title: Imported pediatric malaria at the Hospital for Sick Children, Toronto, Canada: a 16 year review.
abstract: BACKGROUND
  Children under 5 represent 86% of annual malaria deaths in the world. Following increasing trends in international travel, cases of imported malaria are rising in North America. We describe the epidemiology of malaria diagnosed at a tertiary care pediatric center in the multicultural city of Toronto.
  
  
  METHODS
  Retrospective chart review of all laboratory confirmed malaria from birth to <18 years between July 1, 1997 and June 30, 2013. Epidemiological data, travel history, chemoprophylaxis history, as well as clinical presentation, diagnosis and treatment were extracted.
  
  
  RESULTS
  In total 107 children were diagnosed with malaria in the 16 year time period. Plasmodium falciparum malaria was identified in 76 (71%), Plasmodium vivax in 28 (26%). Median age of infected children was 6.7 years where 35% of children were born in Canada, 63% were recent or previous immigrants. Of those who resided in Canada, reason for travel included visiting friends or relatives (VFR) 95% and tourism or education (5%). Most common countries of infection were Ghana (22%), Nigeria (20%) and India (14%). Median parasitemia at presentation to our institution was 0.4% (IQR 0.1-2.3) with a maximum parasitemia of 31%. Nineteen (18%) met the WHO criteria for severe malaria due to hyperparasitemia, with 3 of these cases also meeting clinical criteria for severe malaria. One third of patients had a delay in treatment of 2 or more days. Ten percent of children had seen two or more primary health care professionals prior to admission. Prophylaxis was documented in 22 (21%), and out of those, 6 (27%) were appropriate for the region of travel and only 1 case was documented as adherent to their prescription. There were no cases of fatality.
  
  
  CONCLUSIONS
  Malaria continues to be a significant disease in returning travelers and immigrant or refugee populations. An increase in physician awareness is required. Appropriate pre-travel advice, insect protection measures, effective chemoprophylaxis is needed to reduce the incidence and improve the management of imported pediatric malaria.
authors.forename: Andrea B
authors.initials: AB
authors.lastname: Evans
authors.forename: Dina
authors.initials: D
authors.lastname: Kulik
authors.forename: Anna
authors.initials: A
authors.lastname: Banerji
authors.forename: Andrea
authors.initials: A
authors.lastname: Boggild
authors.forename: Kevin C
authors.initials: KC
authors.lastname: Kain
authors.forename: Mohamed
authors.initials: M
authors.lastname: Abdelhaleem
authors.affiliation: Division of Infectious Diseases, Hospital for Sick Children, 555 University Ave, Toronto, ON M5G1X8, Canada. shaun.morris@sickkids.ca.
authors.forename: Shaun K
authors.initials: SK
authors.lastname: Morris
mesh_terms: D000293:Adolescent; D000962:Antimalarials / Q000627:therapeutic use; D002170:Canada / Q000453:epidemiology; D018890:Chemoprevention / Q000706:statistics & numerical data; D002648:Child; D002675:Child, Preschool; D054242:Emigrants and Immigrants / Q000706:statistics & numerical data*; D005260:Female; D006776:Hospitals, Pediatric; D006801:Humans; D007223:Infant; D007902:Length of Stay; D008288:Malaria / Q000188:drug therapy / Q000453:epidemiology* / Q000517:prevention & control; D008297:Male; D018512:Parasitemia / Q000453:epidemiology; D012189:Retrospective Studies; D061665:Time-to-Treatment; D014195:Travel
chemical_list: D000962:Antimalarials