Volume 83, Issue 2
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



In 2003, 44 U.S. Marines were evacuated from Liberia with either confirmed or presumed malaria. An outbreak investigation showed that only 19 (45%) used insect repellent, 5 (12%) used permethrin-treated clothing, and none used bed netting. Adherence with weekly mefloquine (MQ) was reported by 23 (55%). However, only 4 (10%) had serum MQ levels high enough to correlate with protection (> 794 ng/mL), and 9 (22%) had evidence of steady-state kinetics (MQ carboxy metabolite/MQ > 3.79). Tablets collected from Marines met USP identity and dissolution specifications for MQ. Testing failed to identify isolates with MQ resistance. This outbreak resulted from under use of personal protective measures and inadequate adherence with chemophrophylaxis. It is essential that all international travelers make malaria prevention measures a priority, especially when embarking to regions of the world with high transmission intensity such as west Africa.

“Good doctors are of no use without good discipline. More than half the battle against disease is not fought by doctors, but by regimental officers. It is they who see that the daily dose of mepacrine (anti-malarial chemoprophylactic drug used in WW II) is taken…if mepacrine was not taken, I sacked the commander. I only had to sack three; by then the rest had got my meaning.”

—Lieutenant General William Slim (1891–1970), Burma Campaign, 1943


Article metrics loading...

The graphs shown below represent data from March 2017
Loading full text...

Full text loading...



  1. Beadle C, Hoffman SL, , 1993. History of malaria in the United States Naval Forces at war: World War I though the Vietnam Conflict. Clin Infect Dis 16: 320329.[Crossref] [Google Scholar]
  2. Porter WD, , 2006. Imported malaria and conflict: 50 years of experience in the U.S. Military. Mil Med 171: 925928.[Crossref] [Google Scholar]
  3. Kotwal RS, Wenzel RB, Sterling RA, Porter WD, Jordan NN, Petruccelli BP, , 2005. An outbreak of malaria in US Army Rangers returning from Afghanistan. JAMA 293: 212216.[Crossref] [Google Scholar]
  4. Newton JA, Schnepf GA, Wallace MR, Lobel HO, Kennedy CA, Oldfield EC, , 1994. Malaria in U.S. Marines returning from Somalia. JAMA 272: 397399.[Crossref] [Google Scholar]
  5. Wallace MR, Sharp TW, Smoak B, Iriye C, Rozmajzl P, Thornton SA, Batchelor R, Magill AJ, Lobel HO, Longer CF, Burans JP, , 1996. Malaria among United States troops in Somalia. Am J Med 100: 4955.[Crossref] [Google Scholar]
  6. Whitelaw K, , 2003. Liberia's plea for help. US News and World Report. July 14, 2003. [Google Scholar]
  7. White NJ, , 1998. Why is it that antimalarial drug treatments do not always work? Ann Trop Med Parasitol 92: 449458. [Google Scholar]
  8. BBC Weather Center. World weather. Average conditions - Monrovia. Available at: http://www.bbc.co.uk/weather/world/city_guides/results.shtml?tt=TT000310. Accessed March 1, 2010. [Google Scholar]
  9. World Health Organization, 2009. World Malaria Report 2009. Available at: http://whqlibdoc.who.int/publications/2009/9789241563901_eng.pdf. Accessed March 28, 2010. [Google Scholar]
  10. Snow RW, Guerra CA, Noor AM, Myint HY, Hay SI, , 2005. The global distribution of clinical episodes of Plasmodium falciparum malaria. Nature 434: 214217.[Crossref] [Google Scholar]
  11. Hay SI, Guerra CA, Tatem AJ, Atkinson PM, Snow RW, , 2005. Urbanization, malaria transmission and disease burden in Africa. Nature 3: 8190. [Google Scholar]
  12. Bossi P, Tegnell A, Baka A, Van Loock F, Hendriks J, Werner A, Maidhof H, Gouvras G, , 2004. Bichat guidelines for the clinical management of haemorrhagic fever viruses and bioterrorism-related haemorrhagic fever viruses. Euro Surveill 9: E11E12. [Google Scholar]
  13. Centers for Disease Control and Prevention, 1995. Update: management of patients with suspected viral hemorrhagic fever – United States. MMWR Morb Mortal Wkly Rep 44: 475479. [Google Scholar]
  14. Ogub O, Ajuluchukwu E, Uneke CJ, , 2007. Lassa fever in West African sub-region: an overview. J Vector Borne Dis 44: 111. [Google Scholar]
  15. Susi B, Whitman T, Blazes DL, Burgess TH, Martin GJ, Freilich D, , 2005. Rapid diagnostic test for Plasmodium falciparum in 32 Marines medically evacuated from Liberia with a febrile illness. Ann Intern Med 142: 476477.[Crossref] [Google Scholar]
  16. Todd GD, Hopperus Buma AP, Green MD, Jaspers CA, Lobel HO, , 1997. Comparison of whole blood and serum levels of mefloquine and its carboxylic acid metabolite. Am J Trop Med Hyg 57: 399402. [Google Scholar]
  17. Green MD, Bergqvist Y, Mount DL, Corbett S, D'Souza MJ, , 1999. Improved validated assay for the determination of mefloquine and its carboxy metabolite in plasma, serum and whole blood using solid-phase extraction and high-performance liquid chromatography. J Chromotography B 727: 159165.[Crossref] [Google Scholar]
  18. Lobel HO, Miani M, Eng T, Bernard KW, Hightower AW, Campbell CC, , 1993. Long-term malaria prophylaxis with weekly mefloquine. Lancet 341: 848851.[Crossref] [Google Scholar]
  19. Desjardins RE, Canfield CJ, Haynes JD, Chulay JD, , 1979. Quantitative assessment of antimalarial activity in vitro by a semiautomated microdilution technique. Antimicrob Agents Chemother 16: 710718.[Crossref] [Google Scholar]
  20. Oduola AM, Weatherly NF, Bowdre JH, Desjardins RE, , 1988. Plasmodium falciparum: cloning by single-erythrocyte micromanipulation and heterogeneity in vitro . Exp Parasitol 66: 8695.[Crossref] [Google Scholar]
  21. Price RN, Cassar C, Brockman A, Duraisingh M, van Vugt M, White NJ, Nosten F, Krishna S, , 1999. The pfmdr1 gene is associated with a multidrug-resistant phenotype in Plasmodium falciparum from the western border of Thailand. Antimicrob Agents Chemother 43: 29432949. [Google Scholar]
  22. Jahrling PB, Niklasson BS, McCormick JB, , 1985. Early diagnosis of human Lassa fever by ELISA detection of antigen and antibody. Lancet 1: 250252.[Crossref] [Google Scholar]
  23. Niklasson BS, Jahrling PB, Peters CJ, , 1984. Detection of Lassa virus antigens and Lassa virus-specific immunoglobulins G and M by enzyme-linked immunosorbent asssy. J Clin Microbiol 20: 239244. [Google Scholar]
  24. U.S. Food and Drug Administration; Center for Drug Evaluation and Research. Mefloquine Hydrochloride Abbreviated New Drug Application 76,175. February 20, 2002. [Google Scholar]
  25. Bartelloni PJ, Sheey TW, Tigertt WD, , 1967. Combined therapy for chloroquine-resistant Plasmodium falciparum infection. JAMA 199: 141145.[Crossref] [Google Scholar]
  26. Tuck JJH, Green AD, Roberts KL, , 2003. A malaria outbreak following a British military deployment to Sierra Leone. J Infect 47: 225230.[Crossref] [Google Scholar]
  27. Migliani R, Josse R, Hovette P, Keundjian A, Pages F, Meynard JB, Ollivier L, Sbai Idrissi K, Tifratene K, Orlandi E, Rogier C, Boutin JP, , 2003. Malaria in military personnel: the case of the Ivory Coast in 2002–2003. Med Trop (Mars) 63: 282286. [Google Scholar]
  28. Phillips-Howard PA, Radalowicz A, Mitchell J, Bradley DJ, , 1990. Risk of malaria in British residents returning from malarious areas. BMJ 300: 499503.[Crossref] [Google Scholar]
  29. World Health Organization, 2000. Severe falciparum malaria: World Health Organization, Communicable Diseases Cluster. Trans R Soc Trop Med Hyg 94 (Suppl 1): S1S90. [Google Scholar]
  30. U.S. Centers for Disease Control and Prevention, 2008. Treatment of Malaria (Guidelines for Clinicians). Available at: http://www.cdc.gov/malaria/pdf/clinicalguidance.pdf. Accessed September 9, 2008. [Google Scholar]
  31. U.S. Army, 1999. FORSCOM standing logistics instruction. Headquarters UAFC, ed. Volume FORSCOM Regulation 700-2. Fort McPherson, GA: U.S. Army. [Google Scholar]
  32. Rowland M, Downey G, Rab A, Freeman T, Mohammad N, Rehman H, Durrani N, Reyburn H, Curtis C, Lines J, Fayaz M, , 2004. DEET mosquito repellent provides personal protection against malaria: a household randomized trial in an Afghan refugee camp in Pakistan. Trop Med Int Health 9: 335342.[Crossref] [Google Scholar]
  33. D'Alessandro U, Olaleye B, McGuire W, Langerock P, Bennett S, Aikins MK, Thomson MC, Cham MK, Cham BA, Greenwood BM, , 1995. Mortality and morbidity from malaria in Gambian children after introduction of an impregnated bed net programme. Lancet 345: 479483.[Crossref] [Google Scholar]
  34. Navy and Marine Corps Public Health Center, 2007. Technical Manual NEHC-TM PM 6250.1. Navy Medical Guide to Malaria Prevention and Control. Portsmouth, VA: Navy and Marine Corps Public Health Center. [Google Scholar]
  35. Department of Defense. Neuropsychiatric Effects of Mefloquine. Available at: http://www.nytimes.com/2002/08/24/us/army-to-press-medical-inquiry-at-fort-bragg.html?scp=3&sq=Fort%20bragg%20malaria&st=cse. Accessed May 17, 2010. [Google Scholar]
  36. Bourdreau E, Schuster B, Sanchez J, Novakowski W, Johnson R, Redmond D, Hanson R, Dausel L, , 1993. Tolerability of prophylactic Lariam regimens. Trop Med Parasitol 44: 257265. [Google Scholar]
  37. Oduola AM, Milhous WK, Salako LA, Walker O, Desjardins RE, , 1987. Reduced in-vitro susceptibility to mefloquine in west African isolates of Plasmodium falciparum . Lancet 2: 13041305.[Crossref] [Google Scholar]
  38. Lobel HO, Varma JK, Miani M, Green M, Todd GD, Grady K, Barber AM, , 1998. Monitoring for mefloquine-resistant Plasmodium falciparum in Africa: implications for travelers' health. Am J Trop Med Hyg 59: 129132. [Google Scholar]
  39. Raccurt CP, Dumestre-Toulet V, Abraham E, Le Bras M, Brachet-Liermain A, Ripert C, , 1991. Failure of falciparum malaria prophylaxis by mefloquine in travelers from west Africa. Am J Trop Med Hyg 45: 319324. [Google Scholar]
  40. Peel SA, Bright P, Yount B, Handy J, Baric RS, , 1994. A strong association between mefloquine and halofantrine resistance and amplification, overexpression, and mutation in the P-glycoprotein gene homolog (pfmdr) of Plasmodium falciparum in vitro . Am J Trop Med Hyg 51: 648658. [Google Scholar]
  41. Slim W, , 1956. Defeat Into Victory. London: Cassell. [Google Scholar]
  42. Department of Defense, 2008. Department of Defense Instruction 6200.02. February 27, 2008: Application of Food and Drug Administration (FDA) Rules to Department of Defense Force Health Protection Programs. Washington, DC: Department of Defense. [Google Scholar]

Data & Media loading...

  • Received : 19 Dec 2009
  • Accepted : 23 Apr 2010
  • Published online : 05 Aug 2010

Most Cited This Month

This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error