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thedrifter
09-10-03, 01:29 PM
Malaria Cases Among Marines Probed
Associated Press
September 10, 2003


WASHINGTON - Navy doctors are investigating what one official called an incredibly high rate of malaria among Marines and sailors who were briefly in Liberia last month on a peacekeeping mission.

Forty-three patients have been evacuated from their ships off the West African shore to hospitals in Germany and the United States, 13 confirmed with one of the most common types of the mosquito-borne illness, falciparum, said Capt. Greg Martin of the National Naval Medical Center in Bethesda, Md.

The 43 represent almost 20 percent of 225 Marines and Navy personnel who went ashore last month. Officials are closely watching the rest, an unknown number of whom also are reported to have complained of symptoms, Martin said.

"There are a lot of questions about this," he told a press conference Tuesday in the Washington suburb of Bethesda, to where most were taken. He said doctors are uneasy because the cases represent "an incredibly high attack rate" among those deployed.

Doctors are looking into three possibilities, he said: That type of malaria has become resistant to the drug the Marines have been taking; troops didn't take it correctly; the drug had gone bad or there was a flaw in its manufacture.

All going ashore are being switched to another antimalarial in case resistance is the problem, doctors said.

In addition to the confirmed cases, seven Marines tested positive in initial blood tests but have not been confirmed as having the disease, officials said.

Five are of the cases are serious, including two patients with cerebral malaria, but all are expected to recover, said Lt. Cmdr. David Blazes, who is caring for those brought to Bethesda.

Martin said the Marines and sailors started taking the antimalarial drug mefloquine in late June or early July in a regimen that requires troops to begin dosing two weeks in advance of a deployment, then take the drug once a week thereafter for a month until they have been out of the risk area for a month.

The military also gives troops a repellent cream containing DEET and mosquito netting.

The 40 Marines and three naval officers who fell ill went ashore in Liberia from the amphibious assault ship USS Iwo Jima and the amphibious landing dock USS Carter Hall, said Lt. Cmdr. Chito Peppler, a spokesman at the Bethesda center.

Col. Jay DeFrank, a Defense Department spokesman, said the Marines, members of the 26th Marine Expeditionary Unit based at Camp Lejeune, N.C., were in Liberia in mid-August as part of a U.S. quick-reaction force of about 150 troops. They operated from an airport outside Monrovia, the capital, for about 10 days.

Others went back and forth from the ships to land, sometimes for as little as a couple of hours at a time.

Doctors said they are asking the patients whether they took their drugs faithfully, whether they slept inside or out at night and other pertinent questions.

Forty-one of the patients were taken to Bethesda and two to the Landstuhl Regional Medical Center in Germany in the medical evacuations that began over the weekend.

Because malaria is spread by mosquitoes, it presented no communicable disease risk to the other Marines and Navy men aboard the ships outside the affected area.

Other officials said that as a precaution, movements of Marines ashore in Liberia from the Iwo Jima and two other U.S. Navy ships off the Liberian coast were being limited for the time being.

About 136 American troops still are ashore in Liberia, mostly Marines providing security at the U.S. Embassy in Monrovia. The Iwo Jima and two other ships off the coast carry about 2,200 Marines and about 2,500 sailors.

Malaria is transmitted by mosquitos, which breed in stagnant water and tall grass.

The disease infects 300 million people a year - and kills at least 1 million - in Africa and elsewhere and has become increasingly resistant to drugs, according to the World Health Organization and the United Nations Children's Fund, UNICEF. Some 3,000 African children die every day from it, the United Nations said in a report early this year.

About 800 American civilians come home with malaria each year from trips abroad, according to the Centers for Disease Control and Prevention.

The malaria parasite has developed resistance to the old standby drug, chloroquine, in most of the world, rendering that drug largely useless and leaving only mefloquine and two others.

Large areas of Central and South America, the Dominican Republic and Haiti, the Indian subcontinent, Southeast Asia, the Middle East, and Oceania also are considered malaria-risk areas, according to the CDC.

Sempers,

Roger
:marine:

thedrifter
09-10-03, 01:31 PM
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.


© 2003 The Washington Post Company

http://www.washingtonpost.com/wp-dyn/articles/A51637-2003Sep9.html

http://media.washingtonpost.com/wp-dyn/images/I52772-2003Sep10L

Members of the 26th Marine Expeditionary Unit take up positions after being dropped by helicopter outside Monrovia, Liberia, last month in a peacekeeping effort.

Photo Credit: Ben Curtis -- AP


Sempers,

Roger
:marine: