WASHINGTON - The large outbreak of malaria among Marines who spent time ashore in the West African nation of Liberia in the summer was apparently caused by a nearly wholesale failure of the troops to follow protective measures, and in particular not taking a once a week malaria preventing drug.
Blood samples taken from the 26th Marine Expeditionary Unit right after malaria was diagnosed in several troops in early September showed that only 5 percent had been regularly taking the recommended drug, mefloquine. Only 12 percent wore uniforms properly treated with the insecticide permethrin. Only 27 percent reported using the time-released insect repellant issued to them. And none slept under insecticide-treated mosquito nets.
The findings were presented last week in closed briefings to the House and Senate Armed Services committees.
"It is difficult to get these young Marines, who are willing to charge a machine gun nest, to be worried about a mosquito," said Cmdr. David McMillan, a Navy physician involved in the investigation. "It is much more difficult than we believe it should be."
Out of 290 people who went ashore in Liberia, even briefly, from ships waiting off the Atlantic coast, 80 contracted malaria -- an "attack rate" of 28 percent. Of the 157 troops who spent at least one night ashore, 69 became infected -- an attack rate of 44 percent.
In all, 44 were ill enough with falciparum malaria -- the most serious of the three types of the disease -- to be evacuated to Europe or the United States. No one died, although several developed cerebral malaria -- an infection of the brain -- that required them to be on mechanical ventilators in intensive-care units.
In addition to Marines from the expeditionary force, the victims included seven Navy personnel, two Marine embassy guards, an Army soldier and a civilian.
McMillan said a team of military and civilian epidemiologists, infectious disease physicians and preventive medicine specialists who met on Oct. 9 to review the episode concluded that better education about the risk of malaria is the best way to prevent future outbreaks. The group did not think that requiring unit commanders to directly observe people taking their medicine -- a strategy employed with great success in civilian tuberculosis treatment -- would be practical or necessary.
Liberia and neighboring areas in West Africa have some of the most intense malaria transmission in the world. By one estimate, there is a 50 percent chance that a person who takes no protective measures will be infected within a month. Most of the troops from the expeditionary unit who stayed ashore were there for about two weeks.
Mefloquine, sold under the trade name Lariam, sometimes causes vivid dreams and insomnia, and in a few cases appears to affect mood. After several soldiers who returned from Afghanistan two years ago committed murder or suicide, rumors circulated attributing the violence to mefloquine. Further investigation refuted that idea.
McMillan said that when investigators asked the 41 people treated at the National Naval Medical Center in Bethesda, Md., whether they were afraid mefloquine might have psychological effects, none said he or she was. Complacency appeared to be the main reason people did not take it.
"They had been given the same series of recommendations as for Afghanistan, Djibouti and Iraq. Nobody was having any problems" when they did not closely follow the malaria-prevention orders there, he said. In Liberia, however, the risk of contracting malaria is about 1,000 times higher than in the Persian Gulf or in Central Asia.
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