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Travel Health Advisory
Malaria in the Dominican Republic
Updated: January 31, 2006
The Public Health Agency
of Canada (PHAC) continues to recommend malaria prophylaxis
(medication) and the use personal insect protective measures
against mosquito bites for travel to rural areas of the Dominican
Republic AND to all areas, including resort
areas, within the province of La
Altagracia. Please refer to the recommendations section
of this advisory for additional information.
In October and November of 2005 PHAC was notified of two cases of P.
falciparum malaria in European travellers returning from the province
of La Altagracia in the Dominican Republic - [Map].
The cases, a 24-year-old female tourist from France and a 20-year-old
male tourist from Spain , acquired the disease during travel to the
Bavaro area in the province of La Altagracia in August and September
of 2005.
The Pan American Health Organization (PAHO) is working with the Ministry
of Health in the Dominican Republic to ensure that intensive measures
to interrupt malaria transmission, including intensified surveillance
and vector control, continue to be implemented in the province of La
Altagracia.
The Agency continues to collaborate with the US Centers for Disease
Control and Prevention (CDC) and the Pan American Health Organization
in the monitoring and reporting of cases of malaria in travellers returning
from the Dominican Republic. At this time, no additional cases have
been reported.
Source: GEOSentinel, Eurosurveillance,
Pan American Health Organization
Malaria is an acute flu-like illness caused by one of four species
of parasite of the genus Plasmodium; Plasmodium falciparum,
Plasmodium vivax, Plasmodium ovale and Plasmodium malariae. Infection
with P. falciparum malaria can be fatal.
The disease is most commonly transmitted to humans through the bite
of an infected mosquito, specifically the female Anopheles mosquito,
a dusk-to-dawn biter.
Malaria is endemic (i.e., constantly present) in most of sub-Saharan
Africa; in large areas of the Middle East, South Asia, South East Asia,
Oceania, Haiti, Central and South America; and in parts of Mexico, North
Africa and the Dominican Republic.
For comprehensive information, please refer to the Public Health
Agency of Canada's Disease
Information Backgrounder on malaria.
P. falciparum malaria is known to be endemic (i.e., constantly
occurring) in rural areas of the Dominican Republic , with the highest
risk in areas bordering Haiti . On average, close to 1000 cases are reported
each year. However, in 2004 this figure jumped to more than 2000 cases
due to increased rainfall, an increase in the mosquito population, and
increased movement of migrant workers between rural and resort areas.
Although resort areas in the Dominican Republic are generally not risk
areas, small localized outbreaks have occurred in recent years in and
around resorts in the province of La Altagracia.
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In 1999, a localized outbreak of malaria occurred in a tourist resort
area in the province of La Altagracia . The outbreak, which spanned five-months,
resulted in a total of 359 reported cases of malaria. The majority of which
(76.6%) occurred in temporary construction workers from other parts
of the country. An additional 16.9% occurred in local residents of
the area.
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In 2004, a localized outbreak of malaria occurred in and around
resort areas located in the provinces of La Altagracia . The outbreak
began in mid-October 2004 and ended in January 2005. Among tourists,
the outbreak resulted in a combined total of 21 confirmed cases of
malaria reported in Canadian, American, and European travellers, between
late-2004 and January 2005.
Recommendations |
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The Public Health Agency of Canada (PHAC) continues to recommend malaria
prophylaxis (medication) and the use of personal insect protective measures
(e.g., repellants) against mosquito bites for travel to all rural areas
of the Dominican Republic.
Additionally, in light of the evidence of ongoing malaria transmission
in and around tourist resort areas within the province of La Altagracia
, the Public Health Agency of Canada in consultation with the Malaria
Sub-Committee of the Committee to Advise on Tropical Medicine and Travel
(CATMAT) has expanded its recommendations as follows:
For travel to rural areas of the country AND to
all areas within the province of La Altagracia (including resort areas):
- The Agency recommends malaria prophylaxis (medication) and the use
personal insect protective measures against mosquito bites.
The tourist resort destinations of Punta Cana and Bavaro are located
within the province of La Altagracia.
Note : While chloroquine is the
malaria drug of choice for the Dominican Republic , atovaquone / proguanil
(Malarone ®), doxycycline and mefloquine
are as effective as chloroquine and readily available. |
How to prevent malaria infection
Two important measures can help you prevent malaria infection: avoiding
mosquito bites and using effective anti-malarial medications.
Personal Measures to Avoid Mosquitoes
Female Anopheles mosquitoes bite mainly during the evening
and night. Using personal insect protective measures will reduce your
risk of being bitten by these mosquitoes.
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stay in well-screened or completely enclosed, air-conditioned accommodation;
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sleep under insecticide-treated bed nets;
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wear clothing that reduces the amount of exposed skin; wear long-sleeved
shirts (tightly weaved material, sleeves down, buttoned/zipped up,
tucked into pants) and long pants (tucked into socks or footwear);
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light-coloured clothing may be less attractive to some mosquitoes
and make mosquitoes more noticeable;
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use DEET-based products as repellents on exposed skin. The higher
the concentration of DEET in the repellent formulation, the longer
the duration of protection. However, this relation reaches a plateau
at about 30% to 35%. DEET formulations that are "extended duration" (ED),
such as polymers, are generally considered to provide longer protection
times, and may be associated with less DEET absorption. Formulations
over 30% are not currently available in Canada , although they are
available internationally, including in the United States . It should
be noted, however, that products sold outside Canada have not been
evaluated by Health Canada . Most repellents containing "natural" products
are effective for shorter durations than DEET and for this reason
are not considered the preferred products for protecting against
mosquito bites.
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Regulatory agencies in western nations may differ regarding the recommended
maximum concentration and application rates of DEET, especially for children.
The Committee to Advise on Tropical Medicine and Travel (CATMAT) is satisfied
that, for travel outside of Canada where the risk of malaria outweighs
the risk of any important adverse reaction to DEET, the threshold
for use of DEET should be low.
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CATMAT recommends that concentrations of DEET up to 35% can be used
by any age group.
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For children, alternative personal protective measures,
such as mosquito nets treated with insecticide, should be the first
line of defense, especially for infants less than 6 months of age.
Portable mosquito nets, including self-standing nets, placed over
a car seat, a crib, playpen, or stroller help protect against mosquitoes.
However, as a complement to the other methods of protection, the
judicious use of DEET should be considered for children of any
age. Recent medical literature from Canada suggests that DEET does
not pose a significant or substantial extra risk to infants and children.
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DEET/sunscreen combination products are not generally recommended,
because DEET can decrease the efficacy of sunscreens. As well, sunscreens
should be used liberally and often while DEET should be used sparingly
and only as often as required. If application of both is necessary,
the Canadian Dermatology Association recommends that the sunscreen
be applied first and allowed to penetrate the skin for 20 minutes,
prior to applying DEET.
These precautions will also help to prevent other mosquito-borne infections
such as dengue fever.
Antimalarial Medication (Prophylaxis)
Antimalarial medications decrease the risk of developing symptomatic
malaria. However, they do not provide 100% protection against the disease.
Your individual need for antimalarial medications should be discussed
with your physician or travel medicine professional several weeks before
travel.
If your physician or travel medicine clinic prescribes an antimalarial
medication, it is important that you take it as directed in order to
maximize the protective effect. Each drug has its own dosing regime that
should be strictly followed. Because of the incubation period of the
disease, these medications must be taken both before, during, and after
travel.
Travellers are reminded to complete their prescribed regimen of prophylaxis
on their return. Except for atovaquone/proguanil which must be taken
for one week after returning from a malaria-endemic area, chloroquine,
doxycyline and mefloquine must be taken for four weeks after returning
from a malaria-endemic area.
For travellers who opt not to take malaria prophylaxis during their
travel to La Altagracia, PHAC does not recommend that
they start chemoprophylaxis on their return home to Canada but advises that
individuals seek immediate medical attention should they develop a fever and inform
their physician that they have visited an area where malaria occurs so
that they can be tested without delay.
Important to Note:
If you develop a fever within 3 months after returning from an area
where malaria occurs, you should seek medical advice immediately. Be
sure to inform your physician that you have visited an area where malaria
occurs so that you can be tested without delay. Malaria must be ruled
out by the examination of one or more blood films under a microscope.
As a reminder...
The Public Health Agency of Canada routinely recommends
that Canadian international travellers consult their personal physician
or a travel clinic prior to international travel, regardless of destination,
for an individual risk assessment to determine their individual health
risks and their need for vaccination, preventative medication, and personal
protective measures.
The Public Health Agency of Canada recommends, as well, that travellers
who become sick or feel unwell on their return to Canada should seek
a medical assessment with their personal physician. Travellers should
inform their physician, without being asked, that they have been travelling
or living outside of Canada , and where they have been.
For additional information on malaria:
[Information for Travellers] [Information for Travel Medicine Professionals]
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