PM2ch35.pdf

MILITARY PREVENTIVE MEDICINE:

MOBILIZATION AND DEPLOYMENT

Volume 2

Section 6: Infectious Diseases of Concern

Franklin Boggs

Pill Call

Soldiers in the South Pacific theater during World War II get their daily dose of atabrine, described by the artist as “the

famous new malaria medicine.” Atabrine was used by the allies because Japan controlled the sources of quinine, the

main malaria treatment of the pre-atabrine era. The artist also mentioned that “these pills turn you about the color of

a lemon.” It was the control of malaria that gave General MacArthur of the US Army and General Slim of the British

Army an edge in their battles with the Japanese.

Art: Courtesy of US Center of Military History, Washington, DC.

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Diseases Transmitted Primarily by Arthropod Vectors

Chapter 35

DISEASES TRANSMITTED PRIMARILY

BY ARTHROPOD VECTORS

G. Dennis Shanks, MD, MPH-TM

Jerome J. Karwacki, MD, MPH

Niranjan Kanesa-thasan, MD, MTM&H

Wellington Sun, MD

Bruce L. Innis, MD

Timothy P. Endy, MD, MPH

Charles F. Longer, MD

David W. Vaughn, MD, MPH

George V. Ludwig, P H D

David J. McClain, MD

Kevin Michaels, MD, MPH

Hee-Choon S. Lee, MD, MPH

Victoria B. Solberg, MS

Kathryn L. Clark, MD, MPH

Arthur E. Brown, MD, MPH

Daniel A. Strickman, P H D

Daryl J. Kelly, P H D

Mark G. Kortepeter, MD, MPH

William P. Corr, MD, MPH

Alan J. Magill, MD

William C. Hewitson, MD, MPH

MALARIA

DENGUE VIRUS INFECTIONS

DENGUE-LIKE SYNDROMES

YELLOW FEVER

JAPANESE ENCEPHALITIS

THE EQUINE ENCEPHALITIDES

TICKBORNE ENCEPHALITIS

SANDFLY FEVER

LYME DISEASE

EHRLICHIOSIS

TYPHUS

PLAGUE

FILARIASIS

THE LEISHMANIASES

TRYPANOSOMIASIS

803

Military Preventive Medicine: Mobilization and Deployment, Volume 2

G.D. Shanks ; Colonel, Medical Corps, US Army; Program Manager, DOEM, US Army Center for Health Promotion and Preventive

Medicine, 5158 Blackhawk Road, Aberdeen Proving Ground, MD 21010-5403

J.J. Karwacki ; Colonel, Medical Corps, US Army (Retired). JUSMAGTHAI, PO Box R3081, APO AP 96546; Formerly, Preventive

Medicine Officer, US Army Medical Component, Armed Forces Research Institute of Medical Science, APO AP 96546-5000

N. Kanesa-thasan ; Lieutenant Colonel, Medical Corps, US Army; Chief, Clinical Studies Department, Medical Division, US Army

Medical Research Institute of Infectious Diseass, 1425 Porter Street, Fort Detrick, Frederick, MD 21702-5011

W. Sun ; Colonel, Medical Corps, US Army; Chief, Department of Virus Diseases, Division of Communicable Diseases and Immu-

nology, Walter Reed Army Institute of Research, Silver Spring, MD 20910-7500

B.L. Innis ; Colonel, Medical Corps, US Army (Retired); Group Director, New Vaccines, GlaxoSMithKline Pharmaceuticals, 1250 S.

Collegeville Rd (mailcode UP 4330), Collegeville, PA 19426; Formerly, Chief, Department of Virus Diseases, Division of Communi-

cable Diseases and Immunology, Walter Reed Army Institute of Research, Silver Spring, MD 20910-7500

T. P. Endy ; Colonel, Medical Corps, US Army; Director, Division of Communicable Diseases and Immunology, Walter Reed Army

Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910-7500

C.F. Longer ; Colonel, Medical Corps, US Army (Retired); Chief, Division of Hospital Medicine, Department of Medicine, Univer-

sity of Tennessee College of Medicine, Chattanooga Unit, 975 East 3rd Street, Chattanooga, TN 37403; Formerly, Assistant Chief,

Department of Virus Diseases, Division of Communicable Diseases and Immunology, Walter Reed Army Institute of Research,

Washington, DC 20307-5100

D.W . Vaughn ; Colonel, Medical Corps, US Army; Director, Military Infectious Diseases Research Program, US Army Medical Re-

search and Materiel Command, 504 Scott Street, Fort Detrick, Frederick, MD 21702-5012

G.V. Ludwig ; Chief, Diagnostic Systems Division, US Army Medical Research Institute of Infectious Diseases, 1425 Porter Street,

Fort Detrick, Frederick MD 21702–5011

D.J. McClain ; Asheville Infectious Disease, 445 Biltmore Center, Suite 500, Asheville NC 28801; Formerly, Research Medical Of-

ficer, Division of Virology, US Army Medical Research Institute of Infectious Diseases, 1425 Porter Street, Fort Detrick, Frederick

MD 21702–5011

K. Michaels ; Lieutenant Colonel, Medical Corps, US Army; Chief, Department of Preventive Medicine, Eisenhower Army Medical

Center, Fort Gordon, GA 30905

H.S. Lee ; Lieutenant Colonel, Medical Corps, US Army; Preventive Medicine Consultant, Preventive Services Directorate, 18th

Medical Command, APO AP 96205

V. B. Solberg ; Department of Entomology, Division of Communicable Diseases and Immunology, Walter Reed Army Institute of

Research, Silver Spring, MD 20910-7500

K.L. Clark ; Infectious Disease Analyst, Armed Forces Medical Intelligence center, 1607 Porter Street, Fort Detrick, Frederick MD

21702-5004; Formerly, Major, Medical Corps, US Army; Coordinator, Accession Medical Standards Analysis and Research Activity,

Division of Preventive Medicine, Walter Reed Army Institute of Research, Washington, DC 20307–5100

A.E. Brown ; Lieutenant Colonel, Medical Corps, US Army; Department of Retrovirology, Armed Forces Research Institute of Medi-

cal Sciences, Bangkok, Thailand, APO AP 96546

D.A. Strickman ; Colonel, Medical Service, US Army (Retired); Santa Clara County Vector Control District, 976 Lenzen Avenue, San

Jose, CA 95126; Formerly, Chief, Department of Entomology, Walter Reed Army Institute of Research, Silver Spring MD 20910-

7500

D.J. Kelly ; Lieutenant Colonel, Medical Service, US Army (Retired); Research Associate, Department of Evolution, Ecology, and

Organismal Biology, The Ohio State University, 388 Aronoff Laboratory, 318 West 12th Avenue, Columbus, Ohio, 43210; Formerly,

Department of Rickettsial Disease, Division of Retrovirology, Walter Reed Army Institute of Research, Silver Spring MD 20910-

7500

M.G. Kortepeter ; Lieutenant Colonel, Medical Corps, US Army; Chief,Medicine Division, US Army Medical Research Institute of

Infectious Diseases, 1425 Porter Street, Fort Detrick, Frederick, MD 21702-5011

W.P. Corr ; Lieutenant Colonel, Medical Corps, US Army; Deputy Commander, Clinical Services, Martin Army Community Hospi-

tal, 7950 Martin Loop, Fort Benning, GA 31905-5637

A.J. Magill ; Colonel, Medical Corps, US Army; Science Director, Walter Reed Army Institute of Research, Silver Spring, MD 20910-

7500

W.C. Hewitson ; Lieutenant Colonel, Medical Corps, US Army; Department of Preventive Health Services, Community Health

Practices Branch, AMEDD Center and School, ATTN: MCCS-HPC, Fort Sam Houston, TX 78234-6124

804

Diseases Transmitted Primarily by Arthropod Vectors

MALARIA

Introduction and Military Relevance

Burma Campaign, World War II

Malaria is perhaps the most potentially devas-

tating vector-borne disease for the military. This is

because of its ability to appear in a military unit

suddenly and cause near universal infection, its

ability to incapacitate and kill nonimmune person-

nel within a few days, and the practical difficulty

of controlling infections in tropical garrison units.

Service members with even mild cases of malaria

often have poor stamina and fitness for any military

duties. Malaria is especially a threat for operations

in sub-Saharan Africa, the Amazon River basin,

Central America, Hispaniola, and much of South-

east Asia and Oceania.

The role of the mosquito in malaria was unknown

until 1897 when MAJ Ronald Ross of the Indian Army

Medical Department discovered that mosquitoes

transmit malaria. Despite this knowledge, person-

nel deployed to the tropics continue to be plagued

by malaria. 1 The age of chemotherapy, using at first

the old specific febrifuge quinine and later synthetic

antimalarials from the dye industry, offered great

promise. Ever-present logistical and discipline

problems, however, have been compounded by

drug resistance such that the casualty-producing

potential of malaria is little different today than it

was more than a century ago (Figure 35-1).

General William Slim of the British Army had

several problems with illness in his troops in 1943

during the Burma Campaign. Nearly a thousand

men became ill everyday, and the ratio of sick to

combat wounded was 120 to 1, with malaria caus-

ing 840 cases per 1,000 men per year. In General

Slim’s words, “A simple calculation showed me that

in a matter of months at this rate my army would

have melted away. Indeed, it was doing so under

my eyes.” 2p177 Several measures turned this unac-

ceptable situation around, and not one of them was

primarily medical. Malaria treatment units were

moved up into the combat zone so failure to take

prophylactic medication only earned a soldier a trip

to a field treatment camp and a rapid return to his

combat unit. Discipline in taking prophylactic

atabrine medication was stepped up, and orders

were issued to relieve any commander whose units

did not achieve 95% drug positivity measured by

unannounced urine testing. Again using General

Slim’s words: “I only had to sack three; by then the

rest had got my meaning.” 2p180 Medical support was

not enough to win against malaria; command em-

phasis and discipline were key elements in the vic-

tory in Burma (See chapter 2, The Historical Impact

of Preventive Medicine in War).

Vietnam War

Malaria was a leading cause of illness in the Viet-

nam War, with more than 40,000 cases in the US

Army alone. 3 In spite of very sophisticated medical

care, malaria killed on average one US service mem-

ber during each month of the Vietnam War.

Malaria’s impact on combat effectiveness was mag-

nified by two facts: (1) the concentration of cases in

the frontline infantry operating in the jungle and

(2) drug resistance leading to extended hospital

stays. During 1965, entire battalions of the 1st Cav-

alry (Airmobile) Division were pulled out of the Ia

Drang Valley because of malaria casualties exceed-

ing 1% per day.

Fig. 35-1 . This photograph shows a hospital ward in east-

ern Thailand filled with Thai Marines, all with drug-re-

sistant falciparum malaria. Multidrug resistant malaria

can cause mass casualties in service members deployed

in the tropics.

Photograph: Courtesy of Colonel G. Dennis Shanks,

Medical Corps, US Army.

Somalia

Operation Restore Hope in Somalia (1992-1993)

resulted in the largest epidemic of malaria in US

military forces since the Vietnam War. Mostly due

to noncompliance with the malaria chemoprophy-

805

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