13 Data from annual surveys do not, however, reflect these episodes. The numbers of travelers to malaria-endemic countries have increased since 2000 and were highest

in the first and last quarter of the year, probably reflecting Christmas and winter holidays. The number of malaria cases did not follow any seasonality, likely because of the small number of cases per quarter. The lack of increase in the numbers of organized MAPK inhibitor trips and the concomitant increase in traveling to malaria-endemic areas suggest that self-organized trips to malaria-endemic areas has increased. We used antimalarial drug sales as an indicator of the use of chemoprophylaxis. Drug sales have also been used as an indirect measure of disease activity.14 Antimalarial drug sales were highest in the first and last quarter of the years, following the same trend as traveling to malaria-endemic countries. Drug sales BMN 673 order decreased since 1997, but started to increase slowly from 2005 onward. This increase coincided with the marketing authorization of atovaquone/proguanil combination in Finland in 2006. The drug got its first marketing approval in 1996, but was registered only 10 years later. Sales of proguanil decreased until 2006 when it stopped being used as a single agent. During

the 1990s chloroquine was used also to treat rheumatic disorders but, in the last 10 years, its use for this purpose was very unlikely (Professor Marjatta Leirisalo-Repo, personal communication, January 25, 2010). This change probably contributes to the decrease in the use of chloroquine. Caution buy Forskolin should be used when interpreting the trends on DDD sales. Differences in drug accessibility and approval schemes should be taken into account when drug usage is compared between countries. Although doxycycline is included in the Finnish guidelines for malaria chemoprophylaxis, it was not included in our study. Doxycycline is mainly

used for other indications, and there was no way of discriminating between the proportions of sales used for different purposes. Taking this into account, it remains fully possible that the use of doxycycline as an antimalarial could have increased significantly and this increase could, at least partly, account for the decrease observed with the other drugs sales. Our results show that antimalarial drug sales cannot be used alone to assess the use of chemoprophylaxis. The decrease in drug sales may be explained by several factors such as travelers fearing adverse drug reactions,15 choosing to buy drugs at destination,16 or underestimating the risk of malaria. During recent years internet discussion sites have become an important source of information for travelers and may sometimes even be trusted more than official sites. In addition, the level of compliance to antimalarials is known to be low,5,6,17 and no data exist as to whether people buying the drugs actually take them accurately.