36 Imported Severe and Complicated Malaria at the Hospital for Sick Children, Toronto, 1989–2001

Imported malaria is a growing problem in Canada. Malaria is associated with considerable morbidity and mortality especially in children. The objective of this study was to determine the demographics, risk factors, and management of imported paediatric malaria at our hospital between 1989–2001.

A retrospective chart review was conducted on all inpatient cases of malaria treated at The Hospital for Sick Children (HSC) between 1989–2001. Charts were identified by the discharge diagnosis in the Health Records Department. Study approval was provided by our hospital Research Ethics Board.

Over the 12-year study period, 72 children were treated for malaria as inpatients at the HSC. This represents a 50% increase in the average number of cases a year admitted to our hospital compared to the previous ten years. The majority (72%) of cases were caused by Plasmodium falciparum acquired in Africa. Ninety-five percent of cases were identified in new immigrants or in children of new Canadian families returning to their country of origin to visit friends and relatives (VFRs). Of the Canadians traveling abroad to endemic countries, 58% sought pre-travel advice and were prescribed chemoprophylaxis against malaria. However, only 16% took the medication according to recommended guidelines. Once these patients returned to Canada, physicians missed the diagnosis of falciparum malaria in 29% of cases, leading to a delay in diagnosis by 4.8 days. Of the 52 cases of falciparum malaria, 18 (35%) met WHO criteria for severe malaria including cerebral malaria (25%) and severe anemia requiring transfusion (25%). According to current WHO and Health Canada guidelines, treatment was inappropriate in 61% of cases. No patients in the study population died.

Imported malaria in children, particularly severe falciparum malaria, is on the rise in Toronto. Immigrant children and Canadian-born children to VFR parents represent the major risk group for imported paediatric malaria. Few if any of these children were adequately protected with appropriate chemoprophylaxis. Upon return to Canada, the diagnosis of malaria in these children was frequently missed or delayed. Due to the potential for life-threatening complications and increasing drug resistance, therapy for severe malaria in Canada should include intravenous quinine (including a loading dose) plus a second agent such as clindamycin, doxycycline (for those older than age 7 years), or atovaquone-proguanil.