Table 1. Evidence-based medicine recommendations for prevention of malaria.

Recommendation	EBM rating1
1.Properly used malaria chemoprophylaxis is very effective (6).	A I
2.Travellers should receive expert advice on malaria risks and strategies to avoid mosquitoes (10).	B III
3.A detailed review of the travel itinerary to determine the expected level of malaria endemicity and duration of exposure is essential to provide an accurate risk assessment for travellers (6,10,11).	B III
4.An assessment of the traveller’s health and risk tolerances is also important in making malaria prevention recommendations.	B III
5.It is very important to adhere to recommended malaria prevention practices (e.g. use of chemoprophylaxis and PPM) (12-22).	B III
6.Chloroquine (Aralen®) or hydroxychloroquine (Plaquenil®) is the drug of choice for travellers to areas with chloroquine-sensitive malaria (23).	A I
7.Atovaquone-proguanil, doxycycline or mefloquine is the drug of choice for travellers to areas with chloroquine-resistant or mefloquine-sensitive malaria (12-14,24-27).	A I
8.Atovaquone-proguanil and doxycycline are the drugs of choice for travellers to areas with mefloquine-resistant malaria.	A I
9.Primaquine is recommended for malaria chemoprophylaxis for travellers to regions with chloroquine resistance who are not willing or able to use atovaquone-proguanil, doxycycline or mefloquine.	A I
10.Standby malaria treatment with atovaquone-proguanil or quinine and doxycycline is recommended for travellers who are more than a day away from malaria diagnostic help.	C III
11.Doxycycline is an antibiotic and should never be co-administered with any live, oral bacterial vaccines. Vaccination with live oral typhoid or cholera vaccines should be completed at least three days before the first dose of choloroquine, atovaquone-proguanil or mefloquine.	B III
12.Concurrent use of chloroquine interferes with antibody response to intradermal administration of human diploid cell rabies vaccine. If intradermal rabies vaccine is administered to someone taking chloroquine, it is recommended that post-vaccine rabies antibodies be obtained to verify an adequate immunologic response.	B III
13.Use insecticide-treated bed nets.	A I
14.Use topical repellents on exposed areas of skin to prevent arthropod bites and to reduce the risk of exposure to malaria-carrying mosquitoes.	A I
15.Products registered in Canada that contain 20%–30% DEET (N,N-Diethyl-meta-toluamide) or 20% icaridin should be the first choice for Canadian travellers.	A II
16.Products that contain p-menthane-3,8-diol (a chemical originally derived from the lemon eucalyptus plant) and that are registered in Canada should be considered second-choice topical repellents.	A II
17.Other active ingredients currently registered in Canada (e.g. citronella and soybean oil) are either not widely available and/or do not provide sufficiently long protection times against bites. These products are not recommended for protecting travellers against the bites of vectors.	E II
18.Protect work and accommodation areas against mosquitoes by using screening on doors, windows and eaves (the open area between the roof and wall), eliminating holes in roofs and walls, and closing other gaps around a building.	B I
19.Wear insecticide-treated clothing.	B II
20.Wear appropriate clothing (e.g. full-length, loose-fitting and light-coloured clothing with sleeves rolled down and pants tucked into socks or boots).	B II
21.Do not use/rely on other insecticide-based approaches, such as insecticide coils that are burned, insecticide vaporizers, aerosols and space sprays, and insecticide-treated bed sheets.	E II
22.PPM that are either ineffective or that have not been convincingly shown to be efficacious against arthropod vectors and related diseases are not recommended. These include electronic (ultrasonic) devices; wristbands, neckbands and ankle bands impregnated with repellents; electrocuting devices (“bug zappers”); odour-baited mosquito traps; Citrosa plant (geranium houseplant); orally administered vitamin B1; and skin moisturizers that do not contain an approved repellent active ingredient.	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