Navy Medical Department Guide to Malaria Prevention and Control

Chapter 6: Military Malaria Control Responsibilities

Department of the Navy
Bureau of Medicine and Surgery

Throughout history, diseases and non-battle injuries (DNBI) have resulted in more casualties to the Navy/Marine Corps team than combat. Historically, malaria has been the most formidable disease to prevent. The resources expended in its treatment, and the personnel hours lost due to malaria significantly decrease force readiness, especially in combat situations.

Prevention of DNBI is arguably the most important mission of military medicine. Success is achieved only when line commanders are convinced that principles of preventive medicine are an essential element in force protection. As Field Marshal Slim maintained (see Introduction), the countermeasures necessary to prevent malaria must be enforced by line commanders. Medical personnel must understand and practice the following three basic principles of Force Protection:

1. Threat assessment.

2. Countermeasure selection and implementation.

3. Reassessment of threats and countermeasures guided by outcome measurement and analysis.

After careful analysis of the deployment situation, appropriate countermeasure recommendations to commanders can be made. Then, with command support, countermeasure training and coordination can be instituted throughout the chain of command.

Medical Surveillance. Medical personnel must actively track unit illnesses and injuries. A single case of malaria may constitute an outbreak and signals a breakdown in preventive measures. Cases must be investigated and analyzed by unit medical personnel. Recommendations to correct the problem should be made immediately to the unit commander and followed by the institution of corrective measures.

This chapter will outline the application of the second and third principles to control malaria and other DNBIs by the chain of command. In general, malaria control is achieved through Personal Protective Measures, Mosquito Control, and Chemoprophylaxis. In military situations, personal protective measures and chemoprophylaxis are simple, effective, and successful. Mosquito control may be less suitable in contingency settings but can be particularly useful in long-term or humanitarian operations. Consult the cognizant medical entomologist. To prevent malaria, strong line involvement and enforcement is essential. Medical personnel must work closely with line commanders and staff to implement measures to prevent malaria.

I. Line Commander Responsibilities

CINCs and JTF Commanders. These commanders exercise authority over all assigned and attached forces in their area of operations. The decisions they make regarding medical guidance, assignment of medical tasks, and the joint medical concept of the operation are based on the advice received from CINC or Joint Task Force Surgeons. Prior to the operation, detailed medical guidance is published in Annex Q of the operation order. The malaria risk is characterized, and required countermeasures selected are included in that document. Annex Q is prepared by the CINC or JTF Surgeon staff, endorsed by the CINC or JTF commander.

This process reveals the impact that medical advice has on military operations. Line commanders need their medical officers to supply accurate, clear advice to enable them to make decisions to keep their forces ready. Jonathan Letterman, the Medical Director for the Army of the Potomac during the Civil War, clearly defines that role in the following quote:

"A corps of medical officers was not established solely for the purpose of attending the sick and wounded...the labors of medical officers covers a more extended field. The leading idea, which should be constantly kept in view, is to strengthen the hands of the Commanding General by keeping his army in the most vigorous health, thus rendering it, in the highest degree, efficient for enduring fatigue and for fighting. In this view, the duties of the corps are of vital importance to the success of an army, and commanders seldom appreciate the full affect of their proper fulfillment."

Fleet and Force Commanders. These service commands are responsible for training and equipping units in their service, and maintaining their operational readiness. In prevention of DNBI (malaria control), their function is to provide all supplies necessary for implementation of countermeasures, as well as to ensure that all personnel are trained to employ personal protective measures. An example of this is First Marine Expeditionary Force's readiness policy requiring every Marine deploying as part of a Marine Expeditionary Unit (MEU) to have three sets of utility uniforms pretreated with permethrin.

Unit Commanding Officers. The success of malaria control depends on the enforcement of personal protective measures by Commanding Officers (COs). Part of the responsibility of enforcing personal protective measures is ensuring that personnel are adequately trained and can employ them. Commanding officers ultimately decide how chemoprophylaxis is administered, whether before a meal, by separate departments, or by employment of directly observed therapy (DOT). Finally, they must provide a surveillance report as directed in the Navy reportable disease instruction. Accurate surveillance data and analysis yield accurate reassessment of threats and countermeasures.

II. Medical Department Responsibilities

DNBI and malaria control efforts depend on medical department personnel. They provide the expertise to: 1) perform medical surveillance; 2) educate, train, and supervise the employment of personal protective measures and chemoprophylactic regimens; 3) diagnose and treat malaria, and other diseases and injuries; and 4) perform vector surveillance and control. Superior medical departments train their personnel to demonstrate and instruct other service members in the use of field hygiene and personal protective measures. In addition, they instruct corpsmen as well as medical officers to be familiar with the various chemoprophylaxis and treatment regimens, and the alternate treatments required for G-6-PD deficient individuals, pregnant service members, and persons who have had adverse reactions from anti-malarial drugs.

Medical personnel also must understand the threat in order to counter it. Essential sources of medical intelligence are the Armed Forces Medical Intelligence Center, and Navy Environmental and Preventive Medicine Units. Appendix 1 describes in detail these and other resources from which medical intelligence, threat assessments, and other information can be obtained.

Senior Medical Officers. Force and Fleet medical officers have two priorities:

1. Advising force commanders of DNBI threats, including malaria, and recommending appropriate countermeasures.

2. Preparing medical department personnel to counter identified threats.

Advising force commanders of the appropriate countermeasures to employ requires medical commanders to characterize the DNBI threat. By combining medical intelligence on the area of operation with an understanding of mission operations, plans, and objectives, the risks to the force can be judged. Countermeasures are then recommended to reduce risks and ensure mission accomplishment. This is a synergistic process; countermeasures prevent illness and injury, increasing force readiness.

Part of the process of recommending countermeasures is estimating the resources needed to employ them. This includes identifying and directing necessary training, along with identifying and procuring necessary supplies needed to implement recommended countermeasures. This information needs to be passed on as expeditiously as possible to the personnel responsible for action.

Unit Medical Officers. Unit medical officers, including Independent Duty Corpsmen, are essential in prevention of DNBI and malaria. They advise their CO on all medical matters. Enforcement of personal protective measures and method of administration of chemoprophylaxis depend on the advice given the CO by the Unit medical officer. By doing continuous surveillance of malaria incidence rates, other DNBI rates, and proper employment of personal protective measures, Unit medical officers can monitor the success of countermeasures, and reassess the threats. Unit medical officers must also train and supervise the unit's corpsmen to ensure optimal medical care is delivered.

Flight Surgeons. Flight surgeon responsibility is the same as that of Unit medical officers, with special attention to the effects of malarial chemoprophylaxis medications on flight personnel. Continuous or periodic monitoring of flight personnel on medication may be required to ensure safety. Flight personnel under treatment for malaria cannot fly until completion of treatment and evaluation by a flight surgeon. It is important to note that chemoprophylaxis with mefloquine is not authorized for use in flight personnel.

Preventive Medicine Officers. The General Preventive Medicine Officer (PMO) serves as a source of information for all levels of the chain of command. Currently PMOs serve on all Marine Expeditionary Force staffs, and requests have been made to place PMOs on the staffs of the geographic CINCs. Knowledge of the general duties of all medical department personnel involved in malaria control (Medical Entomologists, Environmental Health Officers, Preventive Medicine Technicians) allows them to consult and coordinate the provision of any needed training, supplies, or control measures with units in the field or in garrison. PMOs will usually deploy to the area of operation with a deployable lab, a resource able to aid in disease diagnosis and vector identification and surveillance.

One of their primary duties is to coordinate or assist in any illness or outbreak investigation. All surveillance data are monitored and analyzed by PMOs, forwarded to all unit and military treatment facility medical departments, and to commanders, along with pertinent recommendations. Current malaria prevalence, incidence, and any pattern of drug resistance in an operational area are included in these reports. (Reports are not limited to malaria statistics).

Hospital Corpsmen. The training and support of hospital corpsmen is of paramount importance to force readiness and must be emphasized at every level in the chain of command. Hospital corpsmen are the first line of defense in malaria and DNBI prevention. Unit corpsmen perform most of the personal protective measures training given to unit personnel. They live among them in the field and monitor the daily employment of countermeasures. They supervise administration of chemoprophylaxis, and are often the first to initiate the diagnosis and care of any malaria cases.

Preventive Medicine Technicians (PMTs). These are specially trained hospital corpsman, and are directly involved in all aspects of malaria and DNBI control. They provide training in personal protective measures to hospital corpsmen and unit personnel. They also perform field vector surveillance, collect epidemiological data, and will supervise or conduct field sanitation and vector control measures if needed. They serve along side PMOs, and are excellent resources for preventive medicine information in the field.

Laboratory Personnel. Laboratory personnel assigned to deployable labs, fleet hospitals, Marine Medical Battalions, or any other unit that deploys to malaria endemic areas must be able to perform thick and thin peripheral blood smears and differentiate between the four plasmodia species that cause malaria in humans. They should be able to teach this diagnostic technique to interested medical personnel.

An important responsibility is sending prepared duplicate blood smear slides to the Navy Environmental and Preventive Medicine Unit assigned to monitor the area of operation. Such samples enable update of the area threat assessment and diagnosis confirmation. The slides should be both stained and unstained, and accompanied by identifying information and the clinical history of the case.

Environmental Health Officers (EHOs). Environmental Health Officers are often assigned to deployable labs, preventive medicine units, Marine Force Service Support Groups, Marine Divisions, Marine Air Wings, and Joint Task Forces. They assist in collection of epidemiological and entomological data, and evaluate the environmental conditions that affect malaria control. They also have a primary role in the training and supervision of PMTs.

Medical Entomologists. Medical entomologists obtain the most current mosquito information and recommend applicable methods of vector control. They supervise adult and larval mosquito surveys, pesticide application, and train personnel in identification and control measures. They are assigned to Marine Force Service Support Groups to:

1. Recommend and ensure that personal protective measures are employed.

2. Select optimum locations for bivouacs and base camps.

3. Recommend safe times for training and field exercises.

Preventive Medicine teams can deploy EHOs, Medical Entomologists, Epidemiologists, Laboratory Technicians, and Industrial Health Officers. These teams can provide varied and useful services to deployed forces.

III. Administrative Responsibilities

Medical Records. Medical records of Navy/Marine Corps service members are required to include:

G-6-PD Screening Results: A result, either deficient or normal, must be entered on a Standard Form 600 (SF 600). If deficient, this information must be highlighted on the Problem Summary List (NAVMED 6150/20). In addition, the "Sensitivities" block in the "Alert box" on the cover of their medical treatment record must be checked. Other health care beneficiaries, including civilian technical experts, should be offered this screening test if traveling to endemic areas.

Chemoprophylaxis. The date prophylaxis began and ended, drug type, and dosage should be entered on a SF 600. If terminal primaquine prophylaxis is given, entry of the same information is required.

All personnel required to take chemoprophylaxis must be informed of the reason for taking the medication, common side effects of the drug, and when to take the medication. It should also be communicated clearly that taking prophylactic medication does not guarantee malaria prevention.

Service members should be advised to seek medical evaluation if they suffer drug side effects or have symptoms of malaria. This information is usually presented at the unit level. When this information is presented, personal protective measures may be demonstrated, and DEET, permethrin, netting, and other necessary items may be issued.

Medical Event Reports. Medical Event Reports (MERs) are required, by instruction, on any member diagnosed with malaria. The report should be generated using the Naval disease Reporting System software package which can be downloaded from the NEHC homepage (http://www-nehc.med.navy.mil). If the software is unavailable, a message can be generated. The MERs are then sent to the Navy Environmental and Preventive Medicine Unit assigned to monitor the area of operation. The message should also "info" all military treatment facilities in the area, the nearest Navy Disease Vector Ecology and Control Center, and the Navy Environmental Health Center (NEHC). The information is important to monitor and update both the malaria threat and presence of drug-resistant malaria in the area of operation.

The following is the minimum information included in the MER:

1. Patient travel history 3 months prior to diagnosis.

2. Type and duration of chemoprophylaxis or treatment medications taken, if applicable.

3. Interpretation (diagnosis) of blood smears performed on the patient.

4. Date that blood smears were sent to a Navy Environmental and Preventive Medicine Unit for confirmation.

Medical Treatment Facilities. The staff of Military Treatment Facilities that may receive malaria patients should be familiarized with treatment. Commanders should arrange training from available sources such as the Internal Medicine or Infectious Disease department, or the nearest Navy Environmental and Preventive Medicine Unit. A general in-service training session that includes the following topics is recommended:

1. Diagnosis, treatment and monitoring.

2. Common complications of severe falciparum malaria infections.

3. The physiology of terminal primaquine prophylaxis and G-6-PD deficiency.

4. Monitoring blood parasite concentration with peripheral blood smears for treatment response.

Another important aspect in the care of malaria patients is to send a timed and dated peripheral blood smear upon transfer, so the receiving facility can compare it with their initial blood smear, and confirm the diagnosis.

Medical Board Evaluations. Service members who develop severe malaria complicated by a severe hemolytic reaction characterized by hemoglobinuria together with the diagnosis of "blackwater fever" and/or renal failure are required to be evaluated for fitness for further duty by a Medical Board. A Medical Board is also required on personnel who develop a similar severe hemolytic reaction as a result of taking malaria chemoprophylactic drugs. The complication of cerebral malaria does not require evaluation by a Medical Board unless permanent neurologic disability has occurred.

Blood Donor Programs. Blood donation programs are subject to the guidance of BUMED P-5120, "Standards for Blood Bank and Transfusion Services." The directive is applicable to both military and civilian blood banks and requires that individuals treated for malaria wait three years from the date of completion of therapy to donate blood. Individuals who took malaria chemoprophylactic drugs while in endemic areas must also wait three years from completion of chemoprophylaxis to donate blood. The reason for the waiting period is to prevent donated blood from being contaminated by malaria parasites, not drugs.

Individuals who visited a malaria-endemic area without taking chemoprophylactic drugs and remained asymptomatic are required to wait 6 months before being eligible to donate blood. Persons placed on chemoprophylactic therapy in readiness, but who did not travel into a malaria endemic area, do not have a required waiting period to donate blood.

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Operational Medicine 2001

Health Care in Military Settings

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