Road map for malaria control (and elimination): public health priorities Anne E McCarthy, MD, FRCPC, DTM&H Director Tropical Medicine and International Health Clinic Ottawa Hospital Professor of Medicine University of Ottawa Chair, Committee to Advise on Tropical Medicine and Travel
Overall Canadian Public Health Support Mother and child malaria
CATMAT Committee to Advise on Tropical Medicine and Travel Advisory role to the Public Health Agency of Canada
Malaria history in Canada Ontario
Rideau Canal built to protect Canadians and Canadian goods from US British Royal Engineers, under Colonel John By, constructed the Rideau Canal system, which links Kingston and Ottawa, using the Rideau and Cataraqui Rivers. From 1826 to 1832, a series of locks, dams, canal sections, and other engineering marvels was built to form a 220 km canal that is still used today Ironically, many tourists on the canal today are Americans it was built to protect us from.
P vivax on the Rideau Rideau Canal construction started in 1826-27 Malaria was well established throughout much of the range of the anopheles mosquito in Ontario. P vivax established in Kingston and Perth Construction camps, hundreds of people co-located with anopheles mosquito (whose highest numbers were in the southern part of the Rideau), meant an explosion of the disease. The summer of 1828 saw the first great outbreak of malaria in the southern construction camps.
P vivax on the Rideau August 1 to September 15 of each year became known as the sickly season. About 60% of the men would annually get sick with malaria. It eventually led to many men abandoning the work sites during that period of the year. Unusual 2-4% mortality rate attributed to P vivax infection thought secondary infection s such as dysentery. less likely that there was also P. falciparum, introduced into the U.S. with the African slave trade, since PF would not have ability to over-winter in Canada, so, if it was present, it must have been re-introduced each year.
The extensive use of Quinine, the draining of swamps in areas of human habitation, and the use of glass (and later screens) in windows, to prevent the entry of mosquitoes at night, served to dramatically decrease the incidents of malaria. Still, it wasn't until about 1900 that malaria was essentially eradicated from Ontario.
Anopheles quadrimaculatus, a competent vector for P vivax, is native to southern Ontario.
Malaria epidemiology in Canada No endemic malaria Surveillance poor 400-1000 imported malaria cases per year Limited potential for local spread Canada is home to 60+ mosquito species An quadrimaculatus
94 malaria cases in travellers seen at five CanTravNet sites 2009-2011
National Coordinator: Anne McCarthy Research Coordinator: Stephanie Carson Pharmacy Techs: Anne-Marie Dugal & Susan Fetzer Pharmacy ID Educator: Rosemary Zvonar
CMN SEVERE MALARIA STATISTICS
IV artesunate available since 2009 Year Statistics 2009- April 2016 (n=303) with parenteral artesunate use Data obtained from CMN Form A & Form B Received Cases of Severe Malaria in Canada Reported to CMN Total 2009-Present Treated with IV-artesunate Treated with IV Quinine & Artesunate 2009 23 9 1 2010 34 24 0 2011 30 30 1 2012 33 32 0 2013 54 54 1 2014 61 59 0 2015 82 82 1 2016 13 13 1 Total 330 303 5
Malaria Species (n=303) Plasmodium Species P.falciparum 248 P.vivax 8 P.malariae 1 P.ovale 7 P.knowlesi 0 Unknown 39
Classification of Malaria (n=303) Classification of Malaria Total Cases Treated with IV- Artesunate WHO Defined Severe Malaria 247 Complicated Malaria 14 IV Therapy Inappropriate 19 Unknown 23
Socio-demographics (n=303) Socio-demographics Male 179 Female 140 Pregnant Females 6 Adult 229 Child (<18) 62 Unknown 12 Canadian Born 91 Not Canadian Born 181 Unknown 31 Endemic Birth Country 162 Residency Status Canadian Residents 203 Other 8 Recent Immigrant 33 Visitor 27 Unknown 32 Over-representation of recent and previous (VFR) and migrants, especially children
Travel Advice & Prophylaxis (n=303) Pre-Travel Advice Received Yes 73 No 141 Unknown 43 Not Applicable 46 ONLY 16% of case of severe malaria used chemoprophylaxis Prophylaxis Used Total Cases of Severe Malaria Treated with IV-artesunate 48 303
Reason For Travel (n=303) 45% of cases reason for travel is VFR Reason for travel Number of Cases VFR *138 (45%) Volunteer 24 (8%) Business *45(15%) Education 10(3%) Vacation 26 (9%) Medical 0 (0%) Immigration *44 (15%) Military 0 (0%) Other 11 (4%) Unknown 12 (4%)
Region of Exposure (n=303) Region of Exposure Africa 262 Asia 8 Caribbean 5 Oceania 0 South/ Central America 4 Unknown 24
Severe Case Distribution (n=303) YT 0 (0%) NT 0 (0%) NU 0 (0%) BC 21 (7%) AB 47 (16%) SK 5 (2%) Fig 1. Illustrates the distribution of severe malaria cases treated with IV-artesunate in Canada from 2009-April 2016 MB 14 (5%) ON 111 (37%) QC 91 (30%) NB 4 (1%) NS 6 (2%) NL 4 (1%) PE 0 (0%)
Working to improve medical malaria care across the country.. Present on our EMR Standing orders Drug orders canadianmalarianetwork@toh.on.ca
Challenges for Public Health and practitioners in Canada Recognition of disease Timely and effective treatment Availability of treatment IV artesunate since 2009 available through generous donation of US army WRAIR Working toward licensure not sure what will happen with ability to maintain surveillance of severe malaria in Canada Oral artesunate NOT licensed or available in Canada little interest for licensure potential for special access distribution through CMN centres
Thank you QUESTIONS?