Texting Away Malaria: A New Alternative to Directly Observed Therapy

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Lambert Miller
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1 MILITARY MEDICINE, 178, 2:e255, 2013 Texting Away Malaria: A New Alternative to Directly Observed Therapy Capt William Scott, USAF MC*; COL Peter J. Weina, MC USA ABSTRACT Objective: Operation Onward Liberty is the current U.S. military mentorship program working with the Armed Forces of Liberia, training their national army. Throughout West Africa, and Liberia in particular, malaria remains a serious health concern. This is a critical concern to all U.S. Forces deployed in areas endemic with malaria. In January 2011, a new protocol was instituted among Operation Onward Liberty members using short message service (SMS) technology to ensure 100% daily accountability. Methods: Beginning in January 2011, SMS was used to report completion of daily ingestion of malaria chemoprophylaxis by U.S. Forces in Liberia. Results: Since then, there were no cases of malaria identified by both Binax rapid diagnostic test and thin smear. The previous year (2010) saw 12 cases of malaria among U.S. Forces in Liberia (9 during the same 6-month period), with 3 evacuations for malaria, costing an estimated 1.5 million dollars. Conclusions: Although directly observed therapy is still the gold standard of malaria chemoprophylaxis, use of cellular telephone texting technology, or SMS, for communicating ingestion may be the best alternative for reasonable accountability in the deployed setting, especially considering the highly decentralized nature of this and other deployment locations. INTRODUCTION Malaria is the second leading cause of death in Sub-Saharan Africa to date, second only to dysentery (usually caused by lack of clean water). 1 Numerous attempts have been made to curtail the devastating effects of this disease on the population. Although this disease has wreaked havoc throughout Africa, it is also of special concern to U.S. Forces working in and throughout the African continent. It can be said that Liberia, in 2003, was the sentinel event for a change in malaria prevention by U.S. Forces. In 2003, 80 marines contracted malaria out of 225 deployed (a devastating 35%). 1 During that deployment, marines were relegated to the buddy system of daily antimalarial accountability. In the after-action review, pill counts revealed numerous missed doses of daily medications, and was likely the single greatest factor in the 80 marines who contracted the disease. 1 In 2009, Operation Onward Liberty (OOL) began, as a U.S. military mentorship program, working with the Armed Forces of Liberia, training their national army. As with all African nations, Liberia is no exception to having a high prevalence of malaria. It has an exceedingly high incidence of Plasmodium falciparum (P. falciparum), and some might argue it is among the worst. In 2010 alone, 12 cases of malaria were documented, diagnosed by using a Binax rapid diagnostic test (RDT) and thin prep smear (Fig. 1). On December 26, 2009, a young construction battalion died after contracting P. falciparum and developing cerebral malaria. 2 Since OOL averages 50 U.S. servicemen during each deployment cycle *99th Medical Operations Squadron, Mike O Callaghan Federal Medical Center, 4700 North Las Vegas Boulevard, Building No. 1300, Nellis AFB, NV Deputy Commander, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD doi: /MILMED-D (about 6 months), the approximate contraction rate for malaria among OOL members was 12% in Given the cost of medical evacuation (approximately $500, per evacuation) and potential loss of life, this rate was completely unacceptable, especially since the Swedish military had deployed to Liberia between 2004 and 2006 without a single case of P. falciparum in 1,170 soldiers with over 7,000 person-months (approximately 210,000 person-hours based on the average 30-day month). 3 METHODS AND MATERIALS The difficulties of combating malaria in Liberia during military deployments are extensive. First, the environment is highly decentralized. In this deployment, members lived up to 1.5 hours apart and at 3 different locations (times were used because of traffic and road conditions). With a small medical contingent and only 1 physician on station, performing daily directly observed therapy (DOT) was not only impractical but also logistically impossible. Using what was available, we developed a short message service (SMS) program and accountability tracking schedule to ensure daily ingestion of chemoprophylaxis. The entire mission was divided five groups, with four groups of daily medications and a single group of weekly medications. Each medical technician and our two preventative medicine technicians were given a list consisting of approximately ten names, whereas the Chief Medical Officer (CMO) took the list of mefloquine users. Every day, the OOL mentors sent a text message to their list monitor and stated that they took their medication. The technician would then mark off that member, showing that they had taken their chemoprophylaxis for the day. If the member did not text by 5:00 p.m., they then received a reminder text or phone call inquiring about ingestion. This was required on several occasions, but usually in the early stages of the deployment, as most members developed a habit with their e255

2 FIGURE 1. Malaria case graph. medications. The on-site rule was that if a member forgot to take their medication repeatedly and required a reminder, then they were required to present to the clinic at 6:00 a.m. daily for a week and undergo DOT until the member was able to remember to take their medication as directed and contact their list manager. Although this was never needed, it served as a deterrent to missing medications and daily texts. Because the mentors were in a closed user group, there was no additional cost to the mission for these daily text messages and follow-up. A second difficulty in combating malaria was that the prevailing attitude upon arrival was one of resigned acceptance. On multiple occasions, I was told that it was not a matter of if, but when you will catch malaria. People were apparently satisfied with the current status and this was objectively reflected in the previous malaria logs where multiple days of signatures were missing and the general attitude was one of complacency. Why should I take my meds if I m gonna catch malaria anyway, noted one Staff Sergeant. This attitude was the second thing we addressed and in a two-fold manner. Education was the first piece, and malaria was FIGURE 2. Malaria handout. e256

3 FIGURE 2. Continued. reviewed during each in-processing as service members arrived on station. This consisted of a 3-page educational printout on malaria (Fig. 2) and a signed acknowledgement of understanding that taking their medications increased the likelihood of avoiding malaria and was a mandatory part of the deployment. In addition to education, a secondary incentive was provided to the entire mission. Two hundred dollars was set aside toward a celebratory party should our group be the first to go an entire deployment cycle without a single case of malaria diagnosed via RDT or thin smear which were reviewed by the Walter Reed Army Institute of Research (WRAIR). The use of positive reinforcement became infectious when the commanding officer, a marine colonel, matched the initial $200.00, followed by numerous others, eventually creating a large pool of money for an end of deployment party celebrating zero cases of malaria. This was eventually changed to a quarterly event, celebrating 3 months of malaria-free deployment status. The overall morale improvement was most evident in a quote by Corporal Jacob Gateman during our first 3-month festivities, I know I do not want to be the individual who gets malaria and ruins the chance for another party. 4 This was likely an additional factor in accomplishing the lack of malaria cases, creating a cultural change that this mission was not only possible, but should be the standard. All additional preventative measures were continued, but with renewed vigor. Bed nets were still mandatory as before, but with a single random inspection during the deployment cycle to make sure that nets were appropriately placed, tucked in during the day, and free of holes. Uniforms as well as one set of civilian clothes were treated with permethrin (at least 2 per member). During the rainy season, wearing long sleeves and pants were mandatory between sunset and sunrise. Deet was made available throughout the deployment, and each member was given four to five 6 oz tubes at the onset of the deployment. e257

4 A member of OOL repeated these Four Measures during the weekly All Hands meeting. During the meeting, a randomly selected member of the team would stand up and recite the four things being done to combat malaria. This random selection process helped to ensure that everyone memorized the four steps and were cognoscente of them on a weekly basis. During the deployment, there were only two instances of failed SMS communication. The first involved a marine forgetting to text that he had taken his medication and then falling asleep. The following morning, he promptly clarified that he had in fact taken his medication but forgot to text his designated medic. The second instance involved an airman who actually missed a dose of medication, leading to a verbal reprimand and reminder that should the behavior continue, DOT would be instituted at 6:00 a.m. in front of the CMO barracks. The exact numbers of sent texts, replies, and reminder texts were not tracked as this was something delegated to the medics and not further accounted for. RESULTS Since January 2011, there have been zero cases of malaria identified by either Binax RDT or thin smear, constituting over 7,125 man-hours in theater during each 6-month deployment cycle. Thin smears were evaluated by the physician on station under oil immersion microscopy, with confirmatory read performed by an independent physician at the WRAIR. At the time of this publication, OOL had yet to encounter a single case among U.S. Service members (a total of 21,375 manhours), suggesting that the above changes are operator independent. This finding is the key for replication in other countries and during other deployments, as well as the civilian population for protective measures. DISCUSSION There are numerous and obvious limitations to this study. The first is the integrity of the members stating that they took their medications. As U.S. Military members, there is an expectation of honor and integrity that may not be able to be replicated in the civilian world. However, as seen in the case of the construction battalion who died in 2009, members can lie and say they took their medications when they did not. The expectation is that troops feel a sense of integrity as well as the need for self-preservation in taking their medications. By constantly stating the threat that malaria posed in the weekly meetings and performing random preventative measure inspections (i.e., bed net checks), it was expected that troops would not only remain honest, but also that the severity of the disease would continue to impress upon them the importance of consuming their chemoprophylaxis. As the physician, I also explained that if side effects from the medications were experienced, members should not hesitate to present to the clinic, but should under no circumstances stop their medications. There was also the counter-productive possibility of troops feeling enough pressure to avoid malaria that they could possibly avoid seeing the physician for symptoms consistent with malaria. On numerous occasions, when seeing patients for acute gastroenteritis, patients remarked that they did not want to have malaria. Their worry, however, was less about the disease itself and more about blowing our record. During the weekly meetings where troops were questioned about what we were doing to combat malaria, they were also reminded that early intervention was key to successful treatment and that they should not hesitate to be seen for symptoms. Although Health Insurance Portability and Accountability Act was still enforced, the small number of members on station made illnesses nearly impossible to keep 100% private. Regarding a second potential limitation, recording individuals (the medics) could have falsified records to the CMO, as well as the CMO falsifying records himself. The honor and integrity part of the military also played a role in this setting, but there was also a fair amount of pressure from the CMO to have 100% daily accountability. Given previous shortfalls in accountability, it was imperative to the OOL mission that our team created a new environment of daily documentation of medication ingestion. The third consideration is that chemoprophylaxis is not 100% effective in combating malaria and therefore may not perfectly correlate to the drop in cases among U.S. deployed forces. In three randomized placebo-controlled trials, doxycycline was shown to be between 92 and 96% efficacious against P. falciparum and 98% against Plasmodium vivax infections. 5 In another study, Malarone was shown to have a prophylactic effectiveness of 95.8% against malaria. 6 Finally, mefloquine has been shown to have an 85 to 94% efficacy against P. falciparum. 7 Given these numbers, the simplest conclusion is that inconsistent usage of antimalarials, if not complete lack of ingestion, led to the majority of the previously seen U.S. malaria cases. It should also be noted that the Swedish Forces in Liberia used primarily Malarone and mefloquine as opposed to doxycycline. 3 That information, combined with the U.S. Africa Command s recent guideline changes making Malarone the drug of choice to forces deploying in endemic areas, like Liberia, would lend support to the experienced efficacy of Malarone over doxycycline. 8 This was also seen in Liberia as none of the 12 patients who contracted malaria were taking Malarone. Although antimalarials are not 100% effective, 90 to 95% prevention is a reasonable goal, if chemoprophylaxis were the sole preventative measure. Since other personal protective measures were enforced, 95 to 100% disease-free state should not only be achievable, but the standard. Therefore, the 88% prevention shown in the previous year of OOL would appear far from that goal, even if chemoprophylaxis were the only means of prevention. Because of the severity of disease and other compounding factors, there could obviously be no control group (not texting or lacking medications). Human randomized controlled studies e258

5 in this setting would create a risk to human life that would outweigh any foreseeable benefits, given the limited medical resources in country. Current Air Force guidance on the subject of biomedical research was also taken into account in when forgoing the creation of a control group. 9 This could be a useful area of future study. The closest reasonable comparison is a historic one; that of the previous deployment iterations, which did not institute the texting protocol, and yielded a 12% case rate vs. 0% for this most recent iteration. Because of varied locations, including extensive field operations up-country, there was obviously no way to isolate members to the same locations as the previous iterations. Therefore, the incidence of infected mosquitoes and exposure to these mosquitoes seeking a blood meal could have been very different from location to location. Seasonal changes could also have played a role in the number of mosquitoes and location of stagnant bodies of water, and therefore disease incidence. Ironically, the period that should have had the highest concentration of cases in the previous iteration had fewer cases comparatively. This could be explained by an increase in vigilance, although the paper records showing missed days of medication would seem to contradict that assertion. FUTURE PLANS As noted earlier, there were numerous limitations and few calculations. The majority of the article was undertaken retrospectively, and so exact information concerning the number of texts and necessary reminders were not tracked. This should be an area of future study and is already partially underway at the WRAIR. SMS applications using smartphones and web-based analysis are planned for testing in late 2012 and early However, this will hopefully be only the tip of the iceberg. There will need to be continued research and innovation using these technologies, with particular consideration for the special operations community and cellular tracking, as well as force strength data that could be acquired via cellular counter intelligence to name a few. As our military forces adapt to current technological advances, it is very important that these applications are explored, vetted, and utilized where and when it is necessary and able. CONCLUSION DOT will remain the gold standard of malaria chemoprophylaxis. However, using cellular telephone texting technology, or SMS, for communicating prophylactic ingestion may be the best alternative for reasonable accountability in the deployed setting, especially considering the highly decentralized nature of many deployed locations. ACKNOWLEDGMENTS The deployment Medical Team from December 2010 to July 2011 consisted of Maj Michael Doiron, Capt William Scott (the author), MSgt Curtis McGehee, TSgt Catalina Caldwell, SSgt Joseph Williams, and SSgt Megan Corbett. Their contributions to this work were critical to the success of the entire mission. REFERENCES 1. Whitman TJ, Coyne PE, Magill AJ, et al: An outbreak of Plasmodium falciparum malaria in U.S. Marines deployed to Liberia. Am J Trop Med Hyg 2010; 83(2): Kronmann: Seabee Dies From Malaria Complications. Available at accessed June 6, Anderson H, Askling HH, Falck B, Rombo L: Well-tolerated chemoprophylaxis uniformly prevented Swedish soldiers from Plasmodium falciparum malaria in Liberia, Mil Med 2008; 173(12): Tiernan CJ: Prevention methods keep U.S. mentors malaria free in Liberia. Available at tabid/5697article/82339/prevention-methods-keep-us-mentors-malaria-freein-liberia.aspx; accessed June 6, Tan KR, Magill AJ, Parise ME, et al: Doxycycline for malaria chemoprophylaxis and treatment: report from the CDC expert meeting on malaria chemoprophylaxis. Am J Trop Med Hyg 2011; 84(4): Halima Nakato, Robert Vivancos, Paul Hunter: A systemic review and meta-analysis of the effectiveness and safety of atovaquone proguanil (Malarone) for chemoprophylaxis against malaria. J Antimicrob Chemother 2007; 60: Wongsrichanalai C, Meshnick SR: Declining artesunate-mefloquine efficacy against falciparum malaria on the Cambodia Thailand Border. Emerg Infect Dis 2008; 14(5): Available at content/14/5/contents.htm; accessed June 6, Polumbo HD Jr: United States Africa Command Notice: Health and Medical. J00-CAN , September 20, Department of Air Force: Protection of Human Subjects in Biomedical and Behavioral Research, Medical Command. Air Force Instruction Available at May 5, 2005; accessed June 6, e259

Malaria Trends in the Navy and Marine Corps,

MILITARY MEDICINE, 181, 5:488, 2016 Malaria Trends in the Navy and Marine Corps, 2005 2013 Courtney L. Rudiger, MS*; Gosia Nowak, MSc, MPH ABSTRACT U.S. Sailors and Marines routinely deploy to regions