EPIDEMIOLOGIC REPORT * ETUDE EPIDEMIOLOGIQUE
Recommendations from the Committee to Advise on Tropical Medicine and Travel T he Committee to Advise on Tropical Medicine and Travel (CATMAT) was recently established (a) to make recommendations on the prevention and treatment of tropical infectious diseases and other health hazards that Canadian travellers may encounter, (b) to advise on priorities for research in this area and (c) to suggest ways of disseminating and using such recommendations. CATMAT is an official advisory committee of the Health Protection Branch (HPB), Department of National Health and Welfare (DNHW), and is supported by the Division of Tropical Health and Quarantine, Bureau of Communicable Disease Epidemiology, Laboratory Centre for Disease Control, Ottawa. Members of CATMAT include recognized Canadian experts in travel and tropical medicine as well as representatives from the following: the Advisory Committee on Epidemiology; the bureaus of Human Prescription Drugs and Biologics, Drugs Directorate, HPB; the Canadian Infectious Disease Society; the Canadian Society for International Health; the Department of National Defence; the Medical Advisory Committee of the Air Transport Association of Canada; the Medical Services Branch, DNHW; the National Advisory Committee on Immunization (NACI); and the US Centers for Disease Control. The first official meeting of CATMAT was held in Ottawa Feb. 1 and 2, 1990. CATMAT has made the following three recom-
mendations.
Indications for meningococcal vaccine This statement is intended to supplement the guidelines of NACI.I
Meningococcal meningitis is a severe disease and has a case-fatality rate of up to 15%. The meningococcal polysaccharide vaccine licensed for use in Canada is safe and is immunogenic for Neisseria meningitidis serotypes A, C, Y and W135; these include the serotypes most often implicated in epidemics (A and C). Primary vaccination with meningococcal vaccine should be considered for travellers who, as a result of their destinations or activities abroad, may be at risk of infection with the above four serotypes. In general, a person staying 2 weeks or more in any of the following areas is at risk for meningococcal disease: Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Egypt, Ethiopia, Kenya, Malawi, Mali, Morocco, Mozambique, Nepal, Niger, Nigeria, Saudia Arabia, Sudan, Tanzania and Togo. The area of India north from Delhi and east to Nepal is also an area of risk. Additions to or deletions from this list will appear in the monthly quarantinable diseases report in Canada Diseases Weekly Report. If activities - such as health care work - involve close exposure to nasopharyngeal secretions of local residents a period of less than 2 weeks would carry risk. For people 2 years of age or older primary vaccination should be given according to the manufacturer's directions; for those under 2 the primary vaccination schedule recommended in the Canadian Immunization Guide' should be followed.
Indications for Japanese encephalitis vaccine Japanese encephalitis is a severe viral disease and has a case-fatality rate of up to 10% despite optimal supportive care; the rate of permanent
Based on material previously reported in Canada Diseases Weekly Report (a publication ofthe Bureau ofCommunicable Disease Epidemiology, Laboratory Centre for Disease Control, Department ofNational Health and Welfare, Tunney's Pasture, Ottawa, Ont. KIA OL2) by the Committee to Advise on Tropical Medicine and Travel, Health Protection Branch, Department ofNational Health and Welfare (1990; 16: 153-155). Publication in CMAJ is with permission of the committee and the bureau. Reprint requests to: Dr. Robert C. Wittes, Chief, Division of Tropical Health and Quarantine, Bureau of Communicable Disease Epidemiology, Laboratory Centre for Disease Control, Tunney's Pasture, Ottawa, Ont. KJA OL2 CAN MED ASSOC J 1990; 143 (12)
1333
neurologic sequelae among survivors is high. The virus is transmitted by mosquitoes in either endemic or epidemic patterns in geographically limited areas of Asia from India east to Japan. The risk of disease among people who travel to Asia for short periods or who remain in urban areas of Asia is very low. Although there is no licensed vaccine in Canada the Biken vaccine - a formalin-inactivated mousebrain preparation produced in Japan - is available by arrangement with Mrs. D.E. Krepps, Bureau of Biologics, HPB, DNHW; (613) 957-0363. This vaccine is safe and highly immunogenic.2 The Biken vaccine should be administered according to the manufacturer's directions. Vaccination should be considered for travellers of any age who will spend 3 weeks or more in rural areas of the following countries during the transmission seasons of endemic or epidemic Japanese encephalitis: the temperate regions during summer and autumnBangladesh, Burma, China, northern India, Japan, Kampuchea, Korea, Laos, Nepal, northern Thailand, northern Vietnam and the eastern Soviet Union; and the tropical regions during the rainy season southern India, Indonesia, Malaysia, Philippines, Singapore, Sri Lanka, Taiwan, southern Thailand and southern Vietnam. Proximity to areas of rice culture or pig farming increases the risk of disease. If this vaccine becomes licensed in Canada NACI will prepare a statement regarding its use.
Prevention and treatment of malaria CATMAT has prepared official recommendations for the prevention and treatment of malaria that will be published imminently as a supplement in Canada Diseases Weekly Report. In the meantime there is a limited supply in Canada of primaquine, which is indicated for the radical cure of vivax and
ovale malaria. It is unclear for how long supplies will be limited. The following recommendations concern the use of primaquine during this shortage. Primaquine should be administered for the radical cure of documented or strongly suspected infection with Plasmodium vivax or P. ovale. It has no other place in the prevention or treatment of malaria. It is contraindicated during pregnancy and may cause significant hemolysis in people with glucose6-phosphate dehydrogenase (G6PD) deficiency. Before the drug is given the patient's G6PD level should be determined. Winthrop Pharma, Aurora, Ont., the distributor of primaquine in Canada, has given its stock of the drug to the Children's Hospital of Eastern Ontario, Ottawa, to be dispensed to physicians as needed. Physicians should send a request in writing, including the indication for the proposed use of the drug, documentation that the G6PD level has been determined and the name of the patient, to Dr. Ross A. Pennie, Director, Tropical and Travellers' Medicine, Children's Hospital of Eastern Ontario, 401 Smyth Rd., Ottawa, Ont. KlH8L1; (613)737-2765, FAX (613) 738-3216. On Pennie's authorization the hospital pharmacy will send the requested number of tablets (cash on delivery) to the requesting physician. Once the shortage of primaquine is rectified the drug will again be available through prescription in pharmacies, and a note will be published in Canada Diseases Weekly Report stating that the special conditions no longer apply.
References 1. Canadian Immunization Guide, 3rd ed, Dept of National Health and Welfare, Ottawa, 1989
2. Japanese encephalitis vaccination, with reference to travellers to Seoul, Korea. Can Dis Wkly Rep 1988; 14: 161-162
Foreign travel Now the rotten diseases of the South, the guts-griping, ruptures, catarrhs, loads o'gravel i' th' back, lethargies, cold palsies, raw eyes, dirt-rotten livers, whissing lungs, bladders full of imposthume, sciaticas, limekilns i' th' palm, incurable boneache, and the rivelled fee simple of the tetter, take and take again such preposterous discoveries!
William Shakespeare (1564-1616)
1334
CAN MED ASSOC J 1990; 143 (12)
Recommendations from the Committee to Advise on Tropical Medicine and Travel T he Committee to Advise on Tropical Medicine and Travel (CATMAT) was recently established (a) to make recommendations on the prevention and treatment of tropical infectious diseases and other health hazards that Canadian travellers may encounter, (b) to advise on priorities for research in this area and (c) to suggest ways of disseminating and using such recommendations. CATMAT is an official advisory committee of the Health Protection Branch (HPB), Department of National Health and Welfare (DNHW), and is supported by the Division of Tropical Health and Quarantine, Bureau of Communicable Disease Epidemiology, Laboratory Centre for Disease Control, Ottawa. Members of CATMAT include recognized Canadian experts in travel and tropical medicine as well as representatives from the following: the Advisory Committee on Epidemiology; the bureaus of Human Prescription Drugs and Biologics, Drugs Directorate, HPB; the Canadian Infectious Disease Society; the Canadian Society for International Health; the Department of National Defence; the Medical Advisory Committee of the Air Transport Association of Canada; the Medical Services Branch, DNHW; the National Advisory Committee on Immunization (NACI); and the US Centers for Disease Control. The first official meeting of CATMAT was held in Ottawa Feb. 1 and 2, 1990. CATMAT has made the following three recom-
mendations.
Indications for meningococcal vaccine This statement is intended to supplement the guidelines of NACI.I
Meningococcal meningitis is a severe disease and has a case-fatality rate of up to 15%. The meningococcal polysaccharide vaccine licensed for use in Canada is safe and is immunogenic for Neisseria meningitidis serotypes A, C, Y and W135; these include the serotypes most often implicated in epidemics (A and C). Primary vaccination with meningococcal vaccine should be considered for travellers who, as a result of their destinations or activities abroad, may be at risk of infection with the above four serotypes. In general, a person staying 2 weeks or more in any of the following areas is at risk for meningococcal disease: Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Egypt, Ethiopia, Kenya, Malawi, Mali, Morocco, Mozambique, Nepal, Niger, Nigeria, Saudia Arabia, Sudan, Tanzania and Togo. The area of India north from Delhi and east to Nepal is also an area of risk. Additions to or deletions from this list will appear in the monthly quarantinable diseases report in Canada Diseases Weekly Report. If activities - such as health care work - involve close exposure to nasopharyngeal secretions of local residents a period of less than 2 weeks would carry risk. For people 2 years of age or older primary vaccination should be given according to the manufacturer's directions; for those under 2 the primary vaccination schedule recommended in the Canadian Immunization Guide' should be followed.
Indications for Japanese encephalitis vaccine Japanese encephalitis is a severe viral disease and has a case-fatality rate of up to 10% despite optimal supportive care; the rate of permanent
Based on material previously reported in Canada Diseases Weekly Report (a publication ofthe Bureau ofCommunicable Disease Epidemiology, Laboratory Centre for Disease Control, Department ofNational Health and Welfare, Tunney's Pasture, Ottawa, Ont. KIA OL2) by the Committee to Advise on Tropical Medicine and Travel, Health Protection Branch, Department ofNational Health and Welfare (1990; 16: 153-155). Publication in CMAJ is with permission of the committee and the bureau. Reprint requests to: Dr. Robert C. Wittes, Chief, Division of Tropical Health and Quarantine, Bureau of Communicable Disease Epidemiology, Laboratory Centre for Disease Control, Tunney's Pasture, Ottawa, Ont. KJA OL2 CAN MED ASSOC J 1990; 143 (12)
1333
neurologic sequelae among survivors is high. The virus is transmitted by mosquitoes in either endemic or epidemic patterns in geographically limited areas of Asia from India east to Japan. The risk of disease among people who travel to Asia for short periods or who remain in urban areas of Asia is very low. Although there is no licensed vaccine in Canada the Biken vaccine - a formalin-inactivated mousebrain preparation produced in Japan - is available by arrangement with Mrs. D.E. Krepps, Bureau of Biologics, HPB, DNHW; (613) 957-0363. This vaccine is safe and highly immunogenic.2 The Biken vaccine should be administered according to the manufacturer's directions. Vaccination should be considered for travellers of any age who will spend 3 weeks or more in rural areas of the following countries during the transmission seasons of endemic or epidemic Japanese encephalitis: the temperate regions during summer and autumnBangladesh, Burma, China, northern India, Japan, Kampuchea, Korea, Laos, Nepal, northern Thailand, northern Vietnam and the eastern Soviet Union; and the tropical regions during the rainy season southern India, Indonesia, Malaysia, Philippines, Singapore, Sri Lanka, Taiwan, southern Thailand and southern Vietnam. Proximity to areas of rice culture or pig farming increases the risk of disease. If this vaccine becomes licensed in Canada NACI will prepare a statement regarding its use.
Prevention and treatment of malaria CATMAT has prepared official recommendations for the prevention and treatment of malaria that will be published imminently as a supplement in Canada Diseases Weekly Report. In the meantime there is a limited supply in Canada of primaquine, which is indicated for the radical cure of vivax and
ovale malaria. It is unclear for how long supplies will be limited. The following recommendations concern the use of primaquine during this shortage. Primaquine should be administered for the radical cure of documented or strongly suspected infection with Plasmodium vivax or P. ovale. It has no other place in the prevention or treatment of malaria. It is contraindicated during pregnancy and may cause significant hemolysis in people with glucose6-phosphate dehydrogenase (G6PD) deficiency. Before the drug is given the patient's G6PD level should be determined. Winthrop Pharma, Aurora, Ont., the distributor of primaquine in Canada, has given its stock of the drug to the Children's Hospital of Eastern Ontario, Ottawa, to be dispensed to physicians as needed. Physicians should send a request in writing, including the indication for the proposed use of the drug, documentation that the G6PD level has been determined and the name of the patient, to Dr. Ross A. Pennie, Director, Tropical and Travellers' Medicine, Children's Hospital of Eastern Ontario, 401 Smyth Rd., Ottawa, Ont. KlH8L1; (613)737-2765, FAX (613) 738-3216. On Pennie's authorization the hospital pharmacy will send the requested number of tablets (cash on delivery) to the requesting physician. Once the shortage of primaquine is rectified the drug will again be available through prescription in pharmacies, and a note will be published in Canada Diseases Weekly Report stating that the special conditions no longer apply.
References 1. Canadian Immunization Guide, 3rd ed, Dept of National Health and Welfare, Ottawa, 1989
2. Japanese encephalitis vaccination, with reference to travellers to Seoul, Korea. Can Dis Wkly Rep 1988; 14: 161-162
Foreign travel Now the rotten diseases of the South, the guts-griping, ruptures, catarrhs, loads o'gravel i' th' back, lethargies, cold palsies, raw eyes, dirt-rotten livers, whissing lungs, bladders full of imposthume, sciaticas, limekilns i' th' palm, incurable boneache, and the rivelled fee simple of the tetter, take and take again such preposterous discoveries!
William Shakespeare (1564-1616)
1334
CAN MED ASSOC J 1990; 143 (12)
