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An Outbreak of Plasmodium falciparum Malaria in U.S. Marines Deployed to Liberia

Timothy J. WhitmanInfectious Diseases Department, National Naval Medical Center, Bethesda, Maryland; Walter Reed Army Institute of Research, Silver Spring, Maryland; Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, Maryland; Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; College of Public Health, University of South Florida, Tampa, Florida; Naval Medical Research Center, Silver Spring, Maryland; Infectious Diseases Division, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, New York; U.S. Navy Environmental and Preventive Medicine Unit Seven, Naples, Italy; Australian Army Malaria Institute, Gallipoli Barracks, Australia

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Philip E. CoyneInfectious Diseases Department, National Naval Medical Center, Bethesda, Maryland; Walter Reed Army Institute of Research, Silver Spring, Maryland; Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, Maryland; Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; College of Public Health, University of South Florida, Tampa, Florida; Naval Medical Research Center, Silver Spring, Maryland; Infectious Diseases Division, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, New York; U.S. Navy Environmental and Preventive Medicine Unit Seven, Naples, Italy; Australian Army Malaria Institute, Gallipoli Barracks, Australia

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Alan J. MagillInfectious Diseases Department, National Naval Medical Center, Bethesda, Maryland; Walter Reed Army Institute of Research, Silver Spring, Maryland; Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, Maryland; Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; College of Public Health, University of South Florida, Tampa, Florida; Naval Medical Research Center, Silver Spring, Maryland; Infectious Diseases Division, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, New York; U.S. Navy Environmental and Preventive Medicine Unit Seven, Naples, Italy; Australian Army Malaria Institute, Gallipoli Barracks, Australia

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David L. BlazesInfectious Diseases Department, National Naval Medical Center, Bethesda, Maryland; Walter Reed Army Institute of Research, Silver Spring, Maryland; Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, Maryland; Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; College of Public Health, University of South Florida, Tampa, Florida; Naval Medical Research Center, Silver Spring, Maryland; Infectious Diseases Division, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, New York; U.S. Navy Environmental and Preventive Medicine Unit Seven, Naples, Italy; Australian Army Malaria Institute, Gallipoli Barracks, Australia

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Michael D. GreenInfectious Diseases Department, National Naval Medical Center, Bethesda, Maryland; Walter Reed Army Institute of Research, Silver Spring, Maryland; Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, Maryland; Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; College of Public Health, University of South Florida, Tampa, Florida; Naval Medical Research Center, Silver Spring, Maryland; Infectious Diseases Division, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, New York; U.S. Navy Environmental and Preventive Medicine Unit Seven, Naples, Italy; Australian Army Malaria Institute, Gallipoli Barracks, Australia

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Wilbur K. MilhousInfectious Diseases Department, National Naval Medical Center, Bethesda, Maryland; Walter Reed Army Institute of Research, Silver Spring, Maryland; Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, Maryland; Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; College of Public Health, University of South Florida, Tampa, Florida; Naval Medical Research Center, Silver Spring, Maryland; Infectious Diseases Division, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, New York; U.S. Navy Environmental and Preventive Medicine Unit Seven, Naples, Italy; Australian Army Malaria Institute, Gallipoli Barracks, Australia

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Timothy H. BurgessInfectious Diseases Department, National Naval Medical Center, Bethesda, Maryland; Walter Reed Army Institute of Research, Silver Spring, Maryland; Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, Maryland; Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; College of Public Health, University of South Florida, Tampa, Florida; Naval Medical Research Center, Silver Spring, Maryland; Infectious Diseases Division, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, New York; U.S. Navy Environmental and Preventive Medicine Unit Seven, Naples, Italy; Australian Army Malaria Institute, Gallipoli Barracks, Australia

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Daniel FreilichInfectious Diseases Department, National Naval Medical Center, Bethesda, Maryland; Walter Reed Army Institute of Research, Silver Spring, Maryland; Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, Maryland; Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; College of Public Health, University of South Florida, Tampa, Florida; Naval Medical Research Center, Silver Spring, Maryland; Infectious Diseases Division, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, New York; U.S. Navy Environmental and Preventive Medicine Unit Seven, Naples, Italy; Australian Army Malaria Institute, Gallipoli Barracks, Australia

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Sybil A. TaskerInfectious Diseases Department, National Naval Medical Center, Bethesda, Maryland; Walter Reed Army Institute of Research, Silver Spring, Maryland; Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, Maryland; Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; College of Public Health, University of South Florida, Tampa, Florida; Naval Medical Research Center, Silver Spring, Maryland; Infectious Diseases Division, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, New York; U.S. Navy Environmental and Preventive Medicine Unit Seven, Naples, Italy; Australian Army Malaria Institute, Gallipoli Barracks, Australia

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Ramzy G. AzarInfectious Diseases Department, National Naval Medical Center, Bethesda, Maryland; Walter Reed Army Institute of Research, Silver Spring, Maryland; Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, Maryland; Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; College of Public Health, University of South Florida, Tampa, Florida; Naval Medical Research Center, Silver Spring, Maryland; Infectious Diseases Division, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, New York; U.S. Navy Environmental and Preventive Medicine Unit Seven, Naples, Italy; Australian Army Malaria Institute, Gallipoli Barracks, Australia

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Timothy P. EndyInfectious Diseases Department, National Naval Medical Center, Bethesda, Maryland; Walter Reed Army Institute of Research, Silver Spring, Maryland; Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, Maryland; Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; College of Public Health, University of South Florida, Tampa, Florida; Naval Medical Research Center, Silver Spring, Maryland; Infectious Diseases Division, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, New York; U.S. Navy Environmental and Preventive Medicine Unit Seven, Naples, Italy; Australian Army Malaria Institute, Gallipoli Barracks, Australia

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Christopher D. ClagettInfectious Diseases Department, National Naval Medical Center, Bethesda, Maryland; Walter Reed Army Institute of Research, Silver Spring, Maryland; Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, Maryland; Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; College of Public Health, University of South Florida, Tampa, Florida; Naval Medical Research Center, Silver Spring, Maryland; Infectious Diseases Division, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, New York; U.S. Navy Environmental and Preventive Medicine Unit Seven, Naples, Italy; Australian Army Malaria Institute, Gallipoli Barracks, Australia

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Gregory A. DeyeInfectious Diseases Department, National Naval Medical Center, Bethesda, Maryland; Walter Reed Army Institute of Research, Silver Spring, Maryland; Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, Maryland; Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; College of Public Health, University of South Florida, Tampa, Florida; Naval Medical Research Center, Silver Spring, Maryland; Infectious Diseases Division, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, New York; U.S. Navy Environmental and Preventive Medicine Unit Seven, Naples, Italy; Australian Army Malaria Institute, Gallipoli Barracks, Australia

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G. Dennis ShanksInfectious Diseases Department, National Naval Medical Center, Bethesda, Maryland; Walter Reed Army Institute of Research, Silver Spring, Maryland; Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, Maryland; Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; College of Public Health, University of South Florida, Tampa, Florida; Naval Medical Research Center, Silver Spring, Maryland; Infectious Diseases Division, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, New York; U.S. Navy Environmental and Preventive Medicine Unit Seven, Naples, Italy; Australian Army Malaria Institute, Gallipoli Barracks, Australia

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Gregory J. MartinInfectious Diseases Department, National Naval Medical Center, Bethesda, Maryland; Walter Reed Army Institute of Research, Silver Spring, Maryland; Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, Maryland; Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; College of Public Health, University of South Florida, Tampa, Florida; Naval Medical Research Center, Silver Spring, Maryland; Infectious Diseases Division, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, New York; U.S. Navy Environmental and Preventive Medicine Unit Seven, Naples, Italy; Australian Army Malaria Institute, Gallipoli Barracks, Australia

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In 2003, 44 U.S. Marines were evacuated from Liberia with either confirmed or presumed Plasmodium falciparum 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 P. falciparum 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

Author Notes

*Address correspondence to Timothy J. Whitman, Infectious Diseases Department, Division of Medicine, National Naval Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889. E-mail: timothy.whitman@med.navy.mil

Disclosure: None of the authors have any potential conflicts of interest.

Authors' addresses: Timothy J. Whitman, David L. Blazes, Sybil A. Tasker, and Ramzy G. Azar, Infectious Diseases Department, Division of Medicine, National Naval Medical Center, Bethesda, MD. Alan J. Magill, Division of Experimental Therapeutics, Walter Reed Army Institute of Research, Silver Spring, MD. Philip E. Coyne and Gregory J. Martin, Infectious Diseases Clinical Research Program, Uniformed Services University, Bethesda, MD. Michael D. Green, Division of Parasitic Diseases, Centers for Disease Control and Prevention, Atlanta, GA. Wilber K. Milhous, College of Public Health, University of South Florida, Tampa, FL. Timothy H. Burgess and Daniel Freilich, Naval Medical Research Center, Silver Spring, MD. Timothy P. Endy, Infectious Diseases Division, Department of Medicine, State University of New York, Upstate Medical University, Syracuse, NY. Christopher D. Clagett, U.S. Navy Environmental and Preventive Medicine Unit Seven, Naples Italy. Gregory A. Deye, Walter Reed Army Institute of Research, Silver Spring, MD. G. Dennis Shanks, Army Malaria Institute, Gallipoli Barracks, Enoggera, Brisbane, Queensland, Australia.

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