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09-10-2003, 09:55 AM
Someone dropped the ball on this one bigtime...
http://www.washingtonpost.com/wp-dyn/articles/A51637-2003Sep9.html
Failed Safeguards Are Blamed For Marines' Malaria Outbreak
By David Brown
Washington Post Staff Writer
Wednesday, September 10, 2003; Page A16
Despite extensive preventive measures, most of the more than 200 Marines who spent time ashore in Liberia last month apparently contracted malaria, with about 43 of them ill enough to be hospitalized.
The malaria outbreak amounts to a stunning failure of standard protections against a disease that the American military is unusually keen to prevent in troops deployed to the tropics. So many Marines became sick in such a short time that Navy physicians for a while doubted the illnesses could all be because of the mosquito-borne infection.
Although the malaria diagnosis has been confirmed in only 15 percent of the troops, they and their officers report that nearly all who spent the two weeks ashore reported at least mild symptoms typical of malaria. Navy physicians and epidemiologists investigating the outbreak believe most of the onshore troops may have been infected.
"We are extremely, extremely concerned about this," said Capt. Gregory J. Martin, a physician at National Naval Medical Center in Bethesda, where all but two patients are being treated. The concern is shared not only by the military's infectious diseases and preventive medicine specialists but by combat commanders, he said.
The outbreak occurred even though the troops were taking a drug to prevent the disease, were instructed to use insect repellents and were wearing uniforms treated with long-acting insecticides.
How the Marines became infected despite these measures is uncertain, although failure of the drug to reach adequate concentrations in the troops' bloodstreams is a leading hypothesis.
The patients, members of the 26th Marine Expeditionary Unit except for several Navy medical corpsmen, were taking mefloquine (sold as Lariam), a standard drug used to prevent and treat malaria. West Africa is not known to be an area with high rates of mefloquine-resistant disease, although occasional cases have been reported there. U.S. troops in West Africa have since switched to an alternative medication, doxycycline.
This is the most intensive outbreak of malaria in the U.S. armed services in recent memory and the largest number of cases among Marines since the deployment to Somalia a decade ago. All of the cases were caused by Plasmodium falciparum, one of three types of malaria parasite and by far the most dangerous.
The number of malaria cases in the armed services in recent years was not available yesterday. The Army, which has the most, reported 57 cases last year, 52 in 2001 and 55 in 2000.
Thirty-one patients arrived at the Bethesda hospital Sunday and 10 yesterday morning. Two others are being treated at the Army hospital in Landstuhl, Germany.
No one has died in the outbreak, but two patients in the Bethesda intensive care unit have cerebral malaria, the most feared form of the disease, with a fatality rate of about 20 percent. They are conscious, improving and expected to recover fully, said Lt. Cmdr. David L. Blazes, an infectious-diseases physician treating them.
Members of the Marine unit, normally stationed at Camp Lejeune, N.C., went ashore Aug. 12-14 and returned to their two ships 10 to 12 days later. Soon afterward, many reported common symptoms of malaria, including headache, pain behind the eyes and muscle aches accompanied by cyclical fevers.
Malaria is normally diagnosed by using a microscope to look for malaria parasites inside red blood cells. Many of the Marines received diagnoses aboard ship that way. In some of the 43 people -- 40 Marines and three sailors -- no parasites were seen, probably because the infection was partially treated by the mefloquine, but "virtually everyone had classical symptoms" of the disease, Blazes said.
About 30 patients who arrived at Bethesda on Sunday were put in a separate unit because physicians feared some might have some other disease; malaria rarely shows up in sudden, severe outbreaks. The possibilities included Lassa fever, which is caused by a virus; leptospirosis, caused by a bacterium; or infections arising from bacteria-like microbes called rickettsia.
"It was hard to believe that you could have almost all of a group that large develop symptoms over a four- to five-day period and have it be malaria," Martin said.
Blood samples were sent to the Army's infectious diseases laboratory at Fort Detrick in Frederick, and within 12 hours those infections were ruled out.
Nearly all the Marines said they had taken their once-a-week mefloquine pills; a few said they had missed a dose or two. Many had been taking it since June.
Normally, a case of malaria is considered severe if more than 3 percent of red blood cells are infected with the parasite. Several of the Marines, including one who reported never missing a dose of mefloquine, had more than 10 percent of their cells infected.
Peter B. Bloland, a malaria epidemiologist at the Centers for Disease Control and Prevention, said there are only a few possible explanations for the outbreak.
"The possibilities include inadequate absorption [of the drug into the bloodstream], people not taking it correctly, poor drug quality or actual resistance" to the drug in the microbes, he said. The experience of Peace Corps volunteers in West Africa, who live in areas of intense malaria transmission for long periods of time, suggests that mefloquine-resistant infections are rare there, he added.
"Based on what we know about failures of prophylaxis in Africa, I think the most common explanation is inadequate blood levels [of the preventive drug] for some reason," he said.
About 120 samples of blood taken from the Marines shortly before they became ill will be sent to CDC to measure mefloquine levels.
http://www.washingtonpost.com/wp-dyn/articles/A51637-2003Sep9.html
Failed Safeguards Are Blamed For Marines' Malaria Outbreak
By David Brown
Washington Post Staff Writer
Wednesday, September 10, 2003; Page A16
Despite extensive preventive measures, most of the more than 200 Marines who spent time ashore in Liberia last month apparently contracted malaria, with about 43 of them ill enough to be hospitalized.
The malaria outbreak amounts to a stunning failure of standard protections against a disease that the American military is unusually keen to prevent in troops deployed to the tropics. So many Marines became sick in such a short time that Navy physicians for a while doubted the illnesses could all be because of the mosquito-borne infection.
Although the malaria diagnosis has been confirmed in only 15 percent of the troops, they and their officers report that nearly all who spent the two weeks ashore reported at least mild symptoms typical of malaria. Navy physicians and epidemiologists investigating the outbreak believe most of the onshore troops may have been infected.
"We are extremely, extremely concerned about this," said Capt. Gregory J. Martin, a physician at National Naval Medical Center in Bethesda, where all but two patients are being treated. The concern is shared not only by the military's infectious diseases and preventive medicine specialists but by combat commanders, he said.
The outbreak occurred even though the troops were taking a drug to prevent the disease, were instructed to use insect repellents and were wearing uniforms treated with long-acting insecticides.
How the Marines became infected despite these measures is uncertain, although failure of the drug to reach adequate concentrations in the troops' bloodstreams is a leading hypothesis.
The patients, members of the 26th Marine Expeditionary Unit except for several Navy medical corpsmen, were taking mefloquine (sold as Lariam), a standard drug used to prevent and treat malaria. West Africa is not known to be an area with high rates of mefloquine-resistant disease, although occasional cases have been reported there. U.S. troops in West Africa have since switched to an alternative medication, doxycycline.
This is the most intensive outbreak of malaria in the U.S. armed services in recent memory and the largest number of cases among Marines since the deployment to Somalia a decade ago. All of the cases were caused by Plasmodium falciparum, one of three types of malaria parasite and by far the most dangerous.
The number of malaria cases in the armed services in recent years was not available yesterday. The Army, which has the most, reported 57 cases last year, 52 in 2001 and 55 in 2000.
Thirty-one patients arrived at the Bethesda hospital Sunday and 10 yesterday morning. Two others are being treated at the Army hospital in Landstuhl, Germany.
No one has died in the outbreak, but two patients in the Bethesda intensive care unit have cerebral malaria, the most feared form of the disease, with a fatality rate of about 20 percent. They are conscious, improving and expected to recover fully, said Lt. Cmdr. David L. Blazes, an infectious-diseases physician treating them.
Members of the Marine unit, normally stationed at Camp Lejeune, N.C., went ashore Aug. 12-14 and returned to their two ships 10 to 12 days later. Soon afterward, many reported common symptoms of malaria, including headache, pain behind the eyes and muscle aches accompanied by cyclical fevers.
Malaria is normally diagnosed by using a microscope to look for malaria parasites inside red blood cells. Many of the Marines received diagnoses aboard ship that way. In some of the 43 people -- 40 Marines and three sailors -- no parasites were seen, probably because the infection was partially treated by the mefloquine, but "virtually everyone had classical symptoms" of the disease, Blazes said.
About 30 patients who arrived at Bethesda on Sunday were put in a separate unit because physicians feared some might have some other disease; malaria rarely shows up in sudden, severe outbreaks. The possibilities included Lassa fever, which is caused by a virus; leptospirosis, caused by a bacterium; or infections arising from bacteria-like microbes called rickettsia.
"It was hard to believe that you could have almost all of a group that large develop symptoms over a four- to five-day period and have it be malaria," Martin said.
Blood samples were sent to the Army's infectious diseases laboratory at Fort Detrick in Frederick, and within 12 hours those infections were ruled out.
Nearly all the Marines said they had taken their once-a-week mefloquine pills; a few said they had missed a dose or two. Many had been taking it since June.
Normally, a case of malaria is considered severe if more than 3 percent of red blood cells are infected with the parasite. Several of the Marines, including one who reported never missing a dose of mefloquine, had more than 10 percent of their cells infected.
Peter B. Bloland, a malaria epidemiologist at the Centers for Disease Control and Prevention, said there are only a few possible explanations for the outbreak.
"The possibilities include inadequate absorption [of the drug into the bloodstream], people not taking it correctly, poor drug quality or actual resistance" to the drug in the microbes, he said. The experience of Peace Corps volunteers in West Africa, who live in areas of intense malaria transmission for long periods of time, suggests that mefloquine-resistant infections are rare there, he added.
"Based on what we know about failures of prophylaxis in Africa, I think the most common explanation is inadequate blood levels [of the preventive drug] for some reason," he said.
About 120 samples of blood taken from the Marines shortly before they became ill will be sent to CDC to measure mefloquine levels.