COMMENTARIES MILITARY MEDICINE, 180, 1:7, 2015 Strengthening Malaria Prevention and Control: Integrating West African Militaries Malaria Control Efforts. The Inaugural Meeting of the West African Malaria Task Force, April 24 26, 2013, Accra, Ghana CDR Jeffrey T. McCollum, USPHS*; Refaat Hanna, MD ; Alaina C. Halbach, MSPH*; COL James F. Cummings, MC USA* ABSTRACT From April 24 to 26, 2013, the Armed Forces Health Surveillance Center and the U.S. Africa Command cosponsored the inaugural meeting of the West Africa Malaria Task Force in Accra, Ghana. The meeting s purpose was to identify common challenges, explore regional and transcontinental collaborations, and to share knowledge about best practices in the fight against malaria in West Africa. Military representatives from Benin, Burkina Faso, Ghana, Liberia, Niger, Nigeria, Senegal, and Togo participated in the Task Force; various U.S. Government agencies were also represented, including the Department of Defense, the Centers for Disease Control and Prevention, and the Agency for International Development. African nation participants presented brief overviews of their military s malaria prevention and control measures, surveillance programs, diagnostic capabilities, and treatment regimens emphasizing gaps within existing programs. Representatives from U.S. agencies discussed activities and capabilities relevant for the region, challenges and lessons learned regarding malaria, and highlighted opportunities for enhanced partnerships to counter malaria in West Africa. This article summarizes the major conclusions of the Task Force meeting, identifies relevant focus areas for future Task Force activities, and outlines opportunities for further inclusion of West African militaries to improve regional malaria surveillance and control efforts. INTRODUCTION AND BACKGROUND According to recent data released by the World Health Organization, during 2012, there were an estimated 207 million cases of malaria and 627,000 deaths attributable to malaria, mostly among African children. 1 Although malaria is endemic throughout many parts of the tropics and subtropics, Africa continues to shoulder a disproportionate share of the global malaria burden with most malaria cases and ³90% of the world s malaria-related deaths occurring there. Despite these sobering statistics, interventions to prevent malaria transmission and disease have yielded marked improvements in recent decades, with malaria mortality decreasing by nearly half since 2000 in the World Health Organization African Region alone. This and other successes are partially attributable to a combination of preventive interventions including increased distribution and use of insecticide-treated bed nets (ITNs), indoor *Global Emerging Infections Surveillance and Response System, Armed Forces Health Surveillance Center, 11800 Tech Road, Suite 220, Silver Spring, MD 20904. U.S. Africa Command, Office of the Command Surgeon, Unit 29951, APO AE 09751. doi: 10.7205/MILMED-D-14-00406 residual spraying of insecticides within communities, intermittent preventive treatment chemoprophylaxis for pregnant women, young children, and other higher-risk groups living in or traveling to high-transmission areas, improved diagnostics, and the availability of highly effective antimalarial medications including the artemisinin-based combination therapies (ACTs). Individuals traveling from nonendemic to endemic areas for malaria transmission might be at higher risk for acquiring malaria and manifesting severe disease when compared with partially immune indigenous populations. Among travelers, military personnel deploying for peacekeeping or other operations represent a unique subpopulation at even greater risk for malaria; longer travel durations, substandard accommodations (e.g., tents), and dynamic, stressful conditions all contribute to increased risk and malaria morbidity among military populations. Like other traveler groups, military members occasionally acquire and transit infectious diseases including malaria to their home country of origin and might pose a risk for introducing novel or drug-resistant parasite strains even into areas previously endemic for malaria. 2 4 Militaries have played an important role in malaria transmission and also endured the negative operational impacts of MILITARY MEDICINE, Vol. 180, January 2015 7
malaria on troop fitness since the origins of armed conflict. 5,6 Because of the acute nature of malaria-related illness and potential for outbreaks, malaria can be particularly detrimental during deployments and can hinder or even halt military operations altogether. In Africa, military personnel from malariaendemic areas likely underestimate the risk of acquiring malaria in deployment areas, overestimate their immunity to malaria infection, and underutilize force health protection measures, if available. The U.S. Africa Command (USAFRICOM; Stuttgart, Germany) hosted a Malaria Symposium in April 2011. 7 The 3-day forum brought together military and public health delegates from the United States, Europe, and Africa to discuss operational, strategic, and security implications of malaria in Africa, as well as successes and challenges in preventing the disease. This initial meeting served as a catalyst for the establishment of follow-on task forces addressing malaria in African militaries in both East and West Africa. Bridging World Malaria Day on April 25, the inaugural meeting of the West Africa Malaria Task Force (W-AMTF) convened during April 24 to 26, 2013 in Accra, Ghana, to identify common challenges, explore regional and transcontinental collaborations, and to share knowledge about best practices in the fight against malaria in West Africa. 8 The 3-day workshop was organized and hosted by USAFRICOM and the U.S. Armed Forces Health Surveillance Center Global Emerging Infections Surveillance and Response System (AFHSC-GEIS; Silver Spring, Maryland). Following assessment of current malaria prevention and control activities, perceived programmatic needs, and expected outcomes of the meeting, 8 member nations of the Economic Community of West African States elected to participate in the Task Force: Benin, Burkina Faso, Ghana, Liberia, Niger, Nigeria, Senegal, and Togo (Fig. 1). In addition to military delegates from these West African nations, various U.S. government agencies were also represented, including the Department of Defense, the Centers for Disease Control and Prevention, and the Agency for International Development (USAID). Commodore Rolland Sowa, Director General of the Ghana Armed Forces Medical Services Directorate, delivered the keynote address in which he lauded sponsors and participants for their support to and attendance of the Task Force meeting, the first of its kind in West Africa. Commodore Sowa called on all attendees to actively engage in the meeting discussions to spur collaborations among militaries within the region and with other international partners to combat malaria in the spirit of the year s World Malaria Day global campaign theme: Invest in the future: defeat malaria. 9 Following these introductory remarks, African military representatives presented summaries of each military s capabilities and challenges FIGURE 1. West Africa Malaria Task Force (W-AMTF) participant and United States President s Malaria Initiative (PMI) focus nations, West Africa, April 2013. Additional PMI-focus nations in Africa include Angola, Democratic Republic of Congo, Ethiopia, Kenya, Madagascar, Malawi, Mozambique, Rwanda, Tanzania, Uganda, Zambia, and Zimbabwe. 8 MILITARY MEDICINE, Vol. 180, January 2015
regarding malaria during both in-garrison and deployment operations to preface and inform discussions of potential enhanced partnerships to combat malaria in West Africa. GAP ANALYSES OF EXISTING AFRICAN MILITARY MALARIA CONTROL EFFORTS All African participants presented a brief overview of malaria prevention and control measures, surveillance programs, diagnostic capabilities, and treatment regimens employed during both in-garrison and deployed operations within their respective militaries. Although all represented nations had an established National Malaria Control Program (NMCP) generally managed by Ministries of Health or similar organizations, only three nations had any formal military malaria control program (Table I). Of the three militaries with militaryspecific programs, all were relatively nascent with none existing before 2009. Regardless of the presence of a militaryspecific malaria control program, all participating militaries reported compliance with NMCP treatment and diagnostic guidelines but varying degrees of operational integration with national programs. Among all eight represented militaries, five received some form of direct support from their NMCP (e.g., antimalarial medications, diagnostics, ITNs, training and outreach support); four militaries were solely reliant on the NMCP for some or all of this type of support with no inherent capacity to meet these malaria-related needs through military channels alone. Three militaries reported receiving no direct support from their NMCP. For those benefitting from a national program, most reported inconsistent supply of medications, diagnostic tests, and related materials necessary to meet the routine needs of military and related populations within the catchment of military healthcare facilities and to ensure compliance with national malaria diagnostic and treatment guidelines. All militaries reported providing a large proportion of medical services to general civilian populations with no military affiliation, with as much as 50% to 80% of delivered health care services provided to civilians. Regarding malaria prevention efforts and countermeasures among participant militaries troops, seven reported systematic use of ITNs during deployments, and none currently employed malaria chemoprophylaxis in troop populations at any time. For groups at higher malaria risk, intermittent preventive treatment was routinely utilized for infants, children, and pregnant women by a majority of militaries in accordance with respective national guidelines. Militaries employed a combination of clinical diagnoses, rapid diagnostic tests (RDTs), and microscopy to identify malaria cases. Most participants recognized quality microscopy as the diagnostic gold standard but reported inconsistent availability of microscopes, trained microscopists, and electricity needed to power microscopes. Various RDTs were routinely used by six militaries and were the primary diagnostic modality in two; RDTs were not widely available in two participant military health care facilities. Because of inconsistent availability of either microscopy or RDTs, participants acknowledged clinical presentation alone without laboratory confirmation as the occasional and sometimes primary de facto diagnostic method. Treatment regimens followed national protocols and generally incorporated ACTs for uncomplicated malaria cases and quinine or parenteral ACTs for complicated clinical presentations. Almost all (7/8) militaries conducted limited malaria surveillance supporting national surveillance programs. However, only one military had an independent TABLE I. Characteristics of Malaria Programs and Countermeasures Employed by West African Militaries Inaugural West Africa Malaria Task Force Meeting, Ghana, 2013. a Program/Countermeasure No./Total No. Have a National Malaria Control Program (NMCP) 8/8 Have a Military-Specific Malaria Control Program 3/8 Military-Specific Program in Place >1 Year 2/3 Military-Specific Program in Place >5 Years 0/3 Comply With NMCP Diagnostic and Treatment Guidelines 8/8 Military Health Facilities Receive Direct Assistance From NMCP 5/8 Anti-Malarial Medications 3/5 Malaria Rapid Diagnostic Tests/Microscopy Support 2/5 Insecticide-Treated Bed Nets 2/5 Training 2/5 Military Reliant on NMCP for Any Form of Assistance 4/5 Provide Military Health Data Supporting NMCP Malaria Surveillance 7/8 Able to Capture/Analyze Military-Specific Malaria Surveillance Data 1/7 Routine Use of Vector or Environmental Interventions Indoor Residual Spraying (IRS) of Insecticides 1/8 Insecticide-Treated Bed Nets During Deployments 7/8 Other Intervention (e.g., Habitat Management, Repellants) 2/8 Malaria Chemoprophylaxis Used During Deployment to Malaria-Endemic Regions b 0/8 a The West African Malaria Task Force meeting was held in Accra, Ghana, during April 24 to 26, 2013, and included West African military representatives from Benin, Burkina Faso, Ghana, Liberia, Niger, Nigeria, Senegal, and Togo. Aggregate data are presented as reported by participating military representatives. b Malaria-endemic regions where participant militaries had recent or ongoing deployments included various portions of Africa and Hispaniola. MILITARY MEDICINE, Vol. 180, January 2015 9
malaria surveillance program in place that facilitated routine collection and analysis of military-specific data. DISCUSSION Militaries play an important role in the prevention, diagnosis, and treatment of malaria in both military and civilian populations throughout West Africa. Discussions during this meeting highlighted the inconsistent availability and use of malaria countermeasures and programs within West African militaries. Perhaps not surprisingly, these inconsistencies were principally attributed to resource limitations. However, prioritization of other disease programs (e.g., HIV), and lack of advocacy among leadership for malaria-focused programs were also mentioned as apparent impediments to the establishment of formal military-specific malaria programs in some countries. In addition, perceptions and attitudes regarding malaria were also highlighted as a barrier. Because many West African nations are malaria-endemic, the commonness and relative acceptance of malaria-related illness as simply a part of life to be endured has potentially tempered the establishment or robustness of some formal military malaria programs. Further obscuring the importance of antimalaria initiatives, military populations are generally younger and fitter than the at-large population, do not incorporate typical higher-risk groups at all or in large numbers (i.e., young children and pregnant women), and are therefore assumed to experience less frequent and less severe malaria illness. Despite these perceptions, most participants stated that malaria remains a significant cause of morbidity and unfitness for duty among West African militaries particularly when deployed. Military members deploying to other malaria-endemic areas might be at greater risk for malariarelated illness when compared with domestic deployments. During foreign deployments, military personnel are more likely to encounter differing antigenic strains of malaria parasites in different regions, thus diminishing or rendering ineffective any inherent immunity acquired to distinct parasites encountered at home. Ill military members also represent a risk for importing nonindigenous malaria strains into new areas including their home countries with potential for diminishing efficacy of established therapeutic regimens (i.e., importation of drug-resistant strains). Because of these increased risks, foreign deployments might represent a relevant focus for nascent military malaria control program efforts with attainable goals (e.g., predeployment risk assessments regarding malaria, distribution of sufficient malaria countermeasures, etc.). In light of the many challenges and successes shared by attendees, participants recognized the newly formed Task Force as an opportunity and a call for action to re-examine their militaries current malaria control efforts and were highly motivated to identify possible improvements to existing malaria programs and potential new programs and initiatives. Members candid discussion of program gaps during this opening meeting was highly conducive to identifying relevant focus areas for future Task Force activities. Attendees discussed the potential for West African militaries to benefit from USAID and the Centers for Disease Control and Prevention through the U.S. President s Malaria Initiative (PMI) and outlined the rules of engagement required for foreign militaries to navigate channels to access PMI-related aid within their respective nations. Generally, USAID is not permitted to work with foreign militaries. However, for certain infectious diseases including HIV and malaria, indirect support is possible if (1) military participation is part of a larger public health initiative and exclusion of the military would impair achievement of overall public health objectives, (2) assistance provided to the military is comparable to other groups receiving aid, and (3) no USAIDprovided resources can be readily adapted for unrelated military purposes. Through PMI, funds are disbursed to the designated executive agent for the NMCP in the recipient host country, typically the ministry of health. Once funds are received by the host nation, there are no prohibitions on PMI resources being used to support host-nation militaries so long as the aforementioned criteria are met. Because direct funds disbursement from PMI to foreign militaries is not possible, military representatives in PMI-focus countries (Fig. 1) are encouraged to liaise with their respective PMI and NMCP officials to garner support. Among participating Task Force nations, only Burkina Faso, Niger, and Togo are not currently designated as PMI-focus countries. Militaries and the health care services they provide are frequently under-recognized and underutilized vehicles for enhancing the prevention and treatment of malaria in West Africa; both are inconsistently integrated into NMCP efforts. Because many military health care centers in West Africa treat a large portion of the civilian population within their catchments, in addition to military service members and their families, incorporating these facilities in national civilian malaria prevention efforts (e.g., ITN distribution, outreach programs) is fundamental to ensuring coverage of these otherwise poorly accessible populations. Failure to include military health care facilities in national malaria campaigns, compounded by the paucity of existing military malaria programs to fill the resulting gap in services, introduces the potential for marked health disparity between populations attending military versus civilian clinics regarding malaria prevention, diagnosis, treatment, and patient health outcomes. In addition, in PMI-focus countries, the inability of PMI to fund military health care facilities directly and the compulsory routing of PMI funds through the civilian authority combine to create operational barriers for military health care facilities and their patients to benefit from PMI funding and related programs. For militaries in non- PMI-focus countries, alternate malaria-related funding programs, if available, able, and willing to work with militaries, would likely route funds in a similar, indirect fashion. In the absence of prescribed affiliation between the military and 10 MILITARY MEDICINE, Vol. 180, January 2015
civilian malaria authority, effectively countering these obstacles to ensure inclusion of military health care in the national malaria conversation is largely reliant on each militaries initiative and ability to persuasively engage their civilian counterparts. FUTURE DIRECTIONS By bringing together military health professionals from countries with varying resources, capabilities, and programs to counter malaria, the meeting reported here is a first step in furthering the exchange of information and coordination of malaria control efforts in West African militaries. Subsequent steps should include the finalization and ratification of the Task Force charter and bylaws to formalize the working relationships initiated at this meeting and to legitimize the Task Force itself, further development of the roles and responsibilities of members to facilitate progress toward the short-term and long-term goals of the Task Force (i.e., a roadmap for action), identifying funding and partnerships to support the development and maturation of military-specific malaria control programs, better integration of military malaria control efforts with national programs, and further gap analyses and assessments of needs to aid prioritization of malaria control efforts within militaries. Efforts to secure financial support for follow-on annual Task Force meetings as proposed should also be initiated, and Task Force members could also explore opportunities for partnering with other organizations with ongoing coordinated health engagements in the region (e.g., The West African Health Organization, a specialized Economic Community of West African States component agency) to advance W-AMTF objectives. Despite the numerous challenges and disparities regarding malaria control capabilities among participating militaries, participants invariably expressed enthusiasm for working together to further the military contribution to improving malaria control efforts in West Africa. ACKNOWLEDGMENTS Funding for the meeting was jointly provided by the Armed Forces Health Surveillance Center and U.S. Africa Command. REFERENCES 1. World Health Organization: Malaria Fact Sheet (December 2013 update). Available at http://www.who.int/mediacentre/factsheets/fs094/en/; accessed January 8, 2014. 2. Mellon G, Ficko C, Thellier M, et al: Two cases of late Plasmodium ovale presentation in military personnel. J Travel Med 2014; 21: 52 4. 3. Ajili F, Battikh R, Laabidi J, et al: Malaria in Tunisian military personnel after returning from external operation. Malar Res Treat 2013; 2013: 359192. 4. Juliao PC, Sosa S, Gonzalez LD, et al: Importation of chloroquineresistant Plasmodium falciparum by Guatemalan peacekeepers returning from the Democratic Republic of the Congo. Malar J 2013; 12: 344. 5. Pages F, Faulde M, Orlandi-Pradines E, Parola P: The past and present threat of vector-borne diseases in deployed troops. Clin Microbiol Infect 2010; 16: 209 24. 6. Porter WD: Imported malaria and conflict: 50 years of experience in the U.S. Military. Mil Med 2006; 171: 925 8. 7. U.S. Africa Command: African Military and Health Officials Gather For Malaria Symposium, April 20, 2011. Available at http://www.africom.mil/newsroom/article/8230/african-military-and-health-officials-gatherfor-m; accessed December 18, 2013. 8. U.S. Africa Command: West Africa Malaria Task Force Partners With U.S. Experts to Share Best Practices During World Malaria Day, April 22, 2013. Available at http://www.africom.mil/newsroom/article/10687/westafrica-malaria-task-force-partners-with-us-experts-to-share-best-practicesduring-world-malaria-day; accessed January 4, 2014. 9. World Health Organization: Campaigns: World Malaria Day, 2013. Available at http://www.who.int/campaigns/malaria-day/2013/en/index.html; accessed February 24, 2014. MILITARY MEDICINE, Vol. 180, January 2015 11