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Malaria Prevention Measures in Coalition Troops in Afghanistan
To the Editor: Following the September 11, 2001, attacks on New York and Washington, the International Security Assistance Force (ISAF) was created in Afghanistan in December 2001 with support from 16 nations. By 2006, ISAF support increased to 36 nations, with approximately 115 000 coalition troops serving during this period. Malaria, especially Plasmodium vivax, is prevalent between May and November in all areas of Afghanistan less than 6667 feet above sea level.1 Since 2002, 85 cases of P vivax malaria have been reported in British, German, and US troops that have been linked to military service with ISAF,2-4 and it is likely that additional cases have occurred.
We conducted a survey to compare malaria prevention measures in use by coalition forces in Afghanistan in 2006 and to evaluate the level of international agreement for this area of clinical practice.
Methods
In June 2006 the malaria prevention policy of each ISAF force was evaluated through a standardized 7-part questionnaire (Box) sent to each senior national representative, a designated staff officer stationed within the ISAF headquarters in the city of Kabul. The senior national representatives were requested to verify national policy with their respective medical personnel in theater. Drug dosage was not ascertained, assuming that all countries would follow manufacturers' standard dosing recommendations.
| Box. Malaria Prevention Questionnaire, ISAF Senior National Representatives, June 2006
- What is your nation's officially recommended antimalaria drug regimen for Afghanistan as of June 2006? (Please give drug names)
- What is your nation's official policy for when antimalaria drugs should be started before entering Afghanistan?
- What is your nation's official policy for when antimalaria drugs should be discontinued after leaving Afghanistan?
- During which months of the year are troops of your nation, deployed in Afghanistan, officially advised to take antimalaria drugs?
- Which of the following additional antimalaria measures are officially recommended to troops of your nation deployed in Afghanistan?
- Use of mosquito net?
- Mosquito net treated with insecticide?
- Uniform treated with insecticide?
- Skin-applied insect repellent?
- Mosquito coils?
- Vaporizing mats?
- Electronic buzzers?
- Carrying of personal-issue malaria warning card?
- Have there been any cases of malaria in your national force in Afghanistan?
- Please mention any other factors relevant to your nation's malaria prevention policy in its troops deployed in Afghanistan.
Abbreviation: ISAF, International Security Assistance Force
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The survey was administered in English, the working language of the North Atlantic Treaty Organization, after piloting on a multinational convenience sample of clinical and nonclinical personnel and minor revision. Representatives were sent 1 written reminder.
Results
Of the 36 troop-contributing nations, representatives of 28 (78%) responded to the survey, with 20 (55%) answering all questions. The nonresponders were Albania, Azerbaijan, Bulgaria, Estonia, Finland, Georgia, Latvia, and Switzerland. Eighteen (64%) of the 28 responders validated their responses in theater and reported more than 98% accuracy.
Except for France and the Irish Republic, no countries had identical malaria prevention policies (Table). Divergence in the antimalarial drugs routinely used by ISAF troops was notable, with 15 nations (54%) reporting the use of mefloquine as their preferred agent, 4 (14%) chloroquine-proguanil, 4 (14%) doxycycline, 2 (7%) chloroquine alone, 1 (4%) atovaquone-proguanil, and 1 (4%) proguanil alone for all deployments in Afghanistan of longer than 2 weeks. One nation (Romania) replied that it did not routinely use malaria prophylaxis for its ISAF force in Afghanistan.
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Table. Malaria Prevention Measures Reported by ISAF Senior National Representatives, June 2006*
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Twenty ISAF nations used at least 1 additional nondrug technology to prevent malaria. Eighteen nations (64%) reported using topically applied insect repellent and 13 (46%) insecticide-treated uniforms. Seventeen nations (61%) reported using bed nets, although only 11 (39%) stated that these were pretreated with insecticide. Five nations (18%) reported issuing malaria warning cards to their ISAF troops. Three (11%) reported using vaporizing mats, 2 (7%) mosquito coils, and 2 (7%) electronic buzzers.
No representatives of any nations reported cases of malaria occurring in Afghanistan except New Zealand (in Bamyan) and Norway (1 in 2004).
Comment
These results indicate discrepancies in malaria prevention policies between ISAF nations with troops serving in Afghanistan, although this lack of concordance may be partly due to differing perceptions of disease risk. There is compelling evidence that insecticide-treated bed nets are effective in preventing malaria in travelers, and insecticide-treated clothing and certain drugs (atovaquone-proguanil, doxycycline) are also likely to be beneficial.5 However, the use of chloroquine for chemoprophylaxis in a region known to have chloroquine-resistant Plasmodium falciparum and the use of electronic buzzers and mosquito coils conflicts with current evidence.5-7
There are limitations to this study. The survey was conducted in English, which may have introduced a response bias or resulted in inaccurate responses. The survey does not measure adherence to policy by individual military personnel, and as such cannot be directly linked to outcomes. Nevertheless, these national differences have the potential to engender confusion locally and contribute to malaria acquisition.
Author Contributions: Dr Croft had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Croft.
Acquisition of data: Darbyshire, Jackson.
Analysis and interpretation of data: Croft, Darbyshire, Jackson, van Thiel.
Drafting of the manuscript: Croft, Darbyshire, van Thiel.
Critical revision of the manuscript for important intellectual content: Croft, Darbyshire, Jackson, van Thiel.
Financial Disclosures: None reported.
Funding/Support: No outside funding or support was received for this study.
Disclaimer: The views, opinions, and/or findings contained in this study are those of the authors and should not be construed as the official North Atlantic Treaty Organization or non-North Atlantic Treaty Organization military position, policy, or decision, unless so designated by other official documentation.
Acknowledgment: We thank Ratimir Ben i , MD (ISAF Croatia), Roman Janto , MD (ISAF Slovakia), Serdor Kavak, MD (ISAF Turkey), Lopez Poves, MD (ISAF Spain), and Carl Gustav Schultz, MD (ISAF Sweden), for their help in facilitating this survey. They received no compensation for participation in this study.
Ashley M. Croft, MD
ashley.croft810{at}land.mod.uk
Headquarters Fifth Division
Shrewsbury, United Kingdom
Alicia H. Darbyshire, MD
Headquarters International Security Assistance Force
Kabul, Afghanistan
Christopher J. Jackson, MD
Camp Souter
Kabul, Afghanistan
Pieter P. van Thiel, MD
Academic Medical Center
University of Amsterdam
Amsterdam, the Netherlands
1. Funk-Baumann M. Geographic distribution of malaria at traveler destinations. In: Schlagenhauf P, ed. Travelers' Malaria. Hamilton, Ontario: BC Decker, Inc; 2001:56-93.
2. Malaria in military personnel returning from Afghanistan. Commun Dis Rep CDR Wkly. 2002;12:4-5. http://www.hpa.org.uk/cdr/archives/2002/cdr2702.pdf. Accessed February 26, 2007.3. Boecken GH. Pathogenesis and management of a late manifestation of vivax malaria after deployment to Afghanistan: conclusions for NATO armed forces medical services. Mil Med. 2005;170:488-491.
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4. Ciminera P, Brundage J. Malaria in US military forces: a description of deployment exposures from 2003 through 2005. Am J Trop Med Hyg. 2007;76:275-279.
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5. Croft AM. Malaria: prevention in travelers. In: Tovey D, ed. Clinical Evidence. London, England: BMJ Publishing Group; 2005:954-972.6. Centers for Disease Control and Prevention. The yellow book, travelers' health, regional malaria information. http://www.cdc.gov/travel/regionalmalaria/indianrg.htm#malariarisk. Accessed February 26, 2007.7. Lawrance CE, Croft AM. Do mosquito coils prevent malaria? a systematic review of trials. J Travel Med. 2004;11:92-96.
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Letters Section Editor: Robert M. Golub, MD, Senior Editor.
JAMA. 2007;297(20):2197-2200.
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
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