax and P. falciparum. Risk lower in the north, including Islamabad, especially during winter months because of cool temperatures. | ATQ-PG, DOXY or MFQ. | Year-round | 30 |
22 | Kenya | Little to no malaria transmission at elevations > 2500 m or in the city of Nairobi. | None; use PPM. | Year-round | 85 |
All areas at elevations < 2500 m, except the city of Nairobi. | ATQ-PG, DOXY or MFQ. | ||||
23 | Tanzania, United Republic of | All areas at elevations < 1800 m. | ATQ-PG, DOXY or MFQ. | Year-round | > 85 |
24 | Indonesia | No malaria transmission in Jakarta Municipality, major metropolitan areas including Ubud, or major tourist resorts in Bali and Java. | None. | n/a | n/a |
In general, risk is higher in more easterly regions of Indonesia: in particular, the provinces of East Nusa Tenggara, Maluku, North Maluku, Papua (Irian Jaya) and West Papua. There is also risk on LombokIsland and the rural areas of KalimantanIsland (Borneo). There is a low risk of transmission in rural Java and Bali and sporadic cases reported among travellers to rural areas of Bali. In the other parts of the country, there is malaria risk in some districts. | ATQ-PG, DOXY or MFQ. | Year-round | 66 | ||
25 | Nicaragua | Little to no malaria transmission in departments not listed below. | None; use PPM. | Year-round | 10 |
Departments of Chinandega, Léon, Managua, and Matagalpa and the autonomous regions of Atlántico Norte (RAAN) and Atlántico Sur (RAAS). | Chloroquine. |
* Chemoprophylaxis is recommended only in the risk areas identified during the transmission season identified. Chemoprophylaxis should always be used in conjunction with PPM. ATQ-PG, atovaquone-proguanil; DOXY, doxycycline; MFQ, melfloquine
Footnotes
Conflict of interest: There are no conflicts of interest to declare.
Funding: This work was supported by the Public Health Agency of Canada.
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