Good afternoon, Mr. Chair and members of the Standing Committee on Veterans Affairs.
Thank you for the opportunity to discuss the use of mefloquine as a medication to prevent malaria in the Canadian Armed Forces.
As you know, malaria is one of the world's most significant infectious diseases. In 2017, the World Health Organization estimated the global burden of this disease to be 219 million cases and 435,000 deaths. The overall fatality rate of malaria is about 1%, and this rises to about 20% for individuals with severe disease.
When deploying to a malaria-prone area, we use a number of complementary countermeasures to prevent malaria. Most important in this regard is the use of prophylactic medications.
Our approach to malaria prevention is based on guidelines developed by the Canadian Committee to Advise on Tropical Medicine and Travel, CATMAT. This group, which advises the Public Health Agency of Canada, recommends a number of different medications, including mefloquine, as being suitable for the prevention of malaria.
Mefloquine is also one of the medications recommended by many other agencies around the world, including the U.S. Centers for Disease Control and Prevention and the World Health Organization.
Health Canada is the agency that regulates and approves drugs for use in Canada. Health Canada continues to approve the use of mefloquine for malaria prevention and treatment. From the 1990s until recently, mefloquine was one of the primary malaria prevention medication options for CAF members. Compared to alternatives, it does have some advantages, including that it need only be taken once a week.
Since its first use in the CAF, approximately 18,000 prescriptions for this medication have been given to CAF members. By contrast, mefloquine has been prescribed to hundreds of thousands of civilian Canadians.
In 2016, recognizing the ongoing concerns about mefloquine, the chief of defence staff directed that a review be conducted on the use of mefloquine by the Canadian Armed Forces. The surgeon general formed a task force to conduct the review. Its work was completed in the spring of 2017.
The task force concluded that the CAF policy on malaria prevention was consistent with Canadian clinical practice guidelines. It also reported that mefloquine use had significantly declined in the CAF in the previous number of years.
The task force reviewed the scientific literature, concluding that the weight of scientific evidence did not support the notion that mefloquine was less safe or less well tolerated than alternative medications. However, it did also note limitations of this evidence and that there was insufficient research evaluating the long-term effects of mefloquine.
The task force recommended that mefloquine be prescribed only under specific circumstances, like intolerance to other medications. Other recommendations led to an enhanced patient screening process for all malaria medications and an online supplemental training program for providers. Since January 2018, three Canadian Armed Forces members have received a prescription for mefloquine.
I know there are Canadian military members and veterans who have or have had long-term neurological or psychiatric symptoms, and many worry that mefloquine contributed to their illness. Their concern is understandable, especially given the level of discussion and debate in the media and in the scientific and medical communities. We know that mefloquine, like any medication, has short-term side effects, and we acknowledge that there is some scientific evidence indicating the possibility of long-term or even permanent neuropsychiatric effects. Certainly, this is listed as a potential in the product monograph.
Our assessment of the literature is that there remain many unanswered questions around this hypothesis. The evidence supporting it is insufficient and has been challenged by many experts. Additionally, population-based studies, which give us an indication of the level of risk, have not demonstrated a significant burden of long-term illness in those who have taken mefloquine. I acknowledge that these population studies have their own limitations as well.
I think there is still much to be learned about the health impacts of mefloquine, so I am pleased that the U.S. National Academies of Sciences, Engineering, and Medicine are undertaking a project specifically to assess the long-term risk of anti-malarial medications, particularly mefloquine. We hope that this and other research work will clarify the situation and help us to better care for those who are suffering.
Thank you for the opportunity to speak to the committee today.